Management of Psoriasis: Dermatologist vs. Rheumatologist Collaboration
Psoriasis in the skin should primarily be managed by a dermatologist, but in cases with clinically significant skin involvement and musculoskeletal manifestations, a rheumatologist and dermatologist should collaborate in diagnosis and management. 1
Specialist Roles in Psoriasis Management
- Dermatologists are the primary specialists for managing skin manifestations of psoriasis 1
- Rheumatologists are the specialists who should primarily care for the musculoskeletal manifestations of patients with psoriatic arthritis 1
- When both significant skin and joint involvement are present, a collaborative approach between dermatology and rheumatology is recommended 1, 2
Multidisciplinary Approach Benefits
- Multidisciplinary management improves diagnostic precision, with studies showing revised diagnoses in up to 46% of cases previously diagnosed at outside clinics 3
- Combined dermatology-rheumatology clinics facilitate earlier diagnosis of psoriatic arthritis in patients with psoriasis 4
- Collaborative care leads to more comprehensive treatment approaches, with patients more likely to receive appropriate systemic medications (odds ratio of 5.1) 3
- Integrated management achieves better outcomes for both skin and musculoskeletal manifestations, improving health-related quality of life 4, 5
When to Involve a Rheumatologist
- When patients with psoriasis develop joint pain, stiffness, or swelling 1, 2
- In the presence of enthesitis (inflammation where tendons/ligaments attach to bone) 1
- When dactylitis (sausage digits) is present 1
- In cases with nail involvement, which can be associated with psoriatic arthritis 1
- When inflammatory axial disease (spine involvement) is suspected 1
Treatment Considerations
- For isolated skin psoriasis without joint involvement, dermatologist-led care is appropriate 1
- In patients with both psoriasis and psoriatic arthritis, treatment decisions should consider both skin and joint manifestations 1
- Methotrexate is preferred in patients with both joint and clinically relevant skin involvement 1
- For patients with peripheral arthritis and inadequate response to conventional synthetic DMARDs, biologics targeting IL-17 or IL-12/23 may be preferred when there is relevant skin involvement 1
Implementation Challenges
- Financial, time management, and human resource constraints can limit the implementation of multidisciplinary clinics 5
- Different hospitals may adopt distinct functional models for collaboration 5
- A consensus core assessment for psoriatic disease in multidisciplinary clinics should evaluate all disease manifestations and quality of life 5
The evidence strongly supports that while dermatologists should lead the management of isolated skin psoriasis, a collaborative approach between dermatology and rheumatology provides optimal care for patients with both skin and joint manifestations, leading to improved diagnosis, treatment decisions, and patient outcomes.