To the Editor:
I read with interest the editorial by Lubrano, et al1 recently published in The Journal, and I fully agree with the authors about the clinical complexity usually provided by the natural course of psoriatic arthritis. Lubrano, et al expressed the idea that, when compared with the term psoriatic disease, that of psoriatic syndrome should better explain this complexity.
This approach could seem a step back. Indeed, the real “syndromic phenotype” is enclosed in the spondyloarthritis (SpA) complex, in which articular involvement may exist with psoriasis, inflammatory bowel disease, uveitis, or alone. The SpA syndrome in the presence of familiarity and/or overt skin or nail psoriasis constitutes a disease usually named psoriatic arthritis, which is characterized by a distinct profile2. Consequently, in this condition we consider 3 clinical presentations: early onset arthritis, established arthritis, and sine psoriasis arthritis. This explains the different stages of the natural clinical expression of the disease.
I remember how the term psoriatic disease was born. Ignazio Olivieri and I were discussing the surprising effectiveness of tumor necrosis factor–α inhibitors on psoriasis and psoriatic arthritis. Olivieri outlined that the evidence of a common pathogenetic mechanism was well represented by the extreme sensibility of the different clinical manifestations to the same treatment, and we discussed the possible existence of a unique condition: psoriatic disease3. We shared these considerations with John Moll and 2 colleagues working in Naples: Fabio Ayala, Professor of Dermatology; and Nicola Caporaso, Professor of Gastroenterology. Moll, in the foreword of the Proceedings of the First Update on Psoriatic Disease, held in Procida in 2008, wrote: “… the term psoriatic disease has served to delineate a new approach to understanding the etiology, manifestations and therapeutic implications of the skin and joint manifestations of psoriasis. This approach has also provided a much needed additional collaboration between rheumatologists and dermatologists. Further valuable liaisons have been generated between these specialists and workers in related disciplines of imaging, molecular biology, and therapeutics, among others, to throw further light on this fascinating and ever challenging disease complex.”4
As president of the Italian Society of Rheumatology, Olivieri organized a series of scientific meetings with dermatologists, gastroenterologists, and ophthalmologists with the aim of developing recommendations for a shared clinical approach to spondyloarthritic patients with psoriasis5, inflammatory bowel diseases6, and uveitis7.
As the authors of the editorial state1, I understand that at present the management of these patients could be delegated only to 2 specialists, but this is only due to a lack of a clinical network rather than to an intrinsic clinical inappropriateness.
As an example, today at the University Hospital Federico II in Naples, an outpatient clinic has been created where dermatologists, rheumatologists, and gastroenterologists (ophthalmologists on demand) work together, considering all clinical aspects of these patients, including also possible comorbidities. This organization permits a complete clinical approach with accurate staging and an appropriate therapeutic choice, with an optimal retention rate of drugs used. Sometimes, patients with uncontrolled arthritis may also show a recalcitrant psoriasis and/or colitic symptoms or uveitis. Treated with a shared therapy, they report a valuable control of their symptoms. This is the better operative approach to patients who have a condition that may still be defined as psoriatic disease.
To reduce this perspective, or to divide this comprehensive horizon, means to substantially impair the attempt of a unitary approach to pathogenesis and to therapy. Actually, regarding therapy, the new perspectives in precision medicine consider this disease as a unitary condition. The target to define treatment is becoming not a clinical manifestation, but a phenotypic differentiation in T helper cells, confirming the appropriateness of defining it as a disease, to focus the efforts of research and assistance8.