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Dermatology-Rheumatology Center
aims to get a jump start on treating arthritis

To raise awareness about the importance of early diagnosis of arthritis and multidisciplinary care, Rheumatology fellow Mary Beth Son, MD, and colleagues Peter Lio, MD, Stephen Gellis, MD, and Marilyn Liang, MD, from Dermatology, have teamed up with Rheumatology Program Director Robert Sundel, MD, to form Children's Hospital Boston's new Dermatology-Rheumatology Center. Children's is home to one of the largest rheumatology programs in the United States, caring for 3,500 outpatients annually. The center, which opened last year, provides one-stop care for children who need consultations for both cutaneous and rheumatologic conditions.

According to Dr. Lio, several arthritis-related diseases require treatment from both dermatology and rheumatology, including psoriatic arthritis, morphea, scleroderma, vasculitis, lupus and dermatomyositis. Specialists at the center use treatments such as phototherapy to treat psoriasis and dermoscopy to evaluate nail capillaries, which can be a clue to disease activity in lupus and dermatomyositis. "Together, we can enhance communication between the subspecialty services of Rheumatology and Dermatology, allowing for more efficient and ultimately better care for our patients," he says. "At the same time, we learn from one another, allowing us to understand more about these diseases."

The Centers for Disease Control and Prevention estimates that approximately 300,000 children in the United States have some form of juvenile arthritis or rheumatic disease. According to Children's rheumatologist Peter Nigrovic, MD, diagnosing juvenile arthritis can be a challenge, since children often adjust to the pain it can cause, rather than complain about discomfort. Thus, treatment is often delayed until other symptoms, such as swelling or a limp, become visible. Also, pain in and of itself isn't indicative of arthritis. "If a child is having pain, the diagnosis is much less likely to be arthritis and much more likely to be musculoskeletal aches and pains," says Dr. Nigrovic. "But if a child has a limp, even if she doesn't have any pain, it's much more likely to be arthritis."

Early diagnosis is key in treating any form of juvenile arthritis because of the severity of long-term effects if untreated. "You're not only fighting for the health of the cartilage, which degrades progressively over time, you're also fighting for the normal growth of the joint and the individual bones," says Dr. Nigrovic. "A joint that's inflamed may overgrow or under-grow regionally or in an abnormal shape that may not correct later on."

One especially hard to diagnose (and debilitating) form of juvenile arthritis is psoriatic arthritis. "In most ways, juvenile psoriatic arthritis looks like regular juvenile rheumatoid arthritis but it involves a somewhat different distribution of joints," Dr. Nigrovic says. "These children experience morning stiffness and occasional joint aches, have difficulty grabbing things, turning door knobs or opening jars or bottles and can develop a limp." Another common symptom is psoriasis. Like most forms of juvenile arthritis, the cause is unknown. A recent study published by Dr. Nigrovic and Rheumatology fellow Matthew Stoll, MD, PhD, warns that these symptoms can develop later in the disease's progression or sometimes not at all, complicating diagnosis. If undiagnosed, patients may experience joint destruction, which can lead to deformity and difficultly performing daily activities.

Dr. Nigrovic also directs the Center for Adults with Pediatric Rheumatic Illness (CAPRI), which is a collaborative effort between Children's and Brigham and Women's Hospital. CAPRI is devoted to the multidisciplinary treatment of adults with childhood-onset arthritic and inflammatory disorders; specialists from both hospitals collaborate with physical therapists, occupational therapists and orthopedic surgeons. Children's new pediatric center will transition patients into CAPRI when they reach adulthood, which allows the same doctors to follow patients as they transition from pediatric arthritis care. But Dr. Nigrovic's goal is to keep patients from ever needing to move to CAPRI. "The role of a rheumatologist is to make sure the disease is extinct or to drive it to extinction," he says.

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