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Case and Research Letter
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[Translated article] Ten-Year Experience in the Joint Dermatology–Rheumatology Approach to Patients With Psoriatic Arthritis
Diez años de experiencia en el abordaje conjunto, dermatología-reumatología, de los pacientes con artritis psoriásica
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A. López Ferrera,
, H. Corominas Maciasb, L. Puig Sanza, A. Laiz Alonsob
a Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
b Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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A. López Ferrer, H. Corominas Macias, L. Puig Sanz, A. Laiz Alonso
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Table 1. Clinical and demographic characteristics of patients and initial and final diagnoses in the PAIDER clinic.
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Table 2. Reasons for consultation by referring service.
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Table 3. Dermatological and rheumatological diagnoses in the PAIDER clinic.
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To the Editor,

Joint management of psoriatic arthritis (PsA) can be very effective in some patients, although there is limited evidence in the literature based on large series of clinical data.1–9

The aim of this article is to quantify the diagnostic and therapeutic changes experienced by patients due to their passage through the PAIDER clinic (Comprehensive Care Program for Dermatology and Rheumatology Patients) of a tertiary referral center specializing in the management of immunomediated diseases from June 29th, 2012 to July 4th, 2023. This study was approved by the center ethics committee. An episode was defined as the set of visits made by a patient until discharge. A complex patient was defined as one who exhibited psychiatric, cardiac, hepatic, or oncological disease, communication problems, or treatment-related issues. Statistical analysis was performed using SPSS 28 statistical software.

The sample consists of 970 episodes generated from 732 patients who attended the clinic on different occasions over the years. A total of 53.8% of these were women, and the mean age was 53.1 years. Disease duration, origin, reasons for consultation detailed by referring services, comorbidities, and the proportion of complex patients are shown in Tables 1 and 2.

Table 1.

Clinical and demographic characteristics of patients and initial and final diagnoses in the PAIDER clinic.

Clinical and demographic characteristics (n=970)
Age (mean, years)  53.1   
Female, n (%)  522  53.8 
Male, n (%)  448  46.2 
Mean disease duration – Dermatology (years)  16.8   
Mean disease duration – Rheumatology (years)  7.5   
Mean number of visits  2.2   
N (%)     
Referringdepartmenta
Primary care  54  5.6 
Dermatology  437  45.1 
Rheumatology  434  44.7 
Other specialties  45  4.6 
Reason for referral  n=968   
Diagnosis  430  44.4 
Treatment  253  26.1 
Both  285  29.4 
Comorbidities  n=959  53.1 
Dyslipidemia  280  29.2 
Diabetes mellitus  124  12.9 
Hypertension  268  28 
Hyperuricemia  105  11.1 
Obesity (BMI>30)  309  33.7 
Smoking  249  26.3 
Inflammatory bowel disease  39  18.9 
Osteoporosis  99  18.7 
Uveitis  32  3.5 
Complexity  n=963  54.3 
Cardiac dysfunction  75  7.8 
Hepatic dysfunction  178  18.5 
Mental disorder  203  21.1 
Neoplasm  78  8.1 
Adverse effects  151  15.7 
Paradoxical reaction  89  9.2 
Communication problem  60  6.2 
Diagnosis, n (%)  Initial  Final 
Peripheral PsA  243 (25.7)  413 (43.9) 
Axial PsA  45 (4.8)  79 (8.4) 
Mixed PsA  93 (9.9)  121 (12.9) 
Rheumatoid arthritis  24 (2.5)  27 (2.9) 
Ankylosing spondylitis  48 (5.1)  24 (2.5) 
SAPHO  11 (1.2)  12 (1.3) 
Hidradenitis suppurativa  73 (0.3)  7 (0.7) 
Dactylitis/enthesitis/mono-oligoarticular arthritis  99 (10.5)  41 (4.3) 
Psoriasis  378 (40)  217 (23.1) 
a

Most referrals for diagnosis came from dermatology and rheumatology, while referrals for both reasons predominantly came from primary care and other specialties. Differences were statistically significant (p<0.001).

Table 2.

Reasons for consultation by referring service.

  Consultation for diagnosis, n (%)  Consultation for treatment, n (%)  Consultation for diagnosis and treatment, n (%) 
Primary care  14 (25.9)  11 (20.4)  29 (53.7) 
Dermatology  220 (50.3)  79 (18.1)  138 (31.6) 
Rheumatology  191 (44.0)  152 (35.0)  91 (21.0) 
Other hospital specialists  5 (11.6)  11 (25.5)  27 (62.7) 

Data from 968 episodes.

The median number of visits per episode was 1, with a minimum of 0 (patient did not attend) and a maximum of 22 visits, interquartile range (IQR)=(1.0; 2.0).

Diagnostic changes showed an increase in favor of PsA. Among the patients’ initial diagnoses, we found 381 (40.4%) with some type of PsA (axial, peripheral, or mixed) and 378 (40%) with psoriasis. Other diagnoses included rheumatoid arthritis (RA), ankylosing spondylitis (AS), SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis), and hidradenitis suppurativa (HS). Patients with diagnoses of dactylitis, enthesitis, and/or mono-oligoarthritis were grouped under the same heading. Final diagnoses showed that 613 (65.2%) patients had some type of PsA (axial, peripheral, or mixed), 217 (23.1%) had psoriasis, and the rest showed other diagnoses (Table 1).

In 329 episodes of patients referred for dermatological evaluation, the diagnoses were psoriasis in 154 (46.8%), psoriatic onychopathy in 35 (10.6%), onychomycosis in 18 (5.5%), and others in 122 (37.1%). Of these, 187 (56.8%) served to confirm the suspicion of PsA. In 432 episodes of patients referred for rheumatological evaluation, the diagnoses were arthritis in 161 (37.3%), enthesitis in 39 (9%), dactylitis in 18 (4.2%), osteoarthritis in 93 (21.5%), crystalline arthritis in 20 (23.4%), and others in 101 (37.1%). Of these, 201 (46.5%) served to confirm the suspicion of PsA (Table 3).

Table 3.

Dermatological and rheumatological diagnoses in the PAIDER clinic.

Dermatological disease in patients with arthritis n=329, n (%)
Psoriasis  154 (46.8) 
Nail psoriasis  35 (10.6) 
Onychomycosis  18 (5.5) 
Others  122 (37.1) 
Rheumatological disease in patients with psoriasis n=432, n (%)
Arthritis  161 (37.3) 
Enthesitis  39 (9) 
Dactylitis  18 (4.2) 
Osteoarthritis  93 (21.5) 
Gout  20 (23.4) 
Others  101 (37.1) 

Patients could present one or more diagnoses from the dermatologist or rheumatologist, in the same episode or successive episodes.

Changes in patient treatment occurred in 430 episodes (46.3%): treatment was initiated in 137 (14.7%), an additional treatment was added to the existing one in 102 (11%), a treatment change within the same therapeutic class was made in 93 (10%), a change of therapeutic class was made in 67 (7.2%), and treatment was stopped in 31 (3%).

As far as we know, this is the largest cohort of patients under joint follow-up in a dermatology–rheumatology clinic. The work describes that more than half experience a change in diagnosis and/or treatment. In our case, the number of new PsA cases increases among patients with an initial diagnosis of psoriasis and, to a lesser extent, with other musculoskeletal symptoms (oligoarthritis, dactylitis, enthesitis, etc.), likely because most of our patients first developed skin signs, as is common in the literature.10

Regarding treatment changes, our data show that these were performed in patients from rheumatology, indicating that the reason was mostly skin involvement. In addition, the approval processes for some drugs can take years of difference between specialties, often favoring dermatology, which means that patients referred to these clinics may have a wider therapeutic arsenal available.

Limitations of this study include the fact that it is a single-center cohort, where patients from smaller hospitals may have been referred due to their complexity, which could lead to referral bias. However, this study includes a large sample size of consecutive patients, referred to a joint clinic and with prolonged follow-up. These results show that multidisciplinary care is associated with a change in diagnosis, fundamentally in favor of PsA and, linked to this, a change in treatment, with the aim of improving the prognosis of the disease.

Funding

This work received funding from UCB Pharma for the statistical analysis of the data.

Conflicts of interest

A. López Ferrer has received payments or honoraria for educational events, support to attend meetings, and participation in advisory boards or consultancies from Abbvie, Almirall, Amgen, Boehringer Ingelheim, Bristol Myers Squibb Janssen, Eli Lilly, Leo Pharma, Novartis, UCB.

H. Corominas has received payments or honoraria for educational events, support to attend meetings, and participation in advisory boards or consultancies from Grünenthal, MSD, Biogen, Galapagos, Abbvie, Roche, Bristol Myers Squibb, Gebro, Sanofi, and UCB.

L. Puig Sanz has received payments or honoraria for educational events, support to attend meetings, and participation in advisory boards or consultancies from Abbvie, Almirall, Amgen, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Dice, Janssen, Leo-Pharma, Lilly, Novartis, Pfizer, Sandoz, Sanofi, and UCB.

A. Laiz Alonso has received payments or honoraria for educational events, support to attend meetings, and participation in advisory boards or consultancies from Abbvie, Almirall, Amgen, Janssen, MSD, Novartis, Pfizer, and UCB.

Acknowledgments

The authors wish to thank the members of the Dermatology and Rheumatology services of Hospital de la Santa Creu and Sant Pau for their participation in the study and for referring patients to the joint PAIDER clinic, and especially Dr. Eva Vilarrasa, Dr. Hye Park, and Dr. Patricia Moya for their close collaboration with the joint management of patients in our clinic.

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