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The eyelids have it: bug bites 101
NEWPORT BEACH, CA. – Bed bugs rise when night falls. Drawn by the carbon dioxide of sleeping humans, they gather to feast, leaving bites galore.
But other insects dine on people, too. Telling their bites apart is an important – and sometimes difficult – job for dermatologists who treat children. Fortunately, there are clinical signs to look for, a pediatric dermatologist told an audience of colleagues, including one that she herself helped introduce.
It’s called the “Eyelid Sign,” a clinical clue, Andrea Zaenglein, MD, said at Skin Diseases Education Foundation’s Women & Pediatric Dermatology Seminar.
Dr. Zaenglein, professor of dermatology and pediatric dermatology at Penn State University, Hershey, has often seen children with bites on their eyelids since they’re being bitten by bed bugs while they’re asleep. “You don’t get a lot of eyelid bites with other things,” she said. “Think about bed bugs whenever you see eyelid bites.”
She and a colleague reported on the “Eyelid Sign” in a study published in 2014, describing papules on the upper eyelid or eyelids associated with erythema and edema in six patients (Pediatr Dermatol. 2014 May-Jun;31[3]:353-5).
During her presentation, Dr. Zaenglein offered more tips on detecting bed bugs:
• Keep in mind that they’re probably not going to be sitting there under the pillow, waiting for your patients to find them. “They like to hide in nooks and crannies,” she said. “They don’t really stay in your bed.” Common hiding places include mattresses, floorboards, and wallpaper.
• Bed bugs are about the size of an apple seed. Stains and dark spots on bed sheets and mattresses can be signs of crushed bed bugs and bed bug excrement.
• They’re more common in urban areas, but “bed bugs are a problem in probably all of our communities,” Dr. Zaenglein noted.
• Some children can develop a reaction to bed bugs and other insects known as papular urticaria. “I have to explain to parents that this is a hypersensitivity response that’s abnormal,” Dr. Zaenglein said.
She noted that papular urticaria tends to be worse in summer and rarely involves the face. Treatments include antihistamines, strong topical steroids, and prevention of insect bites.
As for bed bug bites in general, the Centers for Disease Control and Prevention recommends antiseptic creams or lotions and antihistamine use.
How can bed bugs be killed off for good? The CDC suggests insecticide spraying to eliminate bed bugs, and states that “the best way to prevent bed bugs is regular inspection for the signs of an infestation.”
During the presentation, Dr. Zaenglein also spoke about scabies, focusing on the unique traits of the condition in babies.
“They always present with a lot of rash,” she said. “They won’t have a few papules on their hands and feet like older kids.” The rash will be “dirty-looking,” she continued, and more asymmetric than symmetric. Also, “you’ll almost always get a lot of mites burden if you scrape a baby,” she said. “It’s much harder to find a mite in older kids and young adults.”
Affected babies may be referred from an emergency department or primary care doctor with an incorrect diagnosis of eczema, she said, adding that scabies is extremely contagious. “If a baby has scabies,” she said, “you inevitably have to get your prescription pad. Treat all the household members.”
Babies may be itchy, but itchiness is much more common in older kids and young adults, keeping them up at night, she said. “College students come home over the break with a couple of papules on the belly, and they say it’s driving them crazy. They say it’s crazy, crazy itchy. If you hear that, think scabies.”
Another scabies clue in older kids: hand involvement. “Always look at the wrist, between the fingers. You get these generalized eruptions there.”
Scabies bites can be treated with a topical corticosteroid and, in children aged 2 months and older, permethrin 5% cream. Dr. Zaenglein said there’s concern about a leukemia risk associated with permethrin, but that applies to industrial use and overuse. Ivermectin is an alternative for stubborn and institutional cases.
As for prevention, she said pesticide sprays and fogs are generally discouraged. She advises families to wash recently used clothing and bedding in hot water. Clothing and bedding, including pillows, can also be stored in a closed plastic bag for up to a week.
“You could dry clean it all too,” she said, “but I’ll bet your dry cleaner won’t be too happy about it.”
Dr. Zaenglein disclosed serving as a consultant and researcher for Ranbaxy Laboratories Limited.
SDEF and this news organization are owned by the same parent company.
NEWPORT BEACH, CA. – Bed bugs rise when night falls. Drawn by the carbon dioxide of sleeping humans, they gather to feast, leaving bites galore.
But other insects dine on people, too. Telling their bites apart is an important – and sometimes difficult – job for dermatologists who treat children. Fortunately, there are clinical signs to look for, a pediatric dermatologist told an audience of colleagues, including one that she herself helped introduce.
It’s called the “Eyelid Sign,” a clinical clue, Andrea Zaenglein, MD, said at Skin Diseases Education Foundation’s Women & Pediatric Dermatology Seminar.
Dr. Zaenglein, professor of dermatology and pediatric dermatology at Penn State University, Hershey, has often seen children with bites on their eyelids since they’re being bitten by bed bugs while they’re asleep. “You don’t get a lot of eyelid bites with other things,” she said. “Think about bed bugs whenever you see eyelid bites.”
She and a colleague reported on the “Eyelid Sign” in a study published in 2014, describing papules on the upper eyelid or eyelids associated with erythema and edema in six patients (Pediatr Dermatol. 2014 May-Jun;31[3]:353-5).
During her presentation, Dr. Zaenglein offered more tips on detecting bed bugs:
• Keep in mind that they’re probably not going to be sitting there under the pillow, waiting for your patients to find them. “They like to hide in nooks and crannies,” she said. “They don’t really stay in your bed.” Common hiding places include mattresses, floorboards, and wallpaper.
• Bed bugs are about the size of an apple seed. Stains and dark spots on bed sheets and mattresses can be signs of crushed bed bugs and bed bug excrement.
• They’re more common in urban areas, but “bed bugs are a problem in probably all of our communities,” Dr. Zaenglein noted.
• Some children can develop a reaction to bed bugs and other insects known as papular urticaria. “I have to explain to parents that this is a hypersensitivity response that’s abnormal,” Dr. Zaenglein said.
She noted that papular urticaria tends to be worse in summer and rarely involves the face. Treatments include antihistamines, strong topical steroids, and prevention of insect bites.
As for bed bug bites in general, the Centers for Disease Control and Prevention recommends antiseptic creams or lotions and antihistamine use.
How can bed bugs be killed off for good? The CDC suggests insecticide spraying to eliminate bed bugs, and states that “the best way to prevent bed bugs is regular inspection for the signs of an infestation.”
During the presentation, Dr. Zaenglein also spoke about scabies, focusing on the unique traits of the condition in babies.
“They always present with a lot of rash,” she said. “They won’t have a few papules on their hands and feet like older kids.” The rash will be “dirty-looking,” she continued, and more asymmetric than symmetric. Also, “you’ll almost always get a lot of mites burden if you scrape a baby,” she said. “It’s much harder to find a mite in older kids and young adults.”
Affected babies may be referred from an emergency department or primary care doctor with an incorrect diagnosis of eczema, she said, adding that scabies is extremely contagious. “If a baby has scabies,” she said, “you inevitably have to get your prescription pad. Treat all the household members.”
Babies may be itchy, but itchiness is much more common in older kids and young adults, keeping them up at night, she said. “College students come home over the break with a couple of papules on the belly, and they say it’s driving them crazy. They say it’s crazy, crazy itchy. If you hear that, think scabies.”
Another scabies clue in older kids: hand involvement. “Always look at the wrist, between the fingers. You get these generalized eruptions there.”
Scabies bites can be treated with a topical corticosteroid and, in children aged 2 months and older, permethrin 5% cream. Dr. Zaenglein said there’s concern about a leukemia risk associated with permethrin, but that applies to industrial use and overuse. Ivermectin is an alternative for stubborn and institutional cases.
As for prevention, she said pesticide sprays and fogs are generally discouraged. She advises families to wash recently used clothing and bedding in hot water. Clothing and bedding, including pillows, can also be stored in a closed plastic bag for up to a week.
“You could dry clean it all too,” she said, “but I’ll bet your dry cleaner won’t be too happy about it.”
Dr. Zaenglein disclosed serving as a consultant and researcher for Ranbaxy Laboratories Limited.
SDEF and this news organization are owned by the same parent company.
NEWPORT BEACH, CA. – Bed bugs rise when night falls. Drawn by the carbon dioxide of sleeping humans, they gather to feast, leaving bites galore.
But other insects dine on people, too. Telling their bites apart is an important – and sometimes difficult – job for dermatologists who treat children. Fortunately, there are clinical signs to look for, a pediatric dermatologist told an audience of colleagues, including one that she herself helped introduce.
It’s called the “Eyelid Sign,” a clinical clue, Andrea Zaenglein, MD, said at Skin Diseases Education Foundation’s Women & Pediatric Dermatology Seminar.
Dr. Zaenglein, professor of dermatology and pediatric dermatology at Penn State University, Hershey, has often seen children with bites on their eyelids since they’re being bitten by bed bugs while they’re asleep. “You don’t get a lot of eyelid bites with other things,” she said. “Think about bed bugs whenever you see eyelid bites.”
She and a colleague reported on the “Eyelid Sign” in a study published in 2014, describing papules on the upper eyelid or eyelids associated with erythema and edema in six patients (Pediatr Dermatol. 2014 May-Jun;31[3]:353-5).
During her presentation, Dr. Zaenglein offered more tips on detecting bed bugs:
• Keep in mind that they’re probably not going to be sitting there under the pillow, waiting for your patients to find them. “They like to hide in nooks and crannies,” she said. “They don’t really stay in your bed.” Common hiding places include mattresses, floorboards, and wallpaper.
• Bed bugs are about the size of an apple seed. Stains and dark spots on bed sheets and mattresses can be signs of crushed bed bugs and bed bug excrement.
• They’re more common in urban areas, but “bed bugs are a problem in probably all of our communities,” Dr. Zaenglein noted.
• Some children can develop a reaction to bed bugs and other insects known as papular urticaria. “I have to explain to parents that this is a hypersensitivity response that’s abnormal,” Dr. Zaenglein said.
She noted that papular urticaria tends to be worse in summer and rarely involves the face. Treatments include antihistamines, strong topical steroids, and prevention of insect bites.
As for bed bug bites in general, the Centers for Disease Control and Prevention recommends antiseptic creams or lotions and antihistamine use.
How can bed bugs be killed off for good? The CDC suggests insecticide spraying to eliminate bed bugs, and states that “the best way to prevent bed bugs is regular inspection for the signs of an infestation.”
During the presentation, Dr. Zaenglein also spoke about scabies, focusing on the unique traits of the condition in babies.
“They always present with a lot of rash,” she said. “They won’t have a few papules on their hands and feet like older kids.” The rash will be “dirty-looking,” she continued, and more asymmetric than symmetric. Also, “you’ll almost always get a lot of mites burden if you scrape a baby,” she said. “It’s much harder to find a mite in older kids and young adults.”
Affected babies may be referred from an emergency department or primary care doctor with an incorrect diagnosis of eczema, she said, adding that scabies is extremely contagious. “If a baby has scabies,” she said, “you inevitably have to get your prescription pad. Treat all the household members.”
Babies may be itchy, but itchiness is much more common in older kids and young adults, keeping them up at night, she said. “College students come home over the break with a couple of papules on the belly, and they say it’s driving them crazy. They say it’s crazy, crazy itchy. If you hear that, think scabies.”
Another scabies clue in older kids: hand involvement. “Always look at the wrist, between the fingers. You get these generalized eruptions there.”
Scabies bites can be treated with a topical corticosteroid and, in children aged 2 months and older, permethrin 5% cream. Dr. Zaenglein said there’s concern about a leukemia risk associated with permethrin, but that applies to industrial use and overuse. Ivermectin is an alternative for stubborn and institutional cases.
As for prevention, she said pesticide sprays and fogs are generally discouraged. She advises families to wash recently used clothing and bedding in hot water. Clothing and bedding, including pillows, can also be stored in a closed plastic bag for up to a week.
“You could dry clean it all too,” she said, “but I’ll bet your dry cleaner won’t be too happy about it.”
Dr. Zaenglein disclosed serving as a consultant and researcher for Ranbaxy Laboratories Limited.
SDEF and this news organization are owned by the same parent company.
AT SDEF WOMEN'S & PEDIATRIC DERMATOLOGY SEMINAR
Caution is key when prescribing spironolactone for adult acne
NEWPORT BEACH, CALIF. – While off-label use of spironolactone for treatment of acne is quite common, it should be prescribed with special caution, advised Julie C. Harper, MD.
“The vast majority of you write this for acne,” Dr. Harper, a dermatologist in private practice in Birmingham, Ala., said during a presentation on adult acne at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.
She offered this blunt advice about one potential patient group: “Do not use this in men.” She cited a 2006 Japanese study of 139 patients with acne, treated with oral spironolactone, which found that 3 of the 23 males in the study developed gynecomastia within 4-6 weeks. Subsequently, the treatment was stopped in all male patients (Aesthetic Plast Surg. 2006 Nov-Dec;30[6]:689-94).
In the same study, 80% of the 116 females in the study experienced menstrual irregularities. “We have to tell our patients that’s a possible side effect, that they may get breast tenderness or menstrual irregularities,” Dr. Harper said. “If you don’t tell them, they’re not thinking of acne drugs as causing this.”
What about the risk of hyperkalemia in patients who take spironolactone, which is a diuretic? A retrospective study found similar hyperkalemia rates among healthy young women taking spironolactone for acne or an endocrine disorder with associated acne (mean age 26-27 years) and among healthy young women not taking spironolactone. The authors concluded that routine potassium testing was not necessary in healthy young women who take the drug (JAMA Dermatol. 2015 Sep;151[9]:941-4).
Dr. Harper recommended testing, however, if patients are older, have a history of renal or cardiac disease, have impaired hepatic function, or are taking higher doses of spironolactone.
She also cautioned that spironolactone should not be taken with lithium, and that it boosts the risk of digoxin toxicity.
Research doesn’t indicate that the risk of breast cancer is increased in women taking spironolactone, she said, nor does there appear to be a risk in lactating mothers. But the drug should not be taken during pregnancy or by women who could become pregnant, she noted.
Dr. Harper warned against the use of tetracyclines and erythromycin estolate when treating pregnant women with acne. She avoids using topical retinoids, although she said they are probably safe in small areas. Benzoyl peroxide is acceptable for small areas, as are topical azelaic acid and clindamycin, she added.
For information about acne treatment in lactating mothers, she cited a 2014 review (J Am Acad Dermatol. 2014 Mar;70[3]:417.e1-417.e10.). Erythromycin, azithromycin, and clarithromycin are considered appropriate for short-term use, she said, as are tetracyclines, but for less than 3 weeks only. Oral clindamycin is acceptable, but may cause gastrointestinal side effects in the nursing infant; topical use appears to be appropriate, she said.
Topical treatment with benzoyl peroxide is also appropriate for lactating women, she said, and topical retinoids are probably safe on small areas. Topical azelaic acid is considered a low risk to the nursing infant, she added.
Dr. Harper disclosed financial relationships of various types with Allergan, Bayer, BiopharmX, Galderma, Novan, Promius and Valeant.
SDEF and this news organization are owned by Frontline Medical Communications.
NEWPORT BEACH, CALIF. – While off-label use of spironolactone for treatment of acne is quite common, it should be prescribed with special caution, advised Julie C. Harper, MD.
“The vast majority of you write this for acne,” Dr. Harper, a dermatologist in private practice in Birmingham, Ala., said during a presentation on adult acne at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.
She offered this blunt advice about one potential patient group: “Do not use this in men.” She cited a 2006 Japanese study of 139 patients with acne, treated with oral spironolactone, which found that 3 of the 23 males in the study developed gynecomastia within 4-6 weeks. Subsequently, the treatment was stopped in all male patients (Aesthetic Plast Surg. 2006 Nov-Dec;30[6]:689-94).
In the same study, 80% of the 116 females in the study experienced menstrual irregularities. “We have to tell our patients that’s a possible side effect, that they may get breast tenderness or menstrual irregularities,” Dr. Harper said. “If you don’t tell them, they’re not thinking of acne drugs as causing this.”
What about the risk of hyperkalemia in patients who take spironolactone, which is a diuretic? A retrospective study found similar hyperkalemia rates among healthy young women taking spironolactone for acne or an endocrine disorder with associated acne (mean age 26-27 years) and among healthy young women not taking spironolactone. The authors concluded that routine potassium testing was not necessary in healthy young women who take the drug (JAMA Dermatol. 2015 Sep;151[9]:941-4).
Dr. Harper recommended testing, however, if patients are older, have a history of renal or cardiac disease, have impaired hepatic function, or are taking higher doses of spironolactone.
She also cautioned that spironolactone should not be taken with lithium, and that it boosts the risk of digoxin toxicity.
Research doesn’t indicate that the risk of breast cancer is increased in women taking spironolactone, she said, nor does there appear to be a risk in lactating mothers. But the drug should not be taken during pregnancy or by women who could become pregnant, she noted.
Dr. Harper warned against the use of tetracyclines and erythromycin estolate when treating pregnant women with acne. She avoids using topical retinoids, although she said they are probably safe in small areas. Benzoyl peroxide is acceptable for small areas, as are topical azelaic acid and clindamycin, she added.
For information about acne treatment in lactating mothers, she cited a 2014 review (J Am Acad Dermatol. 2014 Mar;70[3]:417.e1-417.e10.). Erythromycin, azithromycin, and clarithromycin are considered appropriate for short-term use, she said, as are tetracyclines, but for less than 3 weeks only. Oral clindamycin is acceptable, but may cause gastrointestinal side effects in the nursing infant; topical use appears to be appropriate, she said.
Topical treatment with benzoyl peroxide is also appropriate for lactating women, she said, and topical retinoids are probably safe on small areas. Topical azelaic acid is considered a low risk to the nursing infant, she added.
Dr. Harper disclosed financial relationships of various types with Allergan, Bayer, BiopharmX, Galderma, Novan, Promius and Valeant.
SDEF and this news organization are owned by Frontline Medical Communications.
NEWPORT BEACH, CALIF. – While off-label use of spironolactone for treatment of acne is quite common, it should be prescribed with special caution, advised Julie C. Harper, MD.
“The vast majority of you write this for acne,” Dr. Harper, a dermatologist in private practice in Birmingham, Ala., said during a presentation on adult acne at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.
She offered this blunt advice about one potential patient group: “Do not use this in men.” She cited a 2006 Japanese study of 139 patients with acne, treated with oral spironolactone, which found that 3 of the 23 males in the study developed gynecomastia within 4-6 weeks. Subsequently, the treatment was stopped in all male patients (Aesthetic Plast Surg. 2006 Nov-Dec;30[6]:689-94).
In the same study, 80% of the 116 females in the study experienced menstrual irregularities. “We have to tell our patients that’s a possible side effect, that they may get breast tenderness or menstrual irregularities,” Dr. Harper said. “If you don’t tell them, they’re not thinking of acne drugs as causing this.”
What about the risk of hyperkalemia in patients who take spironolactone, which is a diuretic? A retrospective study found similar hyperkalemia rates among healthy young women taking spironolactone for acne or an endocrine disorder with associated acne (mean age 26-27 years) and among healthy young women not taking spironolactone. The authors concluded that routine potassium testing was not necessary in healthy young women who take the drug (JAMA Dermatol. 2015 Sep;151[9]:941-4).
Dr. Harper recommended testing, however, if patients are older, have a history of renal or cardiac disease, have impaired hepatic function, or are taking higher doses of spironolactone.
She also cautioned that spironolactone should not be taken with lithium, and that it boosts the risk of digoxin toxicity.
Research doesn’t indicate that the risk of breast cancer is increased in women taking spironolactone, she said, nor does there appear to be a risk in lactating mothers. But the drug should not be taken during pregnancy or by women who could become pregnant, she noted.
Dr. Harper warned against the use of tetracyclines and erythromycin estolate when treating pregnant women with acne. She avoids using topical retinoids, although she said they are probably safe in small areas. Benzoyl peroxide is acceptable for small areas, as are topical azelaic acid and clindamycin, she added.
For information about acne treatment in lactating mothers, she cited a 2014 review (J Am Acad Dermatol. 2014 Mar;70[3]:417.e1-417.e10.). Erythromycin, azithromycin, and clarithromycin are considered appropriate for short-term use, she said, as are tetracyclines, but for less than 3 weeks only. Oral clindamycin is acceptable, but may cause gastrointestinal side effects in the nursing infant; topical use appears to be appropriate, she said.
Topical treatment with benzoyl peroxide is also appropriate for lactating women, she said, and topical retinoids are probably safe on small areas. Topical azelaic acid is considered a low risk to the nursing infant, she added.
Dr. Harper disclosed financial relationships of various types with Allergan, Bayer, BiopharmX, Galderma, Novan, Promius and Valeant.
SDEF and this news organization are owned by Frontline Medical Communications.
AT SDEF WOMEN’S & PEDIATRIC DERMATOLOGY SEMINAR
Close monitoring of psoriasis patients can delay PsA onset
NEWPORT BEACH, CALIF. – A patient with psoriasis can develop crippling psoriatic arthritis (PsA) within 5 to 10 years of diagnosis, but monitoring patients for signs of trouble can help prevent the onset of PsA, according to Alan Menter, MD.
Even a simple foot examination can make a huge difference, noted Dr. Menter, chief of the division of dermatology and director of the Psoriasis Research Institute at Baylor University Medical Center, Dallas. “At every visit, you and I should be looking for early signs of joint disease,” he said at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar. “We should not let these patients develop any joint disease because we have drugs that can prevent joint destruction.”
Dr. Menter pointed out that PsA is a disease that is distinct from psoriasis. “It’s linked to psoriasis, but genetically, there are differences,” he said, “and immunologically, what goes on in skin is not identical.”
He provided the following pearls regarding diagnosing PsA:
• Be on the lookout for “sausage fingers” and “sausage toes,” both signs of PsA. “You and I are very visual people, and we can see a swollen toe or finger very easily,” Dr. Menter said. “I take the shoes off every psoriasis patient at every visit and run my thumb and index finger down the Achilles. I look for a swollen Achilles – classic enthesitis.” In some cases, swollen big toes in psoriasis patients may be misdiagnosed as gout instead of PsA, he noted.
• Ask patients about how their joints feel when they wake up in the morning: Do they have swelling and tenderness? “That’s an early marker of psoriatic arthritis disease,” Dr. Menter said. In contrast, in a patient with osteoarthritis, “the more they use their joints, the worse it gets.”
• The severity of psoriasis has nothing to do with the severity of PsA. “You can have 50% of the body covered with psoriasis but no arthritis,” he said. “Or you can have someone with one patch of psoriasis on the scalp with devastating joint disease.”
• Be aware that there are five PsA subtypes that can occur in combination with each other:
1. Dactylitis. This is the form that causes the “sausage digit.”
2. Asymmetric oligoarthritis. This is the type most commonly seen on presentation, when there are few joints affected.
3. Symmetric arthritis. This form is more common in females and difficult to differentiate from rheumatoid arthritis.
4. Distal interphalangeal joint arthritis. This type is often linked to dactylitis and nail dystrophy.
5. Arthritis mutilans. This is more common in females, linked to long disease duration, and present in an estimated 5% of cases.
Dr. Menter suggested that dermatologists refer suspected cases of PsA to a rheumatologist. Since patients may have to wait 6-10 weeks for an appointment, he recommended that dermatologists consider NSAIDs, such as the over-the-counter naproxen and prescription meloxicam and celecoxib in the meantime. Dermatologists may also consider bringing up the use of methotrexate and biologics, he said.
Dr. Menter disclosed relationships with multiple pharmaceutical companies, including AbbVie, Allergan, Amgen, Boehringer Ingelheim, Eli Lilly, Merck, Novartis, and Pfizer.
SDEF and this news organization are owned by Frontline Medical Communications.
NEWPORT BEACH, CALIF. – A patient with psoriasis can develop crippling psoriatic arthritis (PsA) within 5 to 10 years of diagnosis, but monitoring patients for signs of trouble can help prevent the onset of PsA, according to Alan Menter, MD.
Even a simple foot examination can make a huge difference, noted Dr. Menter, chief of the division of dermatology and director of the Psoriasis Research Institute at Baylor University Medical Center, Dallas. “At every visit, you and I should be looking for early signs of joint disease,” he said at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar. “We should not let these patients develop any joint disease because we have drugs that can prevent joint destruction.”
Dr. Menter pointed out that PsA is a disease that is distinct from psoriasis. “It’s linked to psoriasis, but genetically, there are differences,” he said, “and immunologically, what goes on in skin is not identical.”
He provided the following pearls regarding diagnosing PsA:
• Be on the lookout for “sausage fingers” and “sausage toes,” both signs of PsA. “You and I are very visual people, and we can see a swollen toe or finger very easily,” Dr. Menter said. “I take the shoes off every psoriasis patient at every visit and run my thumb and index finger down the Achilles. I look for a swollen Achilles – classic enthesitis.” In some cases, swollen big toes in psoriasis patients may be misdiagnosed as gout instead of PsA, he noted.
• Ask patients about how their joints feel when they wake up in the morning: Do they have swelling and tenderness? “That’s an early marker of psoriatic arthritis disease,” Dr. Menter said. In contrast, in a patient with osteoarthritis, “the more they use their joints, the worse it gets.”
• The severity of psoriasis has nothing to do with the severity of PsA. “You can have 50% of the body covered with psoriasis but no arthritis,” he said. “Or you can have someone with one patch of psoriasis on the scalp with devastating joint disease.”
• Be aware that there are five PsA subtypes that can occur in combination with each other:
1. Dactylitis. This is the form that causes the “sausage digit.”
2. Asymmetric oligoarthritis. This is the type most commonly seen on presentation, when there are few joints affected.
3. Symmetric arthritis. This form is more common in females and difficult to differentiate from rheumatoid arthritis.
4. Distal interphalangeal joint arthritis. This type is often linked to dactylitis and nail dystrophy.
5. Arthritis mutilans. This is more common in females, linked to long disease duration, and present in an estimated 5% of cases.
Dr. Menter suggested that dermatologists refer suspected cases of PsA to a rheumatologist. Since patients may have to wait 6-10 weeks for an appointment, he recommended that dermatologists consider NSAIDs, such as the over-the-counter naproxen and prescription meloxicam and celecoxib in the meantime. Dermatologists may also consider bringing up the use of methotrexate and biologics, he said.
Dr. Menter disclosed relationships with multiple pharmaceutical companies, including AbbVie, Allergan, Amgen, Boehringer Ingelheim, Eli Lilly, Merck, Novartis, and Pfizer.
SDEF and this news organization are owned by Frontline Medical Communications.
NEWPORT BEACH, CALIF. – A patient with psoriasis can develop crippling psoriatic arthritis (PsA) within 5 to 10 years of diagnosis, but monitoring patients for signs of trouble can help prevent the onset of PsA, according to Alan Menter, MD.
Even a simple foot examination can make a huge difference, noted Dr. Menter, chief of the division of dermatology and director of the Psoriasis Research Institute at Baylor University Medical Center, Dallas. “At every visit, you and I should be looking for early signs of joint disease,” he said at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar. “We should not let these patients develop any joint disease because we have drugs that can prevent joint destruction.”
Dr. Menter pointed out that PsA is a disease that is distinct from psoriasis. “It’s linked to psoriasis, but genetically, there are differences,” he said, “and immunologically, what goes on in skin is not identical.”
He provided the following pearls regarding diagnosing PsA:
• Be on the lookout for “sausage fingers” and “sausage toes,” both signs of PsA. “You and I are very visual people, and we can see a swollen toe or finger very easily,” Dr. Menter said. “I take the shoes off every psoriasis patient at every visit and run my thumb and index finger down the Achilles. I look for a swollen Achilles – classic enthesitis.” In some cases, swollen big toes in psoriasis patients may be misdiagnosed as gout instead of PsA, he noted.
• Ask patients about how their joints feel when they wake up in the morning: Do they have swelling and tenderness? “That’s an early marker of psoriatic arthritis disease,” Dr. Menter said. In contrast, in a patient with osteoarthritis, “the more they use their joints, the worse it gets.”
• The severity of psoriasis has nothing to do with the severity of PsA. “You can have 50% of the body covered with psoriasis but no arthritis,” he said. “Or you can have someone with one patch of psoriasis on the scalp with devastating joint disease.”
• Be aware that there are five PsA subtypes that can occur in combination with each other:
1. Dactylitis. This is the form that causes the “sausage digit.”
2. Asymmetric oligoarthritis. This is the type most commonly seen on presentation, when there are few joints affected.
3. Symmetric arthritis. This form is more common in females and difficult to differentiate from rheumatoid arthritis.
4. Distal interphalangeal joint arthritis. This type is often linked to dactylitis and nail dystrophy.
5. Arthritis mutilans. This is more common in females, linked to long disease duration, and present in an estimated 5% of cases.
Dr. Menter suggested that dermatologists refer suspected cases of PsA to a rheumatologist. Since patients may have to wait 6-10 weeks for an appointment, he recommended that dermatologists consider NSAIDs, such as the over-the-counter naproxen and prescription meloxicam and celecoxib in the meantime. Dermatologists may also consider bringing up the use of methotrexate and biologics, he said.
Dr. Menter disclosed relationships with multiple pharmaceutical companies, including AbbVie, Allergan, Amgen, Boehringer Ingelheim, Eli Lilly, Merck, Novartis, and Pfizer.
SDEF and this news organization are owned by Frontline Medical Communications.
EXPERT ANALYSIS FROM SDEF WOMEN'S & PEDIATRIC DERMATOLOGY SEMINAR