Cassidy

Coates

Foster

Gale

Kapila

Petty

Burden-Teh, Esther

Thomas, K.S.

Rangaraj, S.

Murphy, R.

Name not available

Interviews with paediatric rheumatologists about psoriasis and psoriatic arthritis in children: how can specialties learn from each other?

Burden-Teh, E.

Repository@Nottingham

Title: Interviews with paediatric rheumatologists about psoriasis and psoriatic arthritis inchildren: How can specialties learn from each other?Manuscript word count: 808Table count: 1Figure count: 0E. Burden-Teh1, K.S. Thomas1, S. Rangaraj2, R. Murphy31 Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK2 Department of Paediatric and Adolescent Rheumatology, Nottingham Children’s Hospital,Nottingham, Nottingham, UK3 Department of Dermatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield,UKCorresponding author:Dr Esther Burden-TehCentre of Evidence Based Dermatology, King’s Meadow Campus, University of Nottingham,NG7 2RDEsther.Burden-Teh@nottingham.ac.ukNo funding sourcesNo conflicts of interestDear Editor,Opportunities exist for cross-specialty learning between dermatology and other medicaldisciplines; to the benefit of patients, clinical decision making and professionaldevelopment. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis(GRAPPA) promotes the concept of ‘psoriatic disease’ to encompass psoriasis and psoriaticarthritis, and in their new disease management recommendations emphasise theimportance of collaborative working between dermatologists and rheumatologists1. Whilstthe group primarily focuses on adult disease we suggest that a similar model should exist forthe paediatric population.Juvenile psoriatic arthritis (JPsA) is a separate disease to psoriatic arthritis in adults and is adistinct subset of juvenile idiopathic arthritis (JIA); an inflammatory arthritis with onsetunder the age of 16 years and unknown aetiology2. Diagnosis of cutaneous psoriasis andpsoriatic nail disease are both core components of the diagnostic classification for JPsA3.However, recognition of psoriasis in children can be more challenging compared to adultdisease as the signs are often more subtle4.Local experience in our Nottingham combined paediatric dermatology and rheumatologyclinics has demonstrated the shared benefit of cross-speciality learning for the assessmentand management of JPsA.To identify learning opportunities we conducted structured telephone interviews with UKpaediatric rheumatologists. The interviews aimed to ascertain paediatric rheumatologists’current practice for assessing for psoriasis, the impact a diagnosis of JPsA has on themanagement of arthritis, experience of the presentation of skin and joint disease, andrecommendations on improving the detection of JPsA.In the UK paediatric rheumatology is a specialist commissioned service with 12 designatedcentres; a rheumatologist at each centre was identified through the British Society ofPaediatrics and Adolescent Rheumatology (BSPAR). Rheumatologists were contacted andprovided study information by email, verbally consented for audio recording and undertookthe interviews as part of service evaluation.The interviews were conducted by one interviewer (EBT) following an interview guide ofopen and closed questions and transcribed as intelligent verbatim. Categorical responseswere analysed quantitatively as percentages and Framework Analysis was used to identifycommon themes in open responses5.Ten out of 12 (83%) centres of paediatric rheumatology expertise were interviewed based inEngland, Scotland and Northern Ireland; a moderate sample that are likely to berepresentative of current paediatric rheumatology practice. All clinicians had children withinflammatory arthritis under their care.Table 1 presents the results of questions about the assessment for psoriasis and the impacta diagnosis of JPsA has on the management of arthritis. Hidden site psoriasis was defined aspsoriasis occurring behind the ears or in the umbilicus, flexures, groin, genitals and natalcleft. Only 50% of rheumatologists ask about or examine at least one hidden site, and asmaller number examine the groin (20%), genitals (10%) and natal cleft (10%). However,paediatric rheumatologists rated their confidence in assessing for psoriasis on average at 6.4(0= no confidence at all, 10 =very confident).The three most frequent suggestions to improve rheumatologists’ recognition of psoriasiswere a close working relationship with dermatologists, experiential training and a diagnostictool. The majority of rheumatologists felt a diagnosis of JPsA compared to other JIAsubtypes made an impact on the explanation given to patients/families (70%), thetreatment plan (80%) and long-term outcomes (70%); highlighting the likely chronic andaggressive course of JPsA.Eight rheumatologists (80%) found it difficult to estimate the percentage of patientspresenting with skin, joint or simultaneous disease. Nine rheumatologists (90%)recommended that paediatric dermatologists could use the Paediatric Gait Arms Legs Spine(pGALS) tool to screen children with psoriasis for JPsA and a third (30%) commented that itis important to practise the technique6.Opportunities exist for paediatric dermatologists and rheumatologists to learn from eachother. JPsA may be missed by paediatric rheumatologists if psoriasis occurring in hiddensites are not asked about and examined. It is important to examine these sites as there issometimes discordance between patients’ awareness of psoriasis and changes detected onexamination. Future work could further explore dermatological practice amongstrheumatologists, including recognition of nail disease and disease severity. Dermatologistsare best placed to develop paediatric psoriasis training material and diagnostic guidance fortheir rheumatology colleagues.Currently there is no specific guidance on how children with psoriasis should be screenedfor JPsA. Available screening tools for adult psoriatic arthritis have not been validated foruse in children7. Paediatric rheumatologists are likewise best placed to develop screeningrecommendations and related training for JPsA assessment by dermatologists. From theseinterviews pGALS should be considered as an annual screening tool for use in paediatricdermatology clinics.We conclude that these interviews provide clear examples of the need for paediatricdermatologists and rheumatologists to learn from each other. Working groups, consensuswork and research studies are needed to take forward these strategies to improve thedetection of JPsA. At a time of limited healthcare resources, this work should opendiscussions about electronic multi-disciplinary working and teaching material.AcknowledgementsWe would like to acknowledge the following rheumatologists who supported this study byparticipating in the interviews.K. Bailey, Department of Paediatric Rheumatology, Nuffield Orthopaedic Centre, Oxford,OX3 &HE, UKD. Hawley, Department of Paediatric Rheumatology, Sheffield Children's NHS FoundationTrust, Sheffield, S10 2TH, UKL. McCann, Department of Paediatric Rheumatology, Alder Hey Children's NHS FoundationTrust , West Derby, Liverpool, L12 2AP, UKJ. McDonagh, Department of Paediatric Rheumatology, Birmingham Children’s Hospital NHSfoundation Trust, Birmingham, B4 6NH, UKK. Warrior, Department of Paediatric Rheumatology, Nottingham Children’s Hospital,Nottingham, NG7 2UH, UKM. Wood, Department of Paediatric Rheumatology, Leeds General Infirmary, Leeds, LS1 3EX,UKReferences1 Coates LC, Murphy R, Helliwell PS. New GRAPPA recommendations for themanagement of psoriasis and psoriatic arthritis: process, challenges andimplementation. The British journal of dermatology 2016; 174: 1174-8.2 Cassidy JT PR, Laxer RM, Lindsley CB. Juvenile Psoriatic Arthritis. In: Textbook ofPaediatric Rheumatology (Cassidy JT, ed), 6th edn. Canada: Saunders Elsevier.2011; 287-97.3 Petty RE, Southwood TR, Manners P et al. International League of Associations forRheumatology classification of juvenile idiopathic arthritis: second revision,Edmonton, 2001. The Journal of rheumatology 2004; 31: 390-2.4 Kapila S, Hong E, Fischer G. A comparative study of childhood psoriasis andatopic dermatitis and greater understanding of the overlapping condition,psoriasis-dermatitis. The Australasian journal of dermatology 2012; 53: 98-105.5 Gale NK, Heath G, Cameron E et al. Using the framework method for the analysisof qualitative data in multi-disciplinary health research. BMC medical researchmethodology 2013; 13: 117.6 Foster HE, Jandial S. pGALS - paediatric Gait Arms Legs and Spine: a simpleexamination of the musculoskeletal system. Pediatric rheumatology online journal2013; 11: 44.7 Coates LC, Aslam T, Al Balushi F et al. Comparison of three screening tools todetect psoriatic arthritis in patients with psoriasis (CONTEST study). The Britishjournal of dermatology 2013; 168: 802-7.Structured Question Number of respondents = n (%)When assessing children withinflammatory arthritis, do youroutinely ask any questionsabout skin disorders?Yes - 10/10 (100%)Directly ask about psoriasis – 7/10 (70%)When assessing children withinflammatory arthritis, are thereany specific areas of the bodywhere you ask about changes tothe skin?Scalp – 7/10 (70%), behind the ears – 1/10 (10%), face – 0/10 (0%), trunk – 0/10 (0%), umbilicus – 3/10 (30%), limbs – 3/10 (30%), acral –0/10 (0%), nails – 4/10 (40%), flexures – 0/10 (0%), groin – 2/10 (20%), genitals – 0/10 (0%), natal cleft – 3/10 (30%).Hidden sites* asked about – 3/10 (30%)When assessing children withinflammatory arthritis, are thereany specific areas of the bodywhere you examine for skinchanges?Scalp – 9/10 (90%), behind the ears – 3/10 (30%), face – 2/10 (20%), trunk – 3/10 (30%), umbilicus – 3/10 (30%), limbs – 5/10 (50%), acral1/10 (10%), nails – 5/10 (50%), flexures – 2/10 (20%), groin – 2/10 (20%), genitals – 1/10 (10%), natal cleft – 1/10 (10%)Hidden sites* examined – 5/10 (50%)How confident do you feel aboutdiagnosing psoriasis on a scale of1 to 10, 1 being not at allconfident to 10 being veryconfident?4 – 1/10 (10%), 5 – 2/10 (20%), 7 – 6/10 (60%), 8 – 1/10 (10%)Mean average score – 6.4In your experience, are there anyreasons why making a diagnosisof psoriasis can be difficult?Example quotations provided.Atypical appearance –8/10 (80%)“appearance is notcharacteristic”“not very scaly in thescalp…difficult if the GPhas already startedtreatment. You aren’tseeing the true clinicalpicture”Anatomical area of thebody involved – 5/10(50%)“young childrenespecially nappies andother excoriated areas”“palmar plantarinvolvement”Minimal amounts of skindisease – 6/10 (60%)“small areas, can varyfrom time to time”“when the presentation ismild sometimes the familycan dismiss or not noticethe changes…a small patchin the scalp may be missedwithout a very thoroughscalp examination”Similarity in appearanceto other skin disease –5/10 (50%)“with the nails fungalneeds to be excluded:“rashes can be difficultto diagnose to a non-dermatologist, canappear very similar”No family history –2/10 (20%)“no family history ofpsoriasis”Can you make any suggestionsabout what would help youdiagnose psoriasis and thereforepsoriatic arthritis? Examplequotations provided.Diagnostic test – 1/10(10%)“any imaging ….skinultrasound”Diagnostic criteria –3/10 (30%)“a list of criteria fordiagnosing psoriasis”Experientialtraining/clinical education– 4/10 (40%)“active learning fromcolleagues… courses…clinical experience“Close workingrelationship betweenrheumatology anddermatology – 6/10(60%)“we have a combinedclinic monthly”“review by adermatologist who hasexperience aroundchildren andunderstands theimportance aroundmaking an accuratediagnosis”Not a problem thatneeds to beaddressed – 1/10(10%)“not a big problem”From your expertise, do youconsider there to be a differencebetween juvenile idiopathicarthritis and juvenile psoriaticarthritis?Yes – 8/10 (80%)No – 2/10 (20%)Specific rheumatological features in JPsA– 7/10 (70%) which include: dactylitis 5/10 (50%), enthesitis – 1/10 (10%), small joints of thehand/DIP -4/10 (40%), minimal swelling/drier synovitis/subtle -3/10 (30%), more aggressive -1/10 (10%), systemic inflammation – 1/10(10%)Each subtype is a different disease – 1/10 (10%)In your experience do you feelthere are any particular jointpatterns in children withpsoriatic arthritis?Small joints of the hand/DIP(60%), large joints (50%), dactylitis (40%), oligoarthritis/asymmetric (40%), mid/hindfoot (30%), sacroilitis(20%), polyarticular (20%), minimal swelling (10%) and no clear pattern (10%).Does a diagnosis of juvenilepsoriatic arthritis instead ofjuvenile idiopathic arthritisinfluence what you explain tochildren and their parents?Example quotations provided.Yes – 7/10 (70%) No – 3/10 (30%)Helps diseaseexplanation (skin andjoints) – 2/10 (20%)Comorbidities – 2/10(20%)“need to monitor eyesCautious explanation ofgenetics - 2/10 (20%)“try to stay away from thePersistent disease andrisk of joint damage –6/10 (60%)Treatment strategy –4/10 (40%)“early interventionTable 1: Responses to questions about how paediatric rheumatologists assess children withinflammatory arthritis for psoriasis and the impact a diagnosis of juvenile psoriatic arthritishas on their management of arthritis. *Hidden psoriasis refers to psoriasis behind the ears,umbilicus, flexures, groin, genitals and natal cleft.“starting point forexplaining autoimmunedisease …helps explaintreatment as you canuse methotrexate forskin and joints”for uveitis” blame of genetics” “prolonged …. can bemore damaging”“less reassuringregarding spontaneousremission”can be very effective…slightly differentapproach”“intermittent lifelongimmunosuppression”Does a diagnosis of juvenilepsoriatic arthritis instead ofjuvenile idiopathic arthritisinfluence your treatment plan?Example quotations provided.Yes – 8/10 (80%) No – 2/10 (20%)Lowers the threshold for treatment escalation 5/10(50%)“lower threshold for starting a DMARD,methotrexate in patients with involvement of lessthan 5 joints”“inclined to start systemic earlier… lower threshold toescalate treatment”Choice of biologic therapy – 2/10 (20%)“more likes to choose Humira overEnbrel”Combined approach for skin/uveitisand joints – 2/10 (20%)“if uveitis and skin involvementmay alter treatment used”In your experience, are long-termoutcomes different in childrenwith psoriatic arthritis comparedto juvenile idiopathic arthritis?Example quotations provided.Yes – 7/10 (70%) No – 3/10 (30%)Persistent disease – 5/10 (50%)“can have ongoing disease into adulthood”“less likely to go into remission”Risk of long-term joint damage andcomorbidity – 4/10 (40%)“adults have been found to have damagefrom undertreated psoriatic JIA”“appears to be more aggressive anderosive but we don’t have thatinformation yet”Increased need for aggressivetreatment – 2/10 (20%)“tend to start methotrexate andbiologic earlier in these patients”

Nottingham ePrints

Burden-Teh, Esther and Thomas, K.S. and Rangaraj, S. and Murphy, R. (2017) Interviews with paediatric rheumatologists about psoriasis and psoriatic arthritis in children: how can specialties learn from each other? British Journal of Dermatology, 177 (1). pp. 316-318. ISSN 1365-2133 Access from the University of Nottingham repository: http://eprints.nottingham.ac.uk/37729/1/How%20can%20specialties%20learn%20from%20each%20other%20Revised%20Final.pdfCopyright and reuse: The Nottingham ePrints service makes this work by researchers of the University of Nottingham available open access under the following conditions.This article is made available under the University of Nottingham End User licence and may be reused according to the conditions of the licence.  For more details see: http://eprints.nottingham.ac.uk/end_user_agreement.pdfA note on versions: The version presented here may differ from the published version or from the version of record. If you wish to cite this item you are advised to consult the publisher’s version. Please see the repository url above for details on accessing the published version and note that access may require a subscription.For more information, please contact eprints@nottingham.ac.ukTitle: Interviews with paediatric rheumatologists about psoriasis and psoriatic arthritis inchildren: How can specialties learn from each other?Manuscript word count: 808Table count: 1Figure count: 0E. Burden-Teh1, K.S. Thomas1, S. Rangaraj2, R. Murphy31 Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK2 Department of Paediatric and Adolescent Rheumatology, Nottingham Children’s Hospital,Nottingham, Nottingham, UK3 Department of Dermatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield,UKCorresponding author:Dr Esther Burden-TehCentre of Evidence Based Dermatology, King’s Meadow Campus, University of Nottingham,NG7 2RDEsther.Burden-Teh@nottingham.ac.ukNo funding sourcesNo conflicts of interestDear Editor,Opportunities exist for cross-specialty learning between dermatology and other medicaldisciplines; to the benefit of patients, clinical decision making and professionaldevelopment. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis(GRAPPA) promotes the concept of ‘psoriatic disease’ to encompass psoriasis and psoriaticarthritis, and in their new disease management recommendations emphasise theimportance of collaborative working between dermatologists and rheumatologists1. Whilstthe group primarily focuses on adult disease we suggest that a similar model should exist forthe paediatric population.Juvenile psoriatic arthritis (JPsA) is a separate disease to psoriatic arthritis in adults and is adistinct subset of juvenile idiopathic arthritis (JIA); an inflammatory arthritis with onsetunder the age of 16 years and unknown aetiology2. Diagnosis of cutaneous psoriasis andpsoriatic nail disease are both core components of the diagnostic classification for JPsA3.However, recognition of psoriasis in children can be more challenging compared to adultdisease as the signs are often more subtle4.Local experience in our Nottingham combined paediatric dermatology and rheumatologyclinics has demonstrated the shared benefit of cross-speciality learning for the assessmentand management of JPsA.To identify learning opportunities we conducted structured telephone interviews with UKpaediatric rheumatologists. The interviews aimed to ascertain paediatric rheumatologists’current practice for assessing for psoriasis, the impact a diagnosis of JPsA has on themanagement of arthritis, experience of the presentation of skin and joint disease, andrecommendations on improving the detection of JPsA.In the UK paediatric rheumatology is a specialist commissioned service with 12 designatedcentres; a rheumatologist at each centre was identified through the British Society ofPaediatrics and Adolescent Rheumatology (BSPAR). Rheumatologists were contacted andprovided study information by email, verbally consented for audio recording and undertookthe interviews as part of service evaluation.The interviews were conducted by one interviewer (EBT) following an interview guide ofopen and closed questions and transcribed as intelligent verbatim. Categorical responseswere analysed quantitatively as percentages and Framework Analysis was used to identifycommon themes in open responses5.Ten out of 12 (83%) centres of paediatric rheumatology expertise were interviewed based inEngland, Scotland and Northern Ireland; a moderate sample that are likely to berepresentative of current paediatric rheumatology practice. All clinicians had children withinflammatory arthritis under their care.Table 1 presents the results of questions about the assessment for psoriasis and the impacta diagnosis of JPsA has on the management of arthritis. Hidden site psoriasis was defined aspsoriasis occurring behind the ears or in the umbilicus, flexures, groin, genitals and natalcleft. Only 50% of rheumatologists ask about or examine at least one hidden site, and asmaller number examine the groin (20%), genitals (10%) and natal cleft (10%). However,paediatric rheumatologists rated their confidence in assessing for psoriasis on average at 6.4(0= no confidence at all, 10 =very confident).The three most frequent suggestions to improve rheumatologists’ recognition of psoriasiswere a close working relationship with dermatologists, experiential training and a diagnostictool. The majority of rheumatologists felt a diagnosis of JPsA compared to other JIAsubtypes made an impact on the explanation given to patients/families (70%), thetreatment plan (80%) and long-term outcomes (70%); highlighting the likely chronic andaggressive course of JPsA.Eight rheumatologists (80%) found it difficult to estimate the percentage of patientspresenting with skin, joint or simultaneous disease. Nine rheumatologists (90%)recommended that paediatric dermatologists could use the Paediatric Gait Arms Legs Spine(pGALS) tool to screen children with psoriasis for JPsA and a third (30%) commented that itis important to practise the technique6.Opportunities exist for paediatric dermatologists and rheumatologists to learn from eachother. JPsA may be missed by paediatric rheumatologists if psoriasis occurring in hiddensites are not asked about and examined. It is important to examine these sites as there issometimes discordance between patients’ awareness of psoriasis and changes detected onexamination. Future work could further explore dermatological practice amongstrheumatologists, including recognition of nail disease and disease severity. Dermatologistsare best placed to develop paediatric psoriasis training material and diagnostic guidance fortheir rheumatology colleagues.Currently there is no specific guidance on how children with psoriasis should be screenedfor JPsA. Available screening tools for adult psoriatic arthritis have not been validated foruse in children7. Paediatric rheumatologists are likewise best placed to develop screeningrecommendations and related training for JPsA assessment by dermatologists. From theseinterviews pGALS should be considered as an annual screening tool for use in paediatricdermatology clinics.We conclude that these interviews provide clear examples of the need for paediatricdermatologists and rheumatologists to learn from each other. Working groups, consensuswork and research studies are needed to take forward these strategies to improve thedetection of JPsA. At a time of limited healthcare resources, this work should opendiscussions about electronic multi-disciplinary working and teaching material.AcknowledgementsWe would like to acknowledge the following rheumatologists who supported this study byparticipating in the interviews.K. Bailey, Department of Paediatric Rheumatology, Nuffield Orthopaedic Centre, Oxford,OX3 &HE, UKD. Hawley, Department of Paediatric Rheumatology, Sheffield Children's NHS FoundationTrust, Sheffield, S10 2TH, UKL. McCann, Department of Paediatric Rheumatology, Alder Hey Children's NHS FoundationTrust , West Derby, Liverpool, L12 2AP, UKJ. McDonagh, Department of Paediatric Rheumatology, Birmingham Children’s Hospital NHSfoundation Trust, Birmingham, B4 6NH, UKK. Warrior, Department of Paediatric Rheumatology, Nottingham Children’s Hospital,Nottingham, NG7 2UH, UKM. Wood, Department of Paediatric Rheumatology, Leeds General Infirmary, Leeds, LS1 3EX,UKReferences1 Coates LC, Murphy R, Helliwell PS. New GRAPPA recommendations for themanagement of psoriasis and psoriatic arthritis: process, challenges andimplementation. The British journal of dermatology 2016; 174: 1174-8.2 Cassidy JT PR, Laxer RM, Lindsley CB. Juvenile Psoriatic Arthritis. In: Textbook ofPaediatric Rheumatology (Cassidy JT, ed), 6th edn. Canada: Saunders Elsevier.2011; 287-97.3 Petty RE, Southwood TR, Manners P et al. International League of Associations forRheumatology classification of juvenile idiopathic arthritis: second revision,Edmonton, 2001. The Journal of rheumatology 2004; 31: 390-2.4 Kapila S, Hong E, Fischer G. A comparative study of childhood psoriasis andatopic dermatitis and greater understanding of the overlapping condition,psoriasis-dermatitis. The Australasian journal of dermatology 2012; 53: 98-105.5 Gale NK, Heath G, Cameron E et al. Using the framework method for the analysisof qualitative data in multi-disciplinary health research. BMC medical researchmethodology 2013; 13: 117.6 Foster HE, Jandial S. pGALS - paediatric Gait Arms Legs and Spine: a simpleexamination of the musculoskeletal system. Pediatric rheumatology online journal2013; 11: 44.7 Coates LC, Aslam T, Al Balushi F et al. Comparison of three screening tools todetect psoriatic arthritis in patients with psoriasis (CONTEST study). The Britishjournal of dermatology 2013; 168: 802-7.Structured Question Number of respondents = n (%)When assessing children withinflammatory arthritis, do youroutinely ask any questionsabout skin disorders?Yes - 10/10 (100%)Directly ask about psoriasis – 7/10 (70%)When assessing children withinflammatory arthritis, are thereany specific areas of the bodywhere you ask about changes tothe skin?Scalp – 7/10 (70%), behind the ears – 1/10 (10%), face – 0/10 (0%), trunk – 0/10 (0%), umbilicus – 3/10 (30%), limbs – 3/10 (30%), acral –0/10 (0%), nails – 4/10 (40%), flexures – 0/10 (0%), groin – 2/10 (20%), genitals – 0/10 (0%), natal cleft – 3/10 (30%).Hidden sites* asked about – 3/10 (30%)When assessing children withinflammatory arthritis, are thereany specific areas of the bodywhere you examine for skinchanges?Scalp – 9/10 (90%), behind the ears – 3/10 (30%), face – 2/10 (20%), trunk – 3/10 (30%), umbilicus – 3/10 (30%), limbs – 5/10 (50%), acral1/10 (10%), nails – 5/10 (50%), flexures – 2/10 (20%), groin – 2/10 (20%), genitals – 1/10 (10%), natal cleft – 1/10 (10%)Hidden sites* examined – 5/10 (50%)How confident do you feel aboutdiagnosing psoriasis on a scale of1 to 10, 1 being not at allconfident to 10 being veryconfident?4 – 1/10 (10%), 5 – 2/10 (20%), 7 – 6/10 (60%), 8 – 1/10 (10%)Mean average score – 6.4In your experience, are there anyreasons why making a diagnosisof psoriasis can be difficult?Example quotations provided.Atypical appearance –8/10 (80%)“appearance is notcharacteristic”“not very scaly in thescalp…difficult if the GPhas already startedtreatment. You aren’tseeing the true clinicalpicture”Anatomical area of thebody involved – 5/10(50%)“young childrenespecially nappies andother excoriated areas”“palmar plantarinvolvement”Minimal amounts of skindisease – 6/10 (60%)“small areas, can varyfrom time to time”“when the presentation ismild sometimes the familycan dismiss or not noticethe changes…a small patchin the scalp may be missedwithout a very thoroughscalp examination”Similarity in appearanceto other skin disease –5/10 (50%)“with the nails fungalneeds to be excluded:“rashes can be difficultto diagnose to a non-dermatologist, canappear very similar”No family history –2/10 (20%)“no family history ofpsoriasis”Can you make any suggestionsabout what would help youdiagnose psoriasis and thereforepsoriatic arthritis? Examplequotations provided.Diagnostic test – 1/10(10%)“any imaging ….skinultrasound”Diagnostic criteria –3/10 (30%)“a list of criteria fordiagnosing psoriasis”Experientialtraining/clinical education– 4/10 (40%)“active learning fromcolleagues… courses…clinical experience“Close workingrelationship betweenrheumatology anddermatology – 6/10(60%)“we have a combinedclinic monthly”“review by adermatologist who hasexperience aroundchildren andunderstands theimportance aroundmaking an accuratediagnosis”Not a problem thatneeds to beaddressed – 1/10(10%)“not a big problem”From your expertise, do youconsider there to be a differencebetween juvenile idiopathicarthritis and juvenile psoriaticarthritis?Yes – 8/10 (80%)No – 2/10 (20%)Specific rheumatological features in JPsA– 7/10 (70%) which include: dactylitis 5/10 (50%), enthesitis – 1/10 (10%), small joints of thehand/DIP -4/10 (40%), minimal swelling/drier synovitis/subtle -3/10 (30%), more aggressive -1/10 (10%), systemic inflammation – 1/10(10%)Each subtype is a different disease – 1/10 (10%)In your experience do you feelthere are any particular jointpatterns in children withpsoriatic arthritis?Small joints of the hand/DIP(60%), large joints (50%), dactylitis (40%), oligoarthritis/asymmetric (40%), mid/hindfoot (30%), sacroilitis(20%), polyarticular (20%), minimal swelling (10%) and no clear pattern (10%).Does a diagnosis of juvenilepsoriatic arthritis instead ofjuvenile idiopathic arthritisinfluence what you explain tochildren and their parents?Example quotations provided.Yes – 7/10 (70%) No – 3/10 (30%)Helps diseaseexplanation (skin andjoints) – 2/10 (20%)Comorbidities – 2/10(20%)“need to monitor eyesCautious explanation ofgenetics - 2/10 (20%)“try to stay away from thePersistent disease andrisk of joint damage –6/10 (60%)Treatment strategy –4/10 (40%)“early interventionTable 1: Responses to questions about how paediatric rheumatologists assess children withinflammatory arthritis for psoriasis and the impact a diagnosis of juvenile psoriatic arthritishas on their management of arthritis. *Hidden psoriasis refers to psoriasis behind the ears,umbilicus, flexures, groin, genitals and natal cleft.“starting point forexplaining autoimmunedisease …helps explaintreatment as you canuse methotrexate forskin and joints”for uveitis” blame of genetics” “prolonged …. can bemore damaging”“less reassuringregarding spontaneousremission”can be very effective…slightly differentapproach”“intermittent lifelongimmunosuppression”Does a diagnosis of juvenilepsoriatic arthritis instead ofjuvenile idiopathic arthritisinfluence your treatment plan?Example quotations provided.Yes – 8/10 (80%) No – 2/10 (20%)Lowers the threshold for treatment escalation 5/10(50%)“lower threshold for starting a DMARD,methotrexate in patients with involvement of lessthan 5 joints”“inclined to start systemic earlier… lower threshold toescalate treatment”Choice of biologic therapy – 2/10 (20%)“more likes to choose Humira overEnbrel”Combined approach for skin/uveitisand joints – 2/10 (20%)“if uveitis and skin involvementmay alter treatment used”In your experience, are long-termoutcomes different in childrenwith psoriatic arthritis comparedto juvenile idiopathic arthritis?Example quotations provided.Yes – 7/10 (70%) No – 3/10 (30%)Persistent disease – 5/10 (50%)“can have ongoing disease into adulthood”“less likely to go into remission”Risk of long-term joint damage andcomorbidity – 4/10 (40%)“adults have been found to have damagefrom undertreated psoriatic JIA”“appears to be more aggressive anderosive but we don’t have thatinformation yet”Increased need for aggressivetreatment – 2/10 (20%)“tend to start methotrexate andbiologic earlier in these patients”

E. Burden-Teh

K.S. Thomas

S. Rangaraj

R. Murphy

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British Journal of Dermatology

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http://eprints.nottingham.ac.uk/37729/1/How%20can%20specialties%20learn%20from%20each%20other%20Revised%20Final.pdf

Interviews with paediatric rheumatologists about psoriasis and psoriatic arthritis in children: how can specialties learn from each other?

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