Each month the JDD Podcast discusses a current issue in dermatology and this December Dr. Adam Friedman sat down with Dr. Gideon Smith, assistant professor of dermatology at Harvard Medical school, Vice Chair for Clinical Affairs in Dermatology, and Director of the Connective Tissue Diseases Clinic and Fellowship to discuss pruritus in the autoimmune connective tissue world.
Dr. Angela Hou, PGY-3 dermatology resident at George Washington University School of Medicine and Health Sciences, shares key takeaways from Dr. Smith’s JDD podcast titled ‘Picking on Pruritus as a Problematic Clinical Biomarker in Autoimmune Connective Tissue Diseases’.
- Skin findings are often not discussed or treated in rheumatology clinics, including pruritus and alopecia.
- Templates can be very useful in clinic as they are consistent and detailed and can help remind the provider what to ask about for different specific diseases.
- Dermatomyositis and lupus often have pruritus in photosensitive areas and often track with disease activity. Dermatomyositis patients often have more pruritus when ultraviolet levels are higher.
- As itch increases, it can be a sign that their disease or muscle disease is flaring. However, itch can be persistent even when patient’s autoimmune disease is well controlled.
- Pruritus can be a later finding in scleroderma or Sjogren’s and does not parallel areas of significant skin involvement.
- Not all pruritus is created equal – dermatomyositis often manifests as a pure itch while lupus pruritus seems to be more of a discomfort. The intensity of the itch also differs, dermatomyositis pruritus is often more severe than lupus pruritus.
- A patient with no skin lesions or muscle changes with increasing pruritus should put a physician on high alert that this is a prodrome of a flare of their disease and further workup and evaluation is warranted. It could also be representative that they are not compliant with their medications.
- Sjogren’s and scleroderma pruritus often requires neuromodulators for itch, such as gabapentin, pregabalin, and amitriptyline instead of topical steroids or antihistamines.
- For patients reporting pruritus, check for compliance and if there have been any changes to their medications, as oftentimes medications given for autoimmune diseases can cause pruritus. Next look for flares or skin activity and try to control the inflammation of the skin, either with topicals or systemic medication.
- Look at systemic complications of the disease such as renal function in lupus, as kidney disease can also cause pruritus. It is important to screen patients appropriately for malignancies as this can also be a cause of itch. The final step is treating the neurologic cause of pruritus, which can be improved with neuromodulators. However, be cautious suppressing itch as often pruritus can be an important warning sign.
- If interested in autoimmune diseases, look for rheumatology departments that are excited to collaborate with dermatology. Find rheumatologists who work well with your style and have similar priorities.
Make sure to tune in and listen to the podcast here.
Words From The Investigator
I had the opportunity to ask Dr. Smith a few questions on his advice to residents and the one book he thinks everyone should read.
What is one piece of advice for current residents and young dermatologists?
As a dermatologist you are incredibly fortunate; you will by most external measures (money, prestige, schedule) be better off than most. So don’t focus on that or worry so much about it. If you want to be successful, happy and avoid burnout find one thing in your career that reflects your values and interests and put your energy into it. You don’t have to enjoy every acne visit, wart freeze or skin check but you do need something in your career that is personally meaningful. That may be helping teenagers with acne. That may be providing free skin checks. That may be treating the sickest patients, studying cell lines, volunteering abroad, or being politically active and lobbying your congressman on issues relevant to you. But find something that has nothing to do with RVUs so that you have a career that feels meaningful throughout your life.
What is one book everyone should read?
‘How will you measure your life’ by Clayton Christensen. I don’t agree with everything he says but its thought provoking. A Harvard Business School professor trying to get you to use business theory normally applied to companies to understand how your life will turn out if you continue making decisions in the way that you currently are. If you want an insight as to whether it appeals or is worth your time, just watch the Tedx of the same title on youtube as it hits the high points. I think its also very relevant to the current crisis of burnout in medicine.
How can dermatologists better collaborate with rheumatologists to treat our autoimmune connective tissue disease patients with pruritus?
We are always in such a rush as dermatologists that collaboration is hard. However, other providers are equally pressured and it is unfair to expect them to read your entire note even if it does have all of the information just to find out if you changed anything or had a question or anything bore any relation to them.
Instead, I suggest you send one or two lines summarizing the pertinent issue. If you must attach it to the note that’s fine, but save them the work of having to read every word and explain what you are doing that may impact them. So, for example, saying “Our patient still has 8/10 itch even though their skin is quiescent and I think it is actually unrelated to their dermatomyositis. It may be a medicine side effect so I am stopping hydroxychloroquine; if her disease flares I would like to consider an alternate rather than restarting hydroxychloroquine so we can truly evaluate if it is the trigger. I will see her in 3 months to evaluate for any change in itch and if none I will restart hydroxychloroquine for the dermatomyositis and consider gabapentin for itch”. Really lets the rheumatologist know that you do not think this itch is part of the patients dermato, so increasing immunosuppression is not indicated, it tells them about a change you are making that may impact the rheumatologists care of the patient, why you are doing it and what specifically the rheumatologist should consider when deciding if changing your instructions is indicated. You will surprised how many rheumatologists/pulmonologists/cardiologists will then send you one or two liners as it is truly communication, not just note sharing.
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