Although combined clinics may not be possible in all settings, Dr. Merola also encourages collaborative education between the two specialties, be it at the medical school level, during fellowships, or during conferences, where a dermatologist may be invited to a rheumatology conference to discuss cases—or vice versa. Dr. Merola spoke of a fellowship program at his organization that gives experience in both specialties. “It’s a one-year training opportunity to increase one’s skills and comfort level with the other specialty. That’s been a unique way to educate as well,” he says.
At Mt. Sinai, Dr. Lebwohl says they are hiring a rheumatologist who would complete a dermatology residency, to help address issues from both specialties.
Dermatologist Delphine Lee, MD, PhD, director of translational immunology, Dirks/Dougherty Laboratory for Cancer Research, the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif., believes that collaborative care between the two fields is the right approach to properly guide patients in their treatment decisions. For example, if she is considering biologic or systemic therapy for a patient, she’ll first discuss it with their primary physician, who might be a rheumatologist. “I like to get a consensus,” she says.
Both rheumatologists and dermatologists can talk to patients about other risks they should monitor for, such as cardiovascular disease or watching their weight, particularly for psoriasis patients at risk for metabolic syndrome, Dr. Lee adds.
2. Find a dermatologist who enjoys handling tougher cases, Dr. Lee advises. She says there’s a perception of dermatologists focusing more on acne, Botox injections or other more cosmetic aspects of care. However, some dermatologists specialize in complex medical dermatology; finding such a person for your referrals will benefit everyone, she says.
3. Don’t overuse oral steroids in psoriasis patients. “In dermatology, we sometimes see the effects of prednisone leading to psoriasis flares,” Dr. Merola says. Systemic steroids can cause psoriasis to become unstable, especially when the oral steroid dose is lowered, Dr. Lebwohl says. “I think every dermatologist has had a harder time treating psoriasis because of steroid use, but I wouldn’t say this was a mistake on the rheumatologist’s part, [because] their reason for using it was correct,” he says. He says other options to use instead include methotrexate, nonsteroidal antiinflammatory drugs, and biologics.
4. Get comfortable with topical steroids. “For patients who are mostly but not completely clear on systemic medications, such as anti-tumor necrosis factor drugs, it would be helpful for a rheumatologist to also use adjunctive therapy like topical steroids to get the patient’s skin more comfortable and clear without having to wait to see a dermatologist,” Dr. Merola says.
