Which specialty doctor should a patient with psoriasis see first?

Specialty Care for Psoriasis Patients

Patients with psoriasis should first see a dermatologist for initial diagnosis and management, with referral to a rheumatologist if psoriatic arthritis is suspected. 1

Primary Care Pathway for Psoriasis

Initial Management by Dermatologists

• Dermatologists are the primary specialists for diagnosing and managing psoriasis 1
• Most patients with stable chronic plaque psoriasis and guttate psoriasis can be managed by dermatologists 1
• Dermatologists play a crucial role in screening for psoriatic arthritis and educating patients about the association between psoriasis and arthritis 1

When to Refer to a Rheumatologist

• Patients showing signs and symptoms of psoriatic arthritis should be referred to a rheumatologist for assessment and management 1
• Key indicators requiring rheumatology referral:
  • Morning joint stiffness lasting longer than 30 minutes 1
  • Dactylitis ("sausage digit") 1
  • Enthesitis (inflammation at tendon/ligament insertion sites) 1
  • Swollen and tender joints unresponsive to NSAIDs 1

Severity-Based Specialty Care

Mild Psoriasis

• Can be managed by dermatologists with topical therapies 1, 2
• Topical agents include corticosteroids, vitamin D analogues, calcineurin inhibitors, and tar preparations 1, 3

Moderate to Severe Psoriasis

• Should be under continuing supervision of a consultant dermatologist due to potential toxicity of systemic treatments 1
• Treatment options include:
  • Phototherapy (narrowband UV-B) 3
  • Systemic agents (methotrexate, acitretin, cyclosporine) 4, 3
  • Biologic therapies (TNF-α inhibitors, IL-12/23, IL-17, and IL-23 inhibitors) 5, 3

Multidisciplinary Care for Comorbidities

Cardiovascular Risk Management

• Patients with psoriasis have increased risk of cardiovascular disease 1
• Dermatologists should alert patients to potential cardiovascular risks and consider referral to primary care for cardiovascular risk assessment 1

Mental Health Considerations

• Depression is common in psoriasis patients 1, 3
• Consider psychiatric or psychological referral for patients with significant psychological impact

Special Considerations

Psoriatic Arthritis

• Occurs in a significant proportion of psoriasis patients
• Skin lesions precede arthritis in approximately 65-73% of cases 1
• Rheumatologists will perform comprehensive joint assessments, order appropriate imaging, and measure inflammatory markers 1

Treatment-Resistant Cases

• Patients with severe psoriasis unresponsive to conventional therapies should be referred to specialized dermatology centers with experience in biologic therapies 5

Common Pitfalls to Avoid

• Delaying rheumatology referral when joint symptoms are present
• Failing to screen for comorbidities (cardiovascular disease, metabolic syndrome, depression)
• Using potent topical corticosteroids without dermatologist supervision, which can lead to skin atrophy and other adverse effects 1
• Missing psoriatic arthritis, which can lead to progressive joint damage and disability if left untreated 1

The evidence strongly supports that dermatologists should be the first specialists to evaluate and treat patients with psoriasis, with appropriate referrals to rheumatologists when joint involvement is suspected or confirmed.