Clinical Features and Diagnostic Considerations in Psoriatic Arthritis
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Dactylitis
Inflammatory arthritis
Nail disease
Abstract: Psoriatic arthritis (PsA) is a heterogeneous chronic inflammatory arthritis associated with psoriasis, which may manifest with different domains such as dactylitis, enthesitis, synovitis and spondylitis. The estimated prevalence of PsA in patients with psoriasis ranges widely between 6% and 42%. In most cases, PsA is preceded by skin involvement by an average time of 7– 8 years. In the complex patho-mechanisms involved in the transition from psoriasis to PsA, the gut and skin have been proposed as the sites of immune activation triggering or contributing to the development of PsA. In such a transition, a subclinical phase has been identified, characterized by enthesopathy where soluble biomarkers and imaging findings but no clinical symptoms are detectable. Recent studies have provided some evidence that timely treated psoriasis may reduce the risk of developing PsA. Keywords: psoriatic arthritis, psoriasis, therapy, prevention, early intervention, disease modification
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Psoriatic arthritis (PsA) is an inflammatory disease that affects as many as 30% of patients with psoriasis, an immune-mediated inflammatory skin condition. Several domains are recognized in PsA, including peripheral arthritis, axial disease, enthesitis, dactylitis, and skin and nail manifestations.1 Although PsA affects men and women equally, there may be a sex influence on the development and expression of the disease.2 In the past few decades, there has been increasing interest in the effect of sex on the manifestations and impact of PsA as well as on the response to therapy. There may be some genetic reasons. For example, a paternal transmission was noted in PsA.3 The role of female hormones has not been confirmed because although some studies suggested that women with PsA had low pregnancy rates, this was not observed in a recent study.4,5 A difference in axial disease expression between men and women was noted in a 1992 study that compared 82 women with 112 men with axial disease and showed that there was more advanced disease in men.6 Similar observations were reported by Queiro et al, who found that axial disease together with HLA-B27 occurred more commonly among men, whereas women had more … Address correspondence to Dr. D.D. Gladman, Toronto Western Hospital, University Health Network, 399 Bathurst Street, 1E410B, Toronto, ON M5T 2S8, Canada. Email: dafna.gladman{at}utoronto.ca.
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Psoriatic arthritis has been defined as an chronic, inflammatory arthritis associated with psoriasis that belongs to a class of arthritis called seronegative spondyloarthritides. The exact cause of psoriatic arthritis is still unclear. However, it is believed that the disease develops due to a combination of genetic, immunologic, and environmental factors. The diagnosis can easily be missed or overlooked because of the diverse clinical manifestations of this condition. It is characterized by synovitis, enthesitis, tendonitis, dactylitis and spondylitis, usually manifesting in a person with skin and nail psoriasis. Physical examination, laboratory findings, x-rays, and, sometimes, magnetic resonance imaging are used to diagnose psoriatic arthritis. Psoriatic arthritis is commonly thought to be a relatively benign arthropathy, but recent findings show that a significant minority of patients develop joint damage and deformities that progress over time and contribute to functional limitations.
The skin disease and the joint disease often appear separately. Most people who develop psoriatic arthritis have skin symptoms of psoriasis first, followed by arthritis symptoms. Several studies have been published about characteristics of skin involvement in psoriastic arthritis, but comprehensive data about prevalence, severity of psoriasis and the development of arthritis are still lacking. These studies found that arthritis is more likely to occur in the more severe cases of psoriasis that affect certain body areas. Controversy regarding the exact nature of the relationship between the severity of the skin lesions and joint involvment still exists
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Psoriasis is a common, chronic inflammatory disease, predominantly affecting the skin and joints. Psoriatic arthritis (PsA), an arthropathy associated with psoriasis, is typically seen years after the onset of skin manifestations and presents as early morning stiffness, swelling, pain, tenderness of joints involved, dactylitis and enthesitis. Here, we report a case of psoriatic arthritis in a young male with plaque psoriasis, presenting as a suspected adverse drug reaction to 3% liquor picis carbonis (LPC), a topical coal tar preparation. Considering the complexity of treatment involved in treating psoriasis and the consequent adverse events, it is worth emphasizing the importance of causality assessment and attributing an adverse event to a particular drug. The dermatologist is often the first interface wherein the signs and symptoms of PsA can be detected, leading to initiation of early treatment and prevention of complications.
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Psoriatic arthritis is an inflammatory arthritis associated with psoriasis. Its prevalence in patients with psoriasis varies from 7 to 42% but its exact prevalence is unknown.Considering the lack of national data related to its diagnosis in patients with psoriasis, this study aims to describe the clinical, laboratorial and radiological manifestations of psoriatic arthritis in these patients.We evaluated 133 patients with psoriasis, treated as outpatients. These patients were asked to fill in the forms with data about the disease and were submitted to a clinical evaluation by a dermatologist and a rheumatologist. Suspected cases of arthritis were referred for further investigation and were classified according to presence or absence of psoriatic arthritis according to CASPAR criteria.The number of patients with psoriatic arthritis was 47 (35%), 17 of them were new cases. There was no difference between the groups regarding the type of psoriasis, nail involvement, presence of scalp lesions and psoriatic arthritis. Patients with psoriatic arthritis had more enthesitis and dactylitis (46.7%) than those without arthritis.Despite the high prevalence of arthritis found, we know that results from epidemiological studies are variable, which limits their use and interpretation. We conclude that more studies are needed to draw a profile of rheumatic manifestations in our population of psoriasis patients.
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Considering that most of the patients (>2/3) are diagnosed with psoriasis in the cutaneous form long before the joint damage occurs and, in these conditions, a significant proportion of them is found in the dermatologist's initial records, a question must be asked: when is it necessary to send these patients to a rheumatology consultation? The recognition of psoriatic arthritis in patients with vulgar psoriasis and the dermatologist's ability to differentiate it from other arthritis, offers the opportunity to improve patient prognosis by prompt intervention and close collaboration with the rheumatologist. Diagnosis of early psoriatic arthropathy should be considered when a patient with psoriasis or family history of psoriasis has peripheral inflammatory arthritis (oligoarthritis or distal interphalangeal joints damage), enthesitis, dactylitis, spinal pain of inflammatory type. Given that patients with psoriasis are included in the dermatologists' medical records, it is very important to recognize psoriatic arthritis in patients with cutaneous psoriasis, to differentiate it from other possible arthritis, thus having the possibility to improve patient prognosis by prompt intervention and through collaboration with the rheumatologist.
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Background Nail involvement in psoriasis is common and may be an indicator not only of disease severity, but also of the presence of psoriatic arthritis. However, the relationship of nail psoriasis with enthesitis remains under-explored. Aims This study was conducted to evaluate the clinical, onychoscopic (nail dermatoscopic) and ultrasonographic features in patients with nail psoriasis. Materials and Methods All nails of twenty adult patients with nail psoriasis were examined clinically and onychoscopically. Patients were evaluated for psoriatic arthritis (Classification Criteria for Psoriatic Arthritis), the severity of cutaneous disease (Psoriasis Area Severity Index) and nail disease (Nail Psoriasis Severity Index). Ultrasonography of the clinically involved digits was performed for evidence of distal interphalangeal joint enthesitis. Results Out of 20 patients, 18 patients had cutaneous psoriasis and 2 had isolated nail involvement. Among the 18 patients with skin psoriasis, 4 had associated psoriatic arthritis. The most commonly observed clinical and onychoscopic features were pitting (31.2% and 42.2%), onycholysis (36% and 36.5%) and subungual hyperkeratosis (30.2% and 30.5%), respectively. Ultrasonographic evidence of distal interphalangeal joint enthesitis was seen in 57% (175/307) of the digits with clinical nail involvement. Enthesitis was more common in patients with psoriatic arthritis (77% vs 50.6%). Nail thickening, crumbling and onychorrhexis (all features of nail matrix involvement) were significantly associated with enthesitis ( P < 0.005). Limitation The major limitation was the small sample size and lack of controls. Only the clinically involved digits were evaluated for enthesitis. Conclusion Enthesitis was frequently detected on ultrasonography in patients with nail psoriasis, even in clinically asymptomatic individuals. Nail features of thickening, crumbling and onychorrhexis may predict underlying enthesitis and the potential development of arthritis. A comprehensive evaluation could help identify patients with psoriasis at risk for arthritis, helping improve long-term outcomes.
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Psoriasis is a common immune-mediated inflammatory condition that primarily affects skin and nails. 6-41% of psoriasis patients develop psoriatic arthritis (PsA). The ways in which PsA can manifest itself include peripheral arthritis, axial spondyloarthritis, dactylitis and enthesitis. This heterogeneous clinical picture makes it sometimes difficult to recognise PsA,potentially resulting in permanent joint damage and functional impairments. Some people see psoriasis and PsA as 2 manifestations of a single disease because the multifactorial origins of psoriasis and PsA are largely overlapping. Psoriatic conditions are associated with a high burden of disease, reduced quality of life and comorbidities, including psychiatric and cardiovascular conditions. In recent years, several immunological pathways, immune cells and cytokines have been identified as important factors in pathophysiology and as new therapeutic targets. For many PsA patients treatment with disease modifying anti-rheumatic drugs leads to significant improvement of symptoms and quality of life.
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