Meeting News

Rosacea, other ‘mimic’ skin conditions often misdiagnosed as rheumatic diseases

Anthony Fernandez

CLEVELAND — Patients with rosacea, livedoid vasculopathy and allergic contact dermatitis present with a multitude of dermatologic symptoms that rheumatologists can easily misdiagnose as rheumatic diseases, according to Anthony Fernandez, MD, PhD, of the Cleveland Clinic.

However, he noted that rheumatologists can distinguish these dermatological conditions from their common rheumatic lookalikes — acute lupus, vasculitis and dermatomyositis — by paying attention to onset timing, chronicity and their associated symptoms.

“As you know, it is very common for rheumatologic conditions to involve skin manifestations, and occasionally those skin manifestations will be the initial presentation of that rheumatologic condition,” Fernandez told attendees at the Biologic Therapies Summit. “On the other hand, there are a number of conditions, that are either primarily dermatologic or most commonly dermatologic, that can present with skin lesions that mimic rheumatic skin disease, and these patients can often be misdiagnosed as having a rheumatologic, systemic disease.”

“This is especially true if they also have other ancillary findings that may be indicative of a rheumatologic condition, like positive ANA or fatigue,” he added. “This, of course, could lead to exposure to immunosuppressant medications that have potential toxicities that the patient doesn’t even need.”

Rosacea can appear as four primary subtypes: Vascular, with flushing and persistent central facial erythema; inflammatory, which presents with persistent central facial erythema with transient papules or pustules; phymatous, with thickening skin as well as irregular surface nodularities that occur on the nose, chin, forehead cheeks or ears; and ocular, which can cause a foreign-body sensation in the eye, as well as burning or stinging, dryness, itching, sensitivity to light and other symptoms.

According to Fernandez, rheumatologists seeking to differentiate rosacea from lupus should consider that longer, chronic durations favor rosacea. In addition, if the condition is aggravated by alcohol, or by hot food and beverages, it is more likely to be rosacea. Meanwhile, sunlight as an aggravating factor most likely points to systemic lupus erythematosus. However, the presence of pustules is likely an indicator of rosacea, Fernandez added.

Livedoid vasculopathy commonly presents as painful ulcerations, reticulate dyspigmentation and atrophie blanche, with intermittent lesions found mostly on the lower legs, ankles and dorsal feet. It can be distinguished from vasculitis through skin biopsies for haematoxylin and eosin, as well as direct immunofluorescence, according to Fernandez. He added that the biopsy should include 2-3 mm of marginal skin and an eventual ulcer. In addition, livedoid vasculopathy can be evaluated and identified through hypercoagulation screening panel.

Contact dermatitis — both irritant and allergic types — are caused by the contact of various entities with the skin, and both types are morphologically indistinguishable from endogenous eczema, Fernandez noted. The allergic form of the condition classically presents as pruritic, erythematous, vesicular and/or eczematous patch or plaque with well-defined margins, which match the area of contact with offending entity, he added.

According to Fernandez, important factors to consider when distinguishing allergic contact dermatitis from dermatomyositis are that acute durations favor the dermatologic condition, while sunlight as an aggravating factor often, but not always, points to the rheumatic disease. In addition, well-demarcated plaques and vesicles are most likely to suggest allergic contact dermatitis. Biopsy and laboratory results can also help determine a diagnosis.

“Clinical history and examination, most of the time, can help you distinguish rheumatologic diseases from these mimickers,” Fernandez said. “However, if not, ancillary studies, like serologies and biopsies, can help give you a definitive answer. I am hoping you can take of these take-home messages you can bring back to your clinics and help you sort out with the patients you see.” – by Jason Laday

Reference:
Fernandez A. Must know dermatologic conditions for the rheumatologist. Presented at: Biologic Therapies Summit VIII; May 16-17, 2019; Cleveland, Ohio.

Disclosure: Fernandez reports speaking fees from AbbVie, consulting fees from AbbVie, Celgene and Novartis; contracted research for Mallinckrodt, Novartis and Pfizer; and being the principal investigator for a Phase 3 clinical trial supported by Roche.

Anthony Fernandez

CLEVELAND — Patients with rosacea, livedoid vasculopathy and allergic contact dermatitis present with a multitude of dermatologic symptoms that rheumatologists can easily misdiagnose as rheumatic diseases, according to Anthony Fernandez, MD, PhD, of the Cleveland Clinic.

However, he noted that rheumatologists can distinguish these dermatological conditions from their common rheumatic lookalikes — acute lupus, vasculitis and dermatomyositis — by paying attention to onset timing, chronicity and their associated symptoms.

“As you know, it is very common for rheumatologic conditions to involve skin manifestations, and occasionally those skin manifestations will be the initial presentation of that rheumatologic condition,” Fernandez told attendees at the Biologic Therapies Summit. “On the other hand, there are a number of conditions, that are either primarily dermatologic or most commonly dermatologic, that can present with skin lesions that mimic rheumatic skin disease, and these patients can often be misdiagnosed as having a rheumatologic, systemic disease.”

“This is especially true if they also have other ancillary findings that may be indicative of a rheumatologic condition, like positive ANA or fatigue,” he added. “This, of course, could lead to exposure to immunosuppressant medications that have potential toxicities that the patient doesn’t even need.”

Rosacea can appear as four primary subtypes: Vascular, with flushing and persistent central facial erythema; inflammatory, which presents with persistent central facial erythema with transient papules or pustules; phymatous, with thickening skin as well as irregular surface nodularities that occur on the nose, chin, forehead cheeks or ears; and ocular, which can cause a foreign-body sensation in the eye, as well as burning or stinging, dryness, itching, sensitivity to light and other symptoms.

According to Fernandez, rheumatologists seeking to differentiate rosacea from lupus should consider that longer, chronic durations favor rosacea. In addition, if the condition is aggravated by alcohol, or by hot food and beverages, it is more likely to be rosacea. Meanwhile, sunlight as an aggravating factor most likely points to systemic lupus erythematosus. However, the presence of pustules is likely an indicator of rosacea, Fernandez added.

Livedoid vasculopathy commonly presents as painful ulcerations, reticulate dyspigmentation and atrophie blanche, with intermittent lesions found mostly on the lower legs, ankles and dorsal feet. It can be distinguished from vasculitis through skin biopsies for haematoxylin and eosin, as well as direct immunofluorescence, according to Fernandez. He added that the biopsy should include 2-3 mm of marginal skin and an eventual ulcer. In addition, livedoid vasculopathy can be evaluated and identified through hypercoagulation screening panel.

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Contact dermatitis — both irritant and allergic types — are caused by the contact of various entities with the skin, and both types are morphologically indistinguishable from endogenous eczema, Fernandez noted. The allergic form of the condition classically presents as pruritic, erythematous, vesicular and/or eczematous patch or plaque with well-defined margins, which match the area of contact with offending entity, he added.

According to Fernandez, important factors to consider when distinguishing allergic contact dermatitis from dermatomyositis are that acute durations favor the dermatologic condition, while sunlight as an aggravating factor often, but not always, points to the rheumatic disease. In addition, well-demarcated plaques and vesicles are most likely to suggest allergic contact dermatitis. Biopsy and laboratory results can also help determine a diagnosis.

“Clinical history and examination, most of the time, can help you distinguish rheumatologic diseases from these mimickers,” Fernandez said. “However, if not, ancillary studies, like serologies and biopsies, can help give you a definitive answer. I am hoping you can take of these take-home messages you can bring back to your clinics and help you sort out with the patients you see.” – by Jason Laday

Reference:
Fernandez A. Must know dermatologic conditions for the rheumatologist. Presented at: Biologic Therapies Summit VIII; May 16-17, 2019; Cleveland, Ohio.

Disclosure: Fernandez reports speaking fees from AbbVie, consulting fees from AbbVie, Celgene and Novartis; contracted research for Mallinckrodt, Novartis and Pfizer; and being the principal investigator for a Phase 3 clinical trial supported by Roche.

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