Psoriatic Arthritis Podcast

The Role of a Combined Rheumatology-Dermatology Clinic in Managing Psoriatic Arthritis

Elaine Husni, MD, MPH; Anthony Fernandez, MD, PhD


March 21, 2022

This transcript has been edited for clarity.

Elaine Husni, MD, MPH: Welcome to today's Medscape InDiscussion. We're going to talk about the benefits and challenges of a combined derm/rheum clinic. I'm very excited to introduce Dr Anthony Fernandez, who's an assistant professor and the co-medical director of continuing medical education, as well as the director of medical dermatology and the W.D. Steck Chair of Clinical Dermatology, at the Cleveland Clinic. He's a good friend and colleague, and I'm really excited to get this started.

Anthony Fernandez, MD, PhD: Thank you, Elaine. It's a pleasure to be here.

Husni: I want to start off with how we met and how we started the derm/rheum clinic here. I know it's been difficult — for me, at least — to get like-minded physicians and dermatologists to work in this combined clinic. In fact, before we even met, I went through three different dermatologists, where I worked with them for a couple of weeks or a couple of months, and each one of them promptly left the Cleveland Clinic after. Hopefully not because of the derm/rheum clinic but for other reasons. But this just really highlights that sometimes it does take a little while to find the right physician that can do a collaborative clinic. Why don't you tell us a little bit about how you got interested in the derm/rheum clinic?

Fernandez: I've always been drawn more to systemic disease, so mainly in my dermatology residency, the patients that I found most interesting and that I felt most fulfilled in diagnosing and treating were patients with systemic rheumatologic disorders that obviously involve the skin. That's why they were showing up to our clinics. I think just from there, just naturally thinking about a combined rheumatology-dermatology clinic, seemed to make sense. It was a great opportunity for me when you approached with the idea of having a combined rheumatology-dermatology clinic, and the rest is history.

Husni: Thank you. That's really helpful to hear because as people are starting to think about a co-management clinic and finding that right partnership, I think it's important to remind the audience of some of the items in dermatology that we look for to make a good partnership. So, I like your thoughts about gravitating toward systemic diseases.

I'd like to start off with a case, Tony, that we see — maybe not too commonly — but we definitely have cases where we need bridge therapy. I want to talk about a case of a middle-aged female teacher who had long-standing psoriasis that was somewhat hard to control. But she did go through some TNF therapy, as well as IL-23 therapy such as brodalumab, and was doing pretty well until about a couple of years ago when she started getting the first signs of psoriatic arthritis. She had a small erosion on her ulnar styloid, and she was diagnosed with erosive psoriatic arthritis. She started feeling that her joints weren't doing as well on the brodalumab and was looking to other therapies. She had already gone through probably six or seven different biologic therapies prior to meeting with me.

After her diagnosis of erosive psoriatic arthritis, she thought that it might be time to switch from brodalumab to an anti-TNF inhibitor, and she did so. She started for a couple of weeks, hadn't noticed a difference on adalimumab, and unfortunately contracted COVID and had to hold her anti-TNF therapy for a couple of weeks and was going to resume. We brought her into our combined clinic because she was not really responding to the initial 2 weeks of anti-TNF therapy, and we were thinking about weekly therapy because she had both psoriasis and psoriatic arthritis flare. But she asked about cyclosporine because she had been on this, she remembered, over 10 years ago and had really good success. I wanted to get your comments on whether you would think about this as a potential option for somebody that is having a particularly rough time getting under control, but yet we're not ready to give up on current medications.

Fernandez: This is a challenging patient, for sure. Cyclosporine is a very good medicine for psoriasis, and we still use it despite all of the biologic medications we have available to us. It works relatively fast and it usually is quite efficacious. My concern for this particular patient would be that she has psoriatic arthritis, and although cyclosporine can be effective for clearing skin, in our experience, we have not seen much efficacy in terms of the arthritis component, and this patient probably had the cyclosporine before the onset of psoriatic arthritis. I would be concerned that she would still have that joint pain. And in her case, depending on how long everyone thought it would take to get approval for a TNF inhibitor, Q 1 week dosing, it may be good to consider corticosteroids for a short period of time to bridge her because she may get better control of her joint pain while waiting for an increased dose of TNF compared with cyclosporine.

But it would really depend on the combination of symptoms she had at that point in time. How bad is her joint pain? How bad is her skin disease in making that decision? I think this is a perfect patient for a combined rheumatology-dermatology clinic, where both the rheumatologist and the dermatologist can be talking to her at the same time and making that decision together.

Husni: That's so helpful to hear. It's really difficult to answer some of those questions on the rheumatology side alone, meaning what we can be using for bridge therapy. What are some of the side effects of cyclosporine? And as you had remarked, cyclosporine may not have any effect on the joints.

She has been to the ER twice because she felt that her skin disease was not only not well controlled but that she was also developing an infection, and she was discharged with antibiotics for possible cellulitis. I do think the skin is very active, but unfortunately so are the joints. And she was denied weekly TNF therapy.

At this point it would be helpful because it may take a little bit longer to get the weekly approval, if at all, and [determine] what we can do in the meantime. I do also like your option of steroids. She has been on some low-dose steroids as well while she was waiting for the initial TNF inhibitor approval. But, as you said, bringing her in and having both of us evaluate her joints and skin could make for a much easier decision than something that we would see alone or separately.

Fernandez: Absolutely. And I don't know all of the options for the joints. I'm sure there are many options instead of just systemic corticosteroids. We may end up giving her two medications — one for the skin, one for the joint pain — that are compatible with each other, as opposed to giving her corticosteroids and assuming the risks that go along with a course of corticosteroids. And again, those decisions can really only be made when you have a good collaborative relationship between a rheumatologist and a dermatologist.

Husni: That's a really important point you just made about making decisions where they might have one for the joints and one for the skin. But as long as they can tolerate it, sometimes both is your only option when you cycle through so many. But, of course, our first choice is always to have one drug that can be effective in both conditions.

Fernandez: Absolutely.

Husni: Let's take a deeper dive into the co-management derm-rheum clinic that we have. Could you take us through that?

Fernandez: Sure. The first component is the scheduling. You and I are both busy. And so, Elaine, you and I communicate behind the scenes to come up with days each month where we can have the clinic, where we know we're both going to be in the office. We don't have conflicting meetings and we do that far ahead of time to make sure that we can accommodate patients' schedules and give them enough lead time to know that they can come. And then the second component is getting the correct patients in those patient slots. So right now, you and I having control of those slots and putting the patients in there that we know are appropriate for a combined rheumatology-dermatology clinic is critical as well. And then when the patients are here, we discuss the patients outside and we go in together; we examine the patient, both the skin and the joints together; we talk to the patient together, and we talk about potential decisions about what to do next — tests to order, medications to potentially prescribe — out loud in front of the patient. There are many different ways to have a combined rheumatology-dermatology clinic. But for me, just having that experience in-person with you and the patient is the ideal way to have a combined rheumatology-dermatology clinic.

Husni: That's really great to hear. In addition to all of the in-person co-management clinics that you and I have, it's also important to note that there are other ways that we've heard people do this, such as the virtual format, where they have predestined communication times, where they can be very effective and efficient. So it's always good to know that even if you can't do it the exact way that Tony and I are doing it, there can be other ways to have a derm-rheum clinic.

The next item I wanted to review is how derm-rheum clinics can really help solve some of the unmet needs in psoriatic disease care. Would you care to comment on some of the benefits or some of the items that we're doing that can really close that gap?

Fernandez: There are many benefits to a combined rheumatology-dermatology clinic in terms of potentially closing some of the gaps we have in psoriatic disease care. One that immediately comes to mind is that as an attending physician, we're all lifelong learners; but learning about different aspects of psoriatic disease is going to make any clinician better. Whenever I'm in a room with you and a patient, just watching you do a joint exam, having you explain what you're feeling, what you're seeing, and then allowing me to palpate a joint, and the questions that you ask patients, it's very educational for me and also for the residents and the fellows that we have in clinic with us.

When you think about rheumatology and dermatology, we are relatively small specialties and there are many more patients than available patient slots. So, for me, as a dermatologist, the last thing I want to do is take up a coveted rheumatology appointment slot with a patient who has psoriasis and joint pain, and then have a rheumatologist see that patient and the joint pain is not even close to psoriatic arthritis. Learning about the questioning and what to look for in a patient, on the joints, can eventually give me education that hopefully leads to me referring fewer patients who really do not have psoriatic arthritis to a rheumatology department.

Also, one of the most important aspects of a combined clinic that can potentially close gaps in the future are the ideas that are born out of seeing patients together and building a relationship between two clinicians in terms of research ideas, especially in an academic center. We both love research, we're both engaged in research, and we can come up with ideas together that we wouldn't think about if just on our own. And when you have a relationship like we have, we do research together. Of course, just carrying out those ideas, getting projects done, hopefully in time can lead to further insight into psoriatic disease that helps to close various gaps that we currently have in psoriatic disease care.

Husni: That was a really great summary. Real-time exam findings has been one of my most valuable experiences. It's one thing, trying to learn about assessing psoriasis skin severity, but to do it in real time with a dermatologist has really been very helpful to both my career and to help patients' outcomes.

And then there's that whole idea of extending our reach beyond clinical care, where we can pick up on research ideas and actually implement them and obtain grants to really get it to the next level. I completely agree with you — it's just so exciting and has been a really great addition to my career path. So thanks for articulating that.

The final thing I wanted to review is challenges of a derm-rheum clinic. Now that we've been doing it for a while, it would really help the audience to talk about some of those things that are kind of a sore spot. You had mentioned a little bit about the administrative issues. Anything else come to mind about how we can improve some of the triage or care coordination, or what we're currently doing that has helped? We certainly stumbled along the way at the beginning, but now we've become more comfortable about scheduling far enough in advance.

Fernandez: Obviously, we have our own clinics within our individual departments, so we cannot have every clinic be a combined rheumatology-dermatology clinic. I think one challenge for potential patients is trying to make sure that we have our clinics at times that can accommodate patients' schedules. And maybe that means there are some months where you have a clinic in the morning and other months where you have a clinic in the afternoon. That's a potential problem. I personally do not think you and I have run into that yet, but I can see that it is a potential problem. Having two clinicians who have similar personalities and neither one has too big of an ego. And when they're in the room together, knowing when one should be talking and the other one should be quiet. That is why we're so successful. You and I just get along. Neither one of us feels like we have to be the one to make the decision. We do things together; we listen to each other. The biggest challenge to having a successful combined rheumatology-dermatology clinic is just making sure that you're partnering with somebody who you can get along with, who you can truly collaborate with. At the end of the day, it's not about ego; it's about what is best for the patient.

It's about learning from somebody else who's trained in a different discipline to become better, realizing you don't know everything, and being engaged. In psoriatic disease or whatever the patient has, that would fall within a combined rheumatology-dermatology clinic to try to figure out how to diagnose and treat all patients better who are suffering from these systemic inflammatory diseases.

Husni: Yes, all of those nonverbal, nonscientific aspects come into play, whether it be personality or ego. I'm just often amazed by what I learn from you even in the nonpsoriatic space. I really like how patients' eyes just light up when they watch us collaborating and making decisions. So much of that decision-making comes from so many different areas in addition to our scientific knowledge. I agree with you that there are a lot of challenges in creating the right partnerships, and hopefully we have been able to articulate to the audience all of these things that make a very synergistic partnership or a combined clinic.

Fernandez: You bring up a very good point about patients watching us collaborate with each other. Despite some challenges, the benefits for a patient just far outweigh the challenges. And what we've seen is that patients are very satisfied with the care they get in that combined clinic. Seeing us communicate with each other about them and realizing that we're doing it in a very collegial academic way — patients know; they can sense when these two individuals are really communicating, trying to figure out the best plan for them. That has been a huge benefit with us, with our clinic and for our patients so far.

Husni: Thank you, Tony, for sharing your passion and insights into a successful combined derm-rheum clinic. It was incredibly helpful and useful to hear about your specific steps and ideas about best practices as we collaborate. Thank you very much.

Fernandez: Thank you, Elaine. I feel like I learn far more from you than you learn from me in these clinics. Thank you for everything that you've taught me. It was a pleasure to be here today speaking with you, and I look forward to our next combined clinic together.

Husni: Excellent. Thanks, Tony.


Bridging the Gaps in the Care of Psoriasis and Psoriatic Arthritis: The Role of Combined Clinics

Clinicians' Perspectives of Shared Care of Psoriatic Arthritis and Psoriasis Between Rheumatology and Dermatology: An Interview Study

Early Recognition and Treatment Heralds Optimal Outcomes: The Benefits of Combined Rheumatology-Dermatology Clinics and Integrative Care of Psoriasis and Psoriatic Arthritis Patients

Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network Consortium (PPACMAN) Survey: Benefits and Challenges of Combined Rheumatology-Dermatology Clinics

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