A 65-year-old female rancher presents to the emergency department with fever, swollen digits, rapid heart rate, and elevated blood pressure. She also has a bright red, pruritic rash all over her body. She has been scratching so much that she’s bleeding through her shirt. What’s going on?
Kara Addison, DNP, DCNP, FNP-C, MSN, APRN
Dr. Kara Addison, a Montana native, is a Dermatology Certified Doctor of Nursing Practice who joined Associated Dermatology in 2012. She received both her Doctor of Nursing Practice (2016) and Masters of Nursing Practice (2012) from Montana State University and obtained her Bachelors of Science in Nursing from Carroll College. She practiced Internal Medicine and Intensive Care before finding her passion and love for dermatology.
Kara specializes in all skin care needs with a specific focus on psoriasis and autoimmune disorders of the skin. Her doctoral research explored safety and monitoring of individuals with psoriasis on biologic medications. Kara’s passion for individualized patient care, patient education, and her depth of knowledge and management of psoriasis make her critical to the dermatology practice and her community.
In Kara’s spare time she speaks around the United States educating providers on psoriasis management and biologic prescribing. She is also an avid mountain biker, skier, yogi, and dog lover.
DDx SEASON 2, EPISODE 1 TRANSCRIPT
The Source of the Bleed
Raj: This episode is brought to you by Novartis Pharmaceuticals Corporation.
Raj: A 65-year-old female rancher presents to the emergency department with fever, swollen digits, rapid heart rate, and elevated blood pressure. She also has a bright red, itchy rash all over her body. She has been scratching so much that she’s bleeding through her shirt.
Raj: This is DDx, a podcast from Figure 1 about how doctors think. This season is all about dermatology. I’m Dr. Raj Bhardwaj. Today’s case comes from Dr. Kara Addison. Dr. Addison is a paid presenter for Novartis.
Kara Addison: I work in a medium-sized clinic. And I do mostly all medical dermatology with about half my practice being autoimmune or psoriasis patients each day.
Raj: Sometimes skin rashes are subtle and hard to describe. Sometimes, they’re isolated, or limited to certain areas of the body, sparing others… But other times….
Kara Addison: So when the patient came in, you can imagine the color of a red, a red delicious apple and the color of her skin was about exactly that. If you can think about when people just have a little bit of dry skin and multiply that by 10, literally, maybe after a bad sunburn, that’s what her skin was doing, just peeling off in these sheets. So when looking specifically at her fingers, they were so swollen, they were leaking fluid. So if you can imagine a very large swollen finger, for example, if you broke it, what it would look like — or if you sprained your finger or sprained your ankle — and then take the skin and stretch it and it starts to leak fluid because of that swelling when you would even touch her joints. They were hot and red and her skin felt like she was on fire.
Raj: The patient had been getting persistent rashes since adolescence. But they usually cleared up in the summer, so she never bothered to get them checked out.
Kara Addison: She did admit to a recent illness where she’d had a cold that had lasted for about two weeks. And she also had a close friend who passed away. So she felt that her stress levels were fairly high and was feeling a little bit depressed.
Raj: Stress can be a significant trigger for dermatologic conditions. With her immune system compromised by her recent viral illness, it was more vulnerable to a flare-up.
Kara Addison: I also think lifestyle. I think there’s probably a lot more; alcohol use, smoking. In addition to just, you know, when you do want to look at the ranch life, more exposure to different chemicals, higher stress rates when they’re been dependent on ranching. And that’s their whole life.
Raj: Ranching is an extremely time-consuming vocation. Tending to something like a rash might seem comparatively unimportant. But untreated skin conditions can progress. Dr Addison suspected erythrodermic psoriasis. Overactive T-cells attack a person’s healthy skin, creating the typical rash: widespread, confluent, erythema, like a bad sunburn, covering over 75% of their body. And if left untreated, the consequences can be very serious.
Kara Addison: We talked to her about her diagnosis of erythrodermic psoriasis with an extensive flare of what we call psoriatic arthritis. She had no idea what any of this was. So we took quite a bit of time to discuss that this literally could be life-threatening. When we think about psoriasis in the clinic setting, we think of plaque psoriasis. This is something that we can usually manage with topical steroids, oral medications or even injectables. But when you have erythrodermic psoriasis, that’s affecting your systemic system.
Raj: This is a patient who had lived most of her life with a relatively benign condition, which suddenly and dramatically worsened. In delivering a diagnosis, it’s important to frame it in a way that helps the patient understand what they’re dealing with.
Kara Addison: One thing to understand with psoriasis is that this is a genetic disease. So once it’s been triggered, there’s not a cure for it, but there’s different tools we can use to manage it.
Kara Addison: So that day we started her on prednisone and an oral systemic medication called cyclosporine to help decrease the overall inflammation of the psoriasis. And she followed up every week for the last three weeks. So when she came in each time, she was about 20 percent improved. She was not having significant sloughing of the skin. Her pain in her joints had significantly resolved. They were no longer a large swollen, what we call sausage digits. So with her, not only did we need to initially stop the progress of the erythrodermic psoriasis, but we also had to create a management plan.
Raj: The patient was reluctant to take a prolonged course of treatment. Her symptoms had cleared — so why continue medication?
Kara Addison: Her first response was, I have never been on medicines in my life and this is not something I want to do long term. She said, you know, I’m already clear. Can I just stop this medicine and be done?
Raj: But with psoriasis, the problem runs deeper.
Kara Addison: And so that’s whereas providers in dermatology, patients come in and think only their skin is being looked at. But this type of disease is so much more than that. That’s something that we’re looking at their joints and their skin and talking about why we need to treat them long term. So that’s where I had the opportunity to really educate that psoriasis is literally an autoimmune disorder that affects individuals systemically. And if we don’t treat them, it will continue to come back.
Raj: Dr. Addison finds it helpful to reference a more common medical condition when explaining to patients how to manage their psoriasis.
Kara Addison: So I always equate it to high blood pressure. If someone has high blood pressure, they start a medicine. Their blood pressure resolves. If they stop the medicine, their blood pressure is going to go back up. And that’s the same thing with psoriasis, because once you have those genes turned on, they’re going to continue to produce that inflammation over time.
Raj: And just like with high blood pressure, erythrodermic psoriasis can be managed. A potentially serious condition can be controlled within a matter of months.
Kara Addison: So this is a lady that had come in, she had 98 percent of her body affected with this rashing, and now we’re down to 100 percent clearance in a matter of I mean, I saw her for two months and she was totally clear. So she was so grateful going through the pain and the journey that she had, not knowing, you know, what this diagnosis was, going to the E.R. a couple times, and just not getting the response she needed was a perfect time just to talk to her about, you know, the long term use of medications for psoriasis.
Raj: Dr. Addison also believes that patients need to be empowered with knowledge about how psoriasis can change their health in ways that are more than skin deep.
Kara Addison: A lot of times I’ll have patients go to primary care providers and they’ll say, yeah, well, I’ve got high blood pressure and that could be related to my psoriasis. And the primary care is like, what? Who’s your dermatologist? But that would be the opportunity I would like to say to providers, is the co-morbidities associated with psoriasis are severe. Again, not only having increased risk for diabetes, increased risk for heart attack, stroke, and then we’re also seen about 30 percent of patients with plaque psoriasis will develop psoriatic arthritis in their lifespan. Patients are like, wait, what? My skin can do this?
Thanks to Dr. Kara Addison for speaking with us.
This is DDx, a podcast by Figure 1.
Figure 1 is an app that lets doctors share clinical images and knowledge about difficult-to-diagnose cases.
I’m Doctor Raj Bhardwaj, host and story editor of DDx. You can follow me on Twitter at RajBhardwajMD
Ddx is produced by David Crosbie for Earshot Podcasts.
Sound design and mixing by Chandra Bulucon.
Our theme music is by Nathan Burley.
The executive producers of DDx are Jesse Brown and Kevin Sexton.
Head to Figure1.com/ddx, where you can find full show notes, photos, and speaker bios.
This episode was brought to you by Novartis Pharmaceuticals Corporation.
Thanks for listening.