Kaleroy Papantoniou, MD, Advanced Dermatology, with various locations in New York and New Jersey, also encourages rheumatologists to get more comfortable with the use of topical steroids when indicated. Class 1 or 2 topical steroids can help obtain better disease control, she says. “A good tip is to alternate your treatments to include corticosteroid-sparing agents, such as topical pimecrolimus and calcipotriene in the treatment of psoriasis,” she says. “Using these steroid-sparing agents on weekdays with the use of pulse topical steroids limited to the weekend can also help lower the risk for side effects.”
5. Refer to dermatologists when your patients might need more time to address their skin treatment, suggests Dr. Papantoniou. “Rheumatologists may not have extra time to discuss details of a skin regimen,” she says. “Also, in the office we can incorporate intralesional injections and phototherapy, which are often potent and can spare the patient from needing systemic medications or help lower the dosages for those already treated with systemics.”
6. Be thoughtful in your referrals to dermatologists. The experts interviewed all agreed that collaboration is helpful. However, also consider how long it might take the patient to be able to see a busy dermatologist, Dr. Merola says. That’s why he advocates rheumatologists getting more comfortable with topical therapy.
Dr. Goodman refers to a dermatologist any patient with disease manifestations who would benefit from focused local therapy, such as intralesional corticosteroids for alopecia or discoid lupus, or phototherapy for psoriasis.
“More importantly, I refer when the skin manifestation may not be related to the underlying diagnosis and may represent a complication, such as infection,” Dr. Goodman says. A dermatologist’s input is particularly valuable on varicella in an immunosuppressed patient or for skin cancer detection, because certain rheumatological medications require surveillance for skin cancer, she adds.
If a rash is questionable, it’s easier to have a dermatologist take a look or do a tissue biopsy if necessary, Dr. Weselman says. However, she wishes skin specialists would be more willing to readily perform biopsies with direct immunofluorescence; she finds it takes a couple of phone calls to get done.
A referral to a dermatologist—be it from a rheumatologist or any other specialty—can sometimes help patients stop various treatments that might be inappropriate and get on a clearer, simpler treatment course, Dr. Lee says.
7. Use technology to your advantage. If you have an electronic health record that you share with other specialists, insert photos of a skin manifestation that you want examined, Dr. Merola advises. This will help the dermatologist take a quick look, although an in-person examination will likely still be needed, Dr. Lee says.
