Dermatology for the Rheumatologist: Lupus and Dermatomyositis
In this episode, Avery H. LaChance, MD, MPH, speaks about the importance of a careful skin examination in connective tissue disease patients and highlights the importance of collaborative care for patients with autoimmune disease. Dr LaChance also spoke about these topics during a session titled “Dermatology for the Rheumatologist 1: Lupus and Dermatomyositis" at the Congress of Clinical Rheumatology in Destin, Florida on May 14, 2022.
Avery LaChance, MD, MPH, is a dermatologist, the director of the Connective Tissue Disease Clinic, and the director of health policy and advocacy at Brigham and Women’s Hospital Department of Dermatology, and an assistant professor of dermatology at Harvard Medical School (Boston, Massachusetts).
For more information about CCR East and West 2022, visit https://www.ccrheumatology.com/
Jessica Bard: Hello everyone, and welcome to another installment of podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 specialty network.
It can be difficult to distinguish between cutaneous lupus and dermatomyositis. Dr Avery LaChance is here to speak with us today about her session at CCR East 2022 “Dermatology for the Rheumatologist 1: Lupus and Dermatomyositis.” Dr LaChance is a dermatologist, the director of the Connective Tissue Disease Clinic and the director of health policy and advocacy at Brigham and Women's Hospital Department of Dermatology, and an assistant professor of dermatology at Harvard Medical School in Boston, Massachusetts. Thank you for joining us today, Dr. LaChance. Can you please provide us with an overview of your session?
Dr Avery LaChance: In this session, we really used a case-based approach to explore clinical pearls in cutaneous lupus and dermatomyositis. In the session, I really wanted to highlight key cutaneous features to both of these diseases and then review essential workup for patients that are diagnosed with either cutaneous lupus or dermatomyositis, and then wrap things up for both disease states by discussing gold-standard treatments, as well as novel therapeutics for these diseases.
Jessica Bard: What are the main things that dermatologists and rheumatologists should know?
Dr Avery LaChance: So, one of the things, actually, that drew me into dermatology and one of the things I really tried to highlight in my session is that I really think that dermatology is such a beautiful lens so often into what is underlying in a patient in terms of underlying systemic illness or their whole-body health. And so we really tried to focus in this session on key clinical cues that you can get from the skin exam that can help you diagnose a patient with cutaneous lupus and dermatomyositis. Some of these clues are really quite subtle and so it takes a keen eye, lots of experience, photos, and understanding of what the skin can look like in these 2 disease states to really start to feel comfortable differentiating, for instance, the malar rash of lupus from mid-facial erythema of dermatomyositis from rosacea or severe dermatitis, some of your more run of the mill dermatosis.
And so, seeing a good number of patients with these 2 conditions and understanding some of the clinical pearls and clues and cues that can help you differentiate between each of these diseases and other either autoimmune skin disease or other more common skin diseases, I think can really help both dermatologists and rheumatologists start to feel comfortable diagnosing these patients in the first place. And then getting them started on the appropriate workup and treatment when indicated when you do come to that diagnosis of either cutaneous lupus or dermatomyositis for patients.
Jessica Bard: What would you say is the importance of collaborative care and education between dermatologists and rheumatologists?
Dr Avery LaChance: I think on both sides for dermatology and rheumatology, there's so much really interesting overlap. And so much of immunology and rheumatology can show up on the skin in terms of autoimmune disease, having subtle little clues that can show up on the skin. And then also a lot of our different systemic manifestations when a patient comes into a dermatology office, in terms of a patient's full review of systems, can give clues and pearls of, is this a scary rash? Or is this a rash that I should be worried about? Or is this an autoimmune skin disease? And so I think really, if you're worried about a connected tissue disease in a patient, both rheumatology and dermatology can really coordinate and collaborate quite nicely together to pick up on subtle clues on, is this truly an inflammatory arthritis on the rheumatology side? Or is this the malar rash of lupus? Or am I dealing with a more common facial erythema for a patient on the dermatology side?
And so, I think cross-collaboration and crosstalk with these patients that you're not quite sure, is there brewing connective tissue disease there? Or are we in a completely different bucket? Is this just eczema? Or something else along those lines? Can be really helpful. And so, I really think in autoimmunity, there's a lot of opportunities for dermatologists and rheumatologists to share their clinical pearls, share their clinical insight, and look at and think about patients together to kind of put the full clinical picture together. Because both dermatomyositis and cutaneous lupus are diagnosed based on a spectrum of different clinical findings that, put together, diagnose the disease. And it's usually not just one clinical finding that you come up with, it's usually a multitude of clinical findings that, together, that constellation of them gets you to that diagnosis of dermatomyositis. And so, I think relying on the expertise, relying on the knowledge of both specialties together can really help us to provide the best, most comprehensive care that we can for our patients in the autoimmune world.
Jessica Bard: In your expert opinion, when should a rheumatologist refer to a dermatologist?
Dr Avery LaChance: I think anytime that there's a clinical clue that's showing up on the skin that a rheumatologist is sitting there scratching their head about, or a primary care doctor is sitting there scratching their head about, and saying “is this giving me a clue to what's going on inside with this patient?” We are more than happy, as dermatologists, to see those patients. I started out my talk at CCR saying, if there's one thing I know about rheumatologists, it's that they really love the skin because I think so many different autoimmune diseases can show up with different cutaneous findings. And so there's going to be a wide variety of comfort levels with different rheumatologists, with how comfortable they feel with the skin examination of patients with different connective tissue and autoimmune diseases.
So some rheumatologists may see a patient with, for instance, that perfect polycyclic annular eruption of subacute cutaneous lupus, and say, "Boom, I know exactly what I'm dealing with! I'm feeling like this is subacute cutaneous lupus. And if it's an older patient, I'm thinking about drugs, then I know I'm going to work them up for systemic lupus."
You may have another rheumatologist, who perhaps has a different focus in their clinical practice, who might see that rash or might have a patient come in with a rash that's perhaps more papulosquamous and not that complete polycyclic annular eruption that you see with subacute cutaneous lupus, and it might have this papulosquamous look, and you might be thinking “is this psoriasis? Is there something else kind of more like eczema going on here, and I'm not quite sure?” Let me then lean in and refer this patient on over to dermatology. And I think then the dermatologist can really say either clinically “yep, we're in this subacute cutaneous lupus bucket or dermatomyositis bucket, or we're in a completely different bucket altogether.”
Or if the dermatologist doesn't feel comfortable with the exam themselves, and it's a little bit of a stumper, they may take a biopsy. And so I think really, depending on any rheumatologist's comfort level with their own skin exam, if they're not quite sure of a diagnosis, or if there's something on the skin that they're thinking could possibly lend a clue to what's going on with the patient's entire systemic presentation, that is what we are there for as dermatologists to really help lend a helping eye and add our expert opinion to what that clinical exam is telling us about that patient and their disease.
Jessica Bard: What would you say are the overall take-home messages from our conversation today?
Dr Avery LaChance: I'd say big highlight features would be number 1, there are really unique and distinct clinical presentations of the 3 main subtypes of cutaneous lupus, acute cutaneous lupus, subacute cutaneous lupus, and our constellation of different chronic cutaneous lupus presentations, and really key clinical cutaneous findings of dermatomyositis as well. And so I'd say our number 1 take-home is really familiarizing yourself with those different clinical presentations and the cutaneous exam in both of those patient populations can make you feel way more comfortable diagnosing these patients with these 2 diseases in your office setting.
I'd say number 2 would be that you'd be so surprised by the number of ways that the skin can reflect internal health. And so whether you're in your primary care, your rheumatology, your dermatology office, really kind of knowing that doing a really careful and key skin exam for your patients can be an important factor, no matter what they're coming in for, to help you understand that patient's underlying illness. And then number 3, specifically when it comes to autoimmune disease, I think there are lots of opportunities for crosstalk and cross-collaboration and multidisciplinary care with our patients. And that's one of the things that brought me into connective tissue disease as a dermatologist. I really love providing collaborative care with my rheumatologists, my pulmonologists, my nephrologist. And so I'd say, the more that we can be multidisciplinary in that care for our patients with autoimmune disease, the better we are going to be able to really comprehensively improve the lives of our patients.
Jessica Bard: Yeah, those are great take-home messages. Is there anything else that you'd like to add today that you think we missed?
Dr Avery LaChance: I'd say the last thing that I just would add in, we talked about familiarizing yourself with the importance of the skin exam in cutaneous lupus and dermatomyositis, and all of your connective tissue diseases is really important. The last thing I'll just add in is that also very important that we're really becoming more comfortable and familiarizing ourselves with the skin exam, not just in one skin tone, but across the entire spectrum of skin tones that we see in the population. And so I think really important that as we're all expanding our education on the skin exam and connective tissue disease, that we're doing so in our patients from very light skin tones to very dark skin tones and everywhere in between so that we can provide also the best culturally-competent care for our patients as well.
Jessica Bard: Absolutely. That was a great addition. Well, thank you so much. I think we learned a lot about collaborative care today. I really appreciate you joining us on the podcast.
Dr Avery LaChance: My pleasure. Thanks so much for having me.