Incorporating Joint Pain Screening Into the Pediatric Dermatologic Examination Pediatric Dermatology

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• The authors surveyed pediatric dermatologists (N=100) regarding their current practice and confidence in assessing joint disease in dermatologic patients. In all, 79% of respondents did not feel confident in their ability to perform a joint examination. Of the respondents, 62% perform a joint examination "sometimes" or less frequently; 92% of respondents "always" or "almost always" refer a patient to rheumatology when they present with joint symptoms. Most (72%) also believed that performing a joint examination would take extra time, but 96% would be willing to perform a joint examination if it took less than 1 minute to complete. In partnership with rheumatology colleagues, the authors created a short video teaching examination of the joints most relevant to dermatologists: hands, wrists, knees, feet, ankles, and spine. The video is available on the Society of Pediatric Dermatologists website (R-JET).

• Based on the findings of this survey, joint examination may be performed infrequently by pediatric dermatologists due to lack of confidence or training and concerns about the additional time required in a busy clinic. Using the R-JET evaluation tool, dermatologists may be able to help detect joint disease earlier in pediatric patients and improve patient outcomes.

– Margaret Hammond, MD

Written by

 

 

Lisa M. Arkin MD

Joint manifestations are a common feature of many pediatric skin disorders, including autoimmune and autoinflammatory disease. Catching joint problems early is important to prevent progressive joint damage, with earlier intervention of appropriate therapy. Pediatric rheumatology is an underserved specialty, and wait times can be long. The intention of this helpful paper is to aid pediatric dermatologists in differentiating joint manifestations requiring more urgent triage to pediatric rheumatology for inflammatory arthritis or synovitis. After review of the literature, and survey of 100 pediatric dermatologists, most of whom noted low confidence in performing a joint exam, the authors created the rapid joint examination technique (R-JET), a 1-minute joint exam that can be performed in a busy pediatric dermatology clinic. It is amazingly simple to administer and begins with clarifying questions asked to the patient/parent to determine whether the joint pain is more likely inflammatory or mechanical. These include timing of the pain (morning pain is more consistent with inflammatory arthritis), chronicity (>6 weeks typically suggests an inflammatory cause), and severity. These questions are directed to children aged ≥8 years with a visual diagram to help localize areas of pain. The examination itself is easy to implement and focuses on the joints most likely to have involvement in three particular disorders with skin manifestations: psoriatic arthritis, systemic lupus erythematosus, and Henoch-Schönlein purpura. I encourage you to watch the accompanying video. We should all be able to incorporate this into our clinical practice in order to expedite triage for patients most likely to need pediatric rheumatology subspecialty care.

Abstract

BACKGROUND/OBJECTIVES

Joint manifestations are a feature of many pediatric skin disorders, among them psoriasis, autoimmune and autoinflammatory diseases, hypermobility disorders, and as an adverse effect of certain medications. Identifying joint disease early is important for intervention and prevention of chronic damage. However, pediatric musculoskeletal complaints are common and determining whether symptoms warrant a rheumatology referral for arthritis can be challenging.

METHODS

Pediatric dermatologists were surveyed for their comfort in screening for joint disease. Through literature review and interviews with three pediatric rheumatologists, key joints involved in disorders with skin manifestations and arthritis were identified and the essential evaluations were determined.

RESULTS

Of 100 surveyed practicing board-certified pediatric dermatologists, 79% did not feel confident in their ability to perform a joint-focused physical examination, a key step in screening for joint disease. A rapid joint examination technique (R-JET) was developed, along with an accompanying three-question survey and body diagram for patient self-report of symptoms. A video demonstration of the R-JET was created as a teaching tool.

CONCLUSIONS

Teaching and incorporation of a rapid screening examination for arthritis by pediatric dermatologists has the potential to identify pediatric arthritis earlier, facilitate referral, and reduce the risk of progressive joint disease. These instruments can easily be incorporated into a pediatric dermatology office visit.

Pediatric Dermatology

Incorporating Joint Pain Screening Into the Pediatric Dermatologic Examination

Pediatr Dermatol 2020 Dec 04;[EPub Ahead of Print], AM Rustad, BE Nolan, A Ollech, MJ Boctor, AS Paller 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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