DART Clinic Review: Experiences from a combined dermatology and rheumatology clinic
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1 DART Clinic Review: Experiences from a combined dermatology and rheumatology clinic Michael Samycia 1, Collette McCourt 2, Kam Shojania 4, Sheila Au 1,3 1 Department of Dermatology and Skin Science, University of British Columbia, Vancouver, Canada 2 Department of Dermatology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, N.I. 3 Division of Dermatology, Department of Medicine, St. Paul s Hospital and Providence Health Care, Vancouver, Canada 4 Division of Rheumatology, Department of Medicine, St. Paul s Hospital and Providence Health Care, Vancouver, Canada Learning Objective: To gain awareness of the common dermatologic conditions that rheumatologic patients are experiencing. Take-Away Messages: 1. Dermatitis, psoriasis, cutaneous lupus and alopecia are highly represented in rheumatologic patients seen in our clinic. 2. Skin problems in rheumatologic patients may not be related to the underlying condition. 3. Rheumatologists and dermatologists can both benefit from being aware of the dermatologic conditions that rheumatologic patients are experiencing. Declaration of conflict: No authors have any conflicts to declare that would impact this project Contact: michaelsamycia@gmail.com
2 Background Objectives and Methods There is considerable overlap between many dermatologic and rheumatologic conditions Lupus, psoriasis, scleroderma, dermatomyositis The purpose of this study is to gather information to be used for quality improvement and to help guide the education of rheumatologists, dermatologists, residents and medical students in our clinic. Diagnosis and management of these conditions are complex and often require multi-disciplinary collaboration We retrospectively reviewed the charts of all DART patients from the two-year period, July 2011 to June The combined Rheumatology and Dermatology Treatment Clinic (DART Clinic) in Vancouver is a novel multi-disciplinary clinic, where patients are concomitantly assessed by both a rheumatologist and dermatologist. The data collected includes: patient age, gender, dermatologic diagnosis, rheumatologic diagnosis, biopsies performed, treatment, number of followup visits, and co-morbidities. It is attended by Dr. Sheila Au, Dr. Kamran Shojania as well as rheumatology and dermatology residents. We also take family practice, physiatry, and oral medicine and pathology residents. Initially a ½ day clinic, the clinic now sees patients, 1 day per week. Results Total Patients Seen Median Age - 48 yo Female Patients Median Age yo Male Patients - 72 Median Age - 49 yo 78 Patients had skin biopsies
3 Rheumatologic Diagnoses Systemic Lupus (58) 91% 9% Rheumatoid Arthri*s (49) 90% 10% IBD Arthri*s (6) 83% 17% Osteoarthri*s (7) 86% 14% Sarcoidosis (7) 57% 43% Mixed CTD (8) 50% 50% ANA + NYD (9) 22% 78% Dermatomyosi*s (9) 78% 22% Vasculi*s (9) 44% 56% Psoria*c Arthri*s (41) 44% 56% *Undifferen*ated Connec*ve Tissue Disease (UCTD) (25) 84% 16% **No Diagnosis (21) 95% 5% Ankylosing Spondyli*s (12) 25% 75% Arthri*s NYD (16) 63% 38% 30 different rheumatologic diagnoses were recorded. SLE and RA were the most common with majority of the pa*ents being female (red = women, blue = men). * UCTD comprises a subset of pa*ents who have features of connec*ve *ssue disease such as rash, arthri*s, and posi*ve immunologic markers, but do not yet fit into a specific disease category. **No Diagnosis was recorded for pa*ents who had been referred for a possible CTD but were found to have none
4 Dermatologic Diagnoses Derma**s (60) 83% 17% Psoriasis (40) 50% 50% Dermatophyte (7) 71% 29% Dermatomyosi*s (7) 71% 29% Erythema Nodosum (8) 63% 38% Chilblains (8) 100% 0% Skin Cancer (9) 56% 44% Cutaneous Lupus (25) 80% 20% Alopecia (21) 95% 5% Benign Skin Lesions (16) 88% 13% Infec*on (16) 63% 38% Acne (15) 87% 13% Rosacea (14) 71% 29% 43 dermatologic diagnoses or diagnos*c categories were recorded Major diagnos*c categories and examples of the condi*ons seen are listed below: Derma**s - allergic/irritant contact derma**s, perioroficial derma**s, lichen simplex chronicus Alopecia - alopecia areata, androgene*c alopecia, scarring alopecia, telogen effluvium Infec*on - EBV, HSV, VZV, HPV, polyoma virus, bacterial Fibrosing condi*ons - Morphea, en coup de sabre, systemic sclerosis, eosinophilic fascii*s Pigmentary disorders - drug induced, melasma Pigmentary disorder (13) 100% 0% Fibrosing Condi*ons (13) 85% 15% Vasculi*s (14) 64% 36%
5 Results The following tables demonstrate the different dermatologic conditions seen in specific rheumatologic patients Dermatologic diagnoses seen in psoriatic arthritis Dermatologic diagnoses seen in SLE Dermatologic diagnoses seen in RA Psoriasis 76% Dermatitis 10% Dermatophyte 5% Skin Cancer 2% Pigmentary disorder 2% Infection 2% Chilblains 2% Benign skin lesion 2% Actinic keratosis 2% Cutaneous Lupus 29% Dermatitis 16% Acne 14% Alopecia 12% Rosacea 9% Pigmentary disorder 9% Chilblains 7% Skin cancer 3% Infection 3% Erythema Nodosum 24% Rheumatoid Nodule 16% Skin Cancer 10% Dermatophyte 10% Pigmentary disorder 8% Actinic Keratosis 6% Alopecia 4% Rosacea 4% Benign skin lesion 4%
6 Results These tables demonstrate the different rheumatologic conditions seen with certain dermatologic diagnoses Rheumatologic diagnoses seen with psoriasis Psoriatic arthritis 78% Rheumatologic diagnoses seen with dermatitis Rheumatoid Arthritis 20% No Diagnosis 15% SLE 15% Undifferentiated CTD 10% Psoriatic Arthritis 7% Arthritis NYD 5% Osteoarthritis 5% Sjogren's syndrome 5% Rheumatologic diagnoses seen with alopecia Systemic LE 33% Rheumatoid Arthritis 24% Undfferentiated CTD 14% Arthritis NYD 5% Ankylosing Spondylitis 5% Fibrosing Conditions 5% Uveitis 5% No Diagnosis 5% Undifferentiated CTD 5% Fibrosing Conditions 3% IBD arthritis 3% Osteoarthritis 3% Rheumatologic diagnoses seen with cutaneous lupus Systemic LE 72% Cutaneous Lupus only 15% Undifferentiated CTD 8% Mixed CTD 4%
7 What s Next? Take home messages 1) Dermatitis, psoriasis, cutaneous lupus and alopecia are highly represented in rheumatologic patients seen in our clinic 2) Skin problems in rheumatologic patients may not be related to the underlying condition 3) Rheumatologists and dermatologists can both benefit from being aware of the dermatologic conditions that rheumatologic patients are experiencing Cutaneous Olyarteritis Nodosa We have completed a patient satisfaction survey and are currently compiling our results. Next, we hope to survey referring physicians. Using the data we collected, we have already begun altering educational seminars for rheumatology and dermatology trainees. For example, teaching rheumatology residents diagnosis and management of conditions such as alopecia and dermatitis Funding has been obtained for practicing dermatologists and rheumatologists to spend preceptorship time in the clinic More collaborative projects and publications Discoid Lupus Erythema elevatinum diutinum Pustular psoriasis from antitnf-a
8 Thank you
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