Hans Herfarth, MD, PhD, on Dermatologic and Rheumatologic Manifestations in IBD

The several different manifestations of inflammatory bowel disease (IBD) vary in severity and may hinder an individual’s quality of life even more than the underlying IBD.

Gastroenterology Consultant caught up with Hans Herfarth, MD, PhD, a professor of medicine in the Division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill School of Medicine, and codirector of the UNC Multidisciplinary Center for IBD Research and Treatment, about what gastroenterologists should know about dermatologic and rheumatologic manifestations in the management of IBD.

Gastroenterology Consultant: Why are the musculoskeletal and dermatological systems the most commonly involved sites of manifestations among patients with IBD?

Hans Herfarth: This is a good question. However, we do not know why. The bottom line is that it is correct, the musculoskeletal and dermatological systems are the most often involved locations. Most of the time, it is due to arthralgia associated with active IBD, which could be attributed to a cross-reaction of microbial antigens with the immune defense of the body in the gut as well as the joint.

GASTRO CON: Are there any unique dermatologic and rheumatologic manifestations that a gastroenterologist may not be aware of?

HH: There are a number of unique manifestations that I think everybody should be aware of. For example, there is a unique manifestation in the dermatological realm, which is called hidradenitis suppurativa. Hidradenitis suppurativa is a chronic condition characterized by swollen, painful lesions found in the axillae, groin, anal, and breast regions. This only recently became known to be associated with IBD. Other unique manifestations include treatment-associated manifestations in the joint and skin, which can be found in a number of patients who receive treatment with biologics. Most of the treatment-associated manifestations are paradoxical inflammatory reactions, such as lupus-like reactions, paradoxical psoriasis, or paradoxical rashes, and are observed with anti-tumor necrosis factor (TNF) therapy. This often necessitates a switch to another therapeutic approach. Paradoxical skin reactions have also been reported with therapies such as vedolizumab or ustekinumab.

GASTRO CON: What do you think is the biggest challenge a gastroenterologist faces in managing extraintestinal manifestations of IBD?

HH: The main challenge is to correctly diagnose the symptoms and manifestations as an extraintestinal manifestation of IBD. It is also a challenge to distinguish manifestations from other complications unrelated to IBD, which may require a different therapeutic approach.

GASTRO CON: What is the role of the rheumatologist and dermatologist in the management of manifestations of IBD?

HH: The rheumatologist and dermatologist are very important for consultation. As gastroenterologists, we only partially understand the problems with the joints and the skin. We can recognize it but need help in managing these manifestations. A close collaboration of rheumatology and dermatology—preferably with colleagues who are somewhat knowledgeable in the IBD field, as well—is mandated for this patient group. 

GASTRO CON: What do you want the main takeaway of your session at the AIBD Regional in Baltimore to be?

HH: I want specialists to identify both common and rare complications of extraintestinal manifestations in the rheumatological and dermatological fields. This is crucial, because in my experience, oftentimes complications or symptoms described by patients are thought to be connected to IBD, when in fact they are not actually associated with IBD. These complications and symptoms need a separate treatment approach from the management approach for IBD. Additionally, it is important to be aware of specific therapeutic approaches such as the beneficial effects of ustekinumab for patients with paradoxical psoriasis caused by anti-TNF therapy or novel or established treatment modalities for pyoderma gangrenosum.

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