Jean-Frederic Colombel, MD, on Dermatologic Manifestations of IBD

In this video, Dr. Colombel discusses the importance of working with a multidisciplinary team to properly diagnosis and treat patients with inflammatory bowel disease who present with skin disorders.

Jean-Frederic Colombel, MD, is a professor of medicine at the Icahn School of Medicine at Mt. Sinai in New York, New York.

TRANSCRIPT

Good morning. My name is Dr. Colombel. I'm doing the AIBD meeting. I will share a session, which is a clinical session entitled, "IBD is More Than Skin Deep."

During this session, I will cover some clinically-challenging cases regarding skin manifestations that may be observed in patients with inflammatory bowel disease. Namely, I will discuss a case of pyoderma, peristomal pyoderma gangrenosum.

Then we will deal with a very difficult case of all manifestations of Crohn's disease. There are so many that we don't really know about them. The third case will be about the association with a very specific condition, which is hidradenitis suppurativa in Crohn's disease.

Then, eventually, to the complexities of the relationship between IBD and the skin, we will present a case of skin manifestations induced by the treatment of IBD, so-called paradoxical manifestations.

What did we learn, and what will we learn from this session? I think there are very important messages. The first point, to me, is that, as a gastroenterologist, even though this is not our specialty, we need to be educated about the skin manifestations because they occur very often.

They are carrying a lot of burdens for the patients who suffer from them, especially young patients. There are some mistakes that need to be avoided. A very important point to me is that when you are treating those patients, very often, you will need to work with a dermatologist.

One important message as well is that for these extra-intestinal manifestations, generally speaking, you need to work as a team. This is what we are doing here at Sinai. We have even a specialized, combined clinic with rheumatologists and gastroenterologists and dermatologists because it's very complex.

The first case presented with peristomal pyoderma gangrenosum. This may occur very often. I will discuss, with analysis, particularly, what are the main features. I will show pictures because it always starts with pictures when you are talking about skin manifestations.

How do you recognize that this is a pyoderma? What are the risk factors for this condition? What do you need to do? What kind of workup do you need to assess the gut? What kind do you need to make biopsies of the skin? Very important questions. And of course, how to manage it?

In this case, it is clear that we need collaboration because there are not a lot of clinical trials on these skin manifestations. You can't rely upon strong evidence-based data.

The care relies upon a lot of recipes from dermatologists, especially in collaboration with gastroenterologists, regarding how to manage this care. This care, for instance, of pyoderma involves also lots of different health care providers, such as a stoma nurse, which is critical in this condition.

The second case that we discussed is case of oral manifestation. I've always been in difficulty when dealing with these manifestations in my own career because they are so diverse, you can't imagine.

We even published a review paper three years ago on oral manifestations of Crohn's disease, and there is a huge variety from fissures to cobblestone to pyostomatitis — there's a lot of different things.

I will start with very simple cases. There is a patient who has Crohn's disease, who well-controlled as far as his Crohn's disease, but complaining of manifestation on his tongue, on his lip, and inside the mouth. What should we do?

Again, we will see that there are a lot of things that you can discuss with your dermatologist about how you need to make the diagnosis, do you need to make biopsies, how you need to rule out, for instance, some nutritional deficiencies, and then how you can manage those cases.

As you will see, again, there is not a lot of evidence-based data because those manifestations are still rare, and the treatments mostly rely upon the experience of dermatologists.

The third case is of huge interest to me because this is something that we have specifically observed at Sinai and we have also published on, which is the association between hidradenitis suppurativa and Crohn's disease.

Hidradenitis suppurativa is a very common condition, but it's specifically associated with Crohn's disease and ulcerative colitis, but more Crohn's disease and its association more than expected by chance.

The case that I will present is one of the most challenging. It's a case of hidradenitis suppurativa in Crohn's disease, involving the perineal area. I've seen so many of those cases, and we have described this in a case that we published in the Clinical Gastroenterology Journal. We were trying to describe the clinical features and the management.

Again, there are no clinical trials. Very often, the management relies upon the biologics that we are already using in Crohn's disease, but there are some cases which are very refractory.

Sometimes, you need mitigating surgery, and this needs to be covered and dealt with by dermatologists because, again, no mistake is permitted.

The last case is fascinating, and I'm pretty sure, as a clinician, you have seen a lot of those cases, which are paradoxical manifestations, clean manifestations.

This is an eczema that induced by anti-TNF. There is a list of different manifestations, from eczema, psoriatic disease, dry skin, and so on, which are associated with anti-TNF treatment, which are challenging.

If a patient is doing well from a gut perspective, that is an embarrassing skin manifestation. What should you do? We'll discuss how to recognize those manifestation, how to make a diagnosis, how to treat, starting with a topical treatment, and need to switch.

This case is something which is fascinating to me, which is a connection between the skin and the gut. I could discuss as well the association between the joints and the gut.

There is still a lot of uncertainty about that. We don't really know what the mechanism of these skin manifestations are, and I think we can learn from our colleagues, dermatologists and rheumatologists.

I hope you will enjoy this session. I think it will be very lively because, again, it's based on case descriptions, and it will illustrate some very important clinical points.

But also, it will open a lot of discussion about research that we can do and we should do in collaboration with our colleagues, dermatologists and rheumatologists.

These results can lead to very important breakthroughs regarding the pathophysiology of extra-intestinal manifestations, but also, the pathophysiology of IBD itself. Thank you for your attention.