Psoriatic arthritis: Difference between revisions

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** Decreased [[quality of life]]
** Decreased [[quality of life]]
*[[Prognosis]] is generally good with early [[diagnosis]] and treatment with [[Disease-modifying antirheumatic drug|DMARDs]] and [[TNF inhibitor|TNF inhibitors]]. Overall survival rate also depends on management of [[Comorbidity|comorbid conditions]] along with [[arthritis]] treatment.<ref name="pmid25603589">{{cite journal |vauthors=McLaughlin M, Ostör A |title=Early treatment of psoriatic arthritis improves prognosis |journal=Practitioner |volume=258 |issue=1777 |pages=21–4, 3 |date=December 2014 |pmid=25603589 |doi= |url=}}</ref><ref name="pmid20682670">{{cite journal |vauthors=Buckley C, Cavill C, Taylor G, Kay H, Waldron N, Korendowych E, McHugh N |title=Mortality in psoriatic arthritis - a single-center study from the UK |journal=J. Rheumatol. |volume=37 |issue=10 |pages=2141–4 |date=October 2010 |pmid=20682670 |doi=10.3899/jrheum.100034 |url=}}</ref>
*[[Prognosis]] is generally good with early [[diagnosis]] and treatment with [[Disease-modifying antirheumatic drug|DMARDs]] and [[TNF inhibitor|TNF inhibitors]]. Overall survival rate also depends on management of [[Comorbidity|comorbid conditions]] along with [[arthritis]] treatment.<ref name="pmid25603589">{{cite journal |vauthors=McLaughlin M, Ostör A |title=Early treatment of psoriatic arthritis improves prognosis |journal=Practitioner |volume=258 |issue=1777 |pages=21–4, 3 |date=December 2014 |pmid=25603589 |doi= |url=}}</ref><ref name="pmid20682670">{{cite journal |vauthors=Buckley C, Cavill C, Taylor G, Kay H, Waldron N, Korendowych E, McHugh N |title=Mortality in psoriatic arthritis - a single-center study from the UK |journal=J. Rheumatol. |volume=37 |issue=10 |pages=2141–4 |date=October 2010 |pmid=20682670 |doi=10.3899/jrheum.100034 |url=}}</ref>
==Screening==
* Various screening tools have been proposed to screen psoriatic arthritis:<ref name="pmid20617467">{{cite journal |vauthors=Dominguez P, Gladman DD, Helliwell P, Mease PJ, Husni ME, Qureshi AA |title=Development of screening tools to identify psoriatic arthritis |journal=Curr Rheumatol Rep |volume=12 |issue=4 |pages=295–9 |date=August 2010 |pmid=20617467 |doi=10.1007/s11926-010-0113-2 |url=}}</ref>
** The Psoriatic Arthritis Screening and Evaluation tool (PASE)
** The Psoriasis Epidemiology Screening Tool (PES)
** Toronto Psoriatic Arthritis Screen (ToPAS)


== Diagnosis ==
== Diagnosis ==

Revision as of 20:23, 26 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Chandrakala Yannam, MD [2]

Overview

Psoriatic arthritis is a systemic, immune- mediated inflammatory arthritis, associated with psoriasis. The etiology is not clearly understood. It may be caused by complex interaction between genetic, immunologic and environmental mechanisms which act as triggers for the disease development. Both psoriatic arthritis and psoriasis have been shown to have strong familial predisposition. Psoriatic arthritis present with pain and stiffness in the affected joints. According to Moll and Wright criteria, joint involvement pattern in psoriatic arthritis include distal arthritis usually involving distal interphalangeal joints, asymmetric oligoarthritis, symmetric polyarthritis, arthritis mutilans, spondylitis, and sacroiliitis. Other symptoms include enthesitis (pain and tenderness at the insertion of tendons and ligaments to the bone), dactylitis ( sausage like finger or toe swelling), psoriatic skin plaques, nail changes (pitting, hyperkeratosis, and nail destruction). The pathophysiology of psoriatic arthritis consists of interactions between cytokinesdendritic cells, and T lymphocytes. Psoriatic arthritis must be differntiated from other inflammatory arthritides including rheumatoid arthritis, ankylosing spondylitis, reactive arthritis, gout, pseudogout, osteoarthritis, arthritis associated with inflammatory bowel disease. The prevalence of psoriatic arthritis in general population ranges from 60 - 250 cases per 100,000 individuals and the prevalence of psoriatic arthritis among psoriasis patients is 11,000 per 100,000 individuals. The mainstay of therapy for psoriatic arthritis NSAIDs, conventional DMARDs (eg, methotrexate, sulfasalazine, cyclosporine) and biologic DMARDs (eg, TNF inhibitors), anti IL therapy (eg, secukinumab, ustekinumab). Other treatment options include physiotherapy, patient education about disease and joint preservation and surgery. Psoriatic arthritis is associated with a number of comorbid conditions due to circulating immunoglobulins, antibodies including metabolic syndrome, increased insulin resistance, atherosclerosis, stroke, hypertension, uveitis, osteoporosis and depression. Patients are monitored regularly for disease activity, drug efficacy, adverse effects and associated comorbid conditions.

Historical Perspective

  • In 1822, the association between psoriasis and psoriatic arthritis was noticed by Dr. Alibert.
  • In 1948 after the discovery of rheumatoid factor, psoriatic arthritis was considered as a separate entity from rheumatoid arthritis by UK physician Wright.[1]

Classification

  • Based on the severity, psoriatic arthritis may be classified into following categories:[2]
    • Mild
    • Moderate
    • Severe
Organ system involvement Mild psoriatic arthritis Moderate psoriatic arthritis Severe psoriatic arthritis
Peripheral arthritis <5 joints involvement

No damage can be seen on x-ray

No loss of physical function

Minimal impact on patient's quality of life

⩾5 joints involvement

Damage can be visible on x-ray

Non-responsive to NSAIDs

Moderate impact on patient's quality of life

⩾5 joints involvement

Severe damage may be seen on x-ray Nonresponsive to NSAIDs, standard DMARDs

Severe impact on patient's quality of life

Axial joint involvement Mild pain present

No loss of physical function

Loss of physical function

Bath Ankylosing Spondylitis Disability Activity Index (BASDAI) >4

Failure of response
Skin Body Surface Area ( BSA) <5

Psoriasis area and severity index (PASI) <5

Resistant to topical therapy

Dermatology Life Quality Index (DLQI)<10

PASI<10

BSA>10, DLQI>10PASI>10
Dactylitis +/- Pain

Normal activity/ function

Presence of erosive disease or loss of physical function Failure of response to NSAIDs and conventional DMARDs
Enthesitis Number of sites involved:1–2

No loss of physical function

Number of sites involved >2

or

Loss of function

Loss of function

>2 sites involvement and failure of response

Causes

There are no established causes of psoriatic arthritis. The occurrence of psoriatic arthritis is secondary to a combination of genes, immune mechanisms and exposure to specific external factors or triggers, which increase an individual's risk of developing psoriatic arthritis. These risk factors lead to complex interactions between the geneticsimmune system, and the environment.[3]

Pathophysiology

The pathogenesis of psoriatic arthritis (PsA) involves the following events:[4]

Osteoclast mediated joint destruction

Differentiating psoriatic arthritis from other Diseases

Epidemiology and Demographics

  • The prevalence of psoriatic arthritis in general population ranges from 60 - 250 cases per 100,000 individuals in United states.[9]
  • The prevalence ranges in genreal population from 50 - 210 cases per 100,000 individuals in Europe.[10]
  • The prevalence among psoriasis patients is 11,000 per 100,000 individuals.
  • Incidence of psoriatic arthritis is approximately 6 per 100,000 individuals.[11]

Age

Gender

Race

Risk Factors

Natural History, Complications and Prognosis

Screening

  • Various screening tools have been proposed to screen psoriatic arthritis:[38]
    • The Psoriatic Arthritis Screening and Evaluation tool (PASE)
    • The Psoriasis Epidemiology Screening Tool (PES)
    • Toronto Psoriatic Arthritis Screen (ToPAS)

Diagnosis

Diagnostic Criteria

  • The diagnosis of psoriatic arthritis is easily confirmed when the cutaneous manifestations of psoriasis coexist with arthritis.[39][40][5][41]
  • It must be differentiated from other arthritides based on the joint involvement patterns, clinical features, imaging and laboratory studies.
  • The following manifestations may be helpful in diagnosing psoriatic arthritis in an individual in the absence of psoriatic skin lesions.[42]
  • The CASPAR criteria (ClASsification criteria for Psoriatic ARthritis):[43]
    • The CASPAR study stated that a patient present with inflammatory articular disease (inflammatory peripheral arthritis, enthesitis, spondylitis) can be diagnosed as having psoriatic arthritis if a total of at least three points are present from the presence of the following possibilities.
    • The specificity is approximately 98.7% and sensitivity is approximately 91.4%.

Symptoms

Physical Examination

Image by - By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9445021

Laboratory Findings

Imaging Findings

Psoriatic-arthritis of hands showing pencil-in-cup deformity - By Case courtesy of Dr Jeremy Jones, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/8798">rID: 8798</a>

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

References

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