PSORIATIC ARTHRITIS
Section snippets
CLINICAL FEATURES OF PSORIATIC ARTHRITIS
With the recognition of PsA as an entity separate from RA, it was noted that there were several features which distinguished this form of arthritis associated with psoriasis. Whereas rheumatoid arthritis tends to affect women more often than men, with a 3:1 ratio, PsA has no gender preference and most studies demonstrate a ratio closer to one (Table 1). PsA also tends to be less symmetric in its distribution than RA. Several patterns of PsA were recognized by Wright and Moll.81 These include:
PSORIATIC SPONDYLOARTHROPATHY
In their initial studies Wright and Moll81 identified spondyloarthropathy as a specific pattern of PsA. They defined that group as predominantly spondyloarthropathy. However, it has become clear that the presence of isolated spondyloarthropathy in PsA is unusual and, in most cases, it occurs with peripheral arthritis. Once peripheral arthritis is noted, it is difficult to consider the arthritis as predominantly spondyloarthritis, since the patient would tend to complain more about what is
EXTRA-ARTICULAR FEATURES OF PSORIATIC ARTHRITIS
The most common extra-articular feature in patients with PsA is, by definition, the psoriatic skin lesions. The skin lesions, however, do help make the correct articular diagnosis. The majority of patients with PsA have psoriasis vulgaris, with much lower frequency of guttate psoriasis, pustular psoriasis, or flexural psoriasis. About 80% of the patients with PsA will have nail lesions, including nail pits and onycholysis. In a study comparing patients with PsA to patients with uncomplicated
RADIOLOGICAL FEATURES OF PSORIATIC ARTHRITIS
The peripheral arthritis of PsA has several unique radiologic features. In addition to the distribution noted clinically, including the presence of distal interphalangeal (DIP) joint disease and the tendency to asymmetry, the specific radiologic features of PsA include: lack of juxta-articular osteopenia; the presence of pencil-in-cup change; ankylosis; periosteal reaction; and spur formation. The erosions noted in PsA are often not marginal, as they are in RA, but are paramarginal.
PSORIATIC SPONDYLOARTHROPATHY COMPARED TO
OTHER SERONEGATIVE SPONDYLOARTHROPATHIES
Since spondyloarthropathy occurs frequently in patients with PsA, and the disease shares many of the extra-articular features common to the seronegative spondyloarthropathies, PsA is classified among this group of conditions.50, 81 The spondyloarthropathy of PsA can be distinguished clinically from that of classic ankylosing spondylitis by the lower level of pain and less restriction of spinal movement.29 Both Reiter's disease and idiopathic ankylosing
CLASSIFICATION OF PSORIATIC ARTHRITIS
There are no valid classification criteria for PsA.21 Most investigators have used the definition of an inflammatory arthritis associated with psoriasis, usually seronegative for rheumatoid factor, to include patients in their studies. Once included, patients were classified according to the clinical patterns described above. The European Spondyloarthropathy Study Group (ESSG) proposed preliminary criteria for the classification of spondyloarthropathy which are not particularly helpful for PsA,
COURSE OF PSORIATIC ARTHRITIS
Despite the fact that arthritis mutilans was recognized as a distinct pattern of PsA, the disease was initially thought to be a benign form of arthritis, as the presence of arthritis mutilans was described in only 5% of the patients.44, 62, 80 However, more recent studies demonstrated that the disease may be as severe as RA.20, 24, 41, 71 Patients with PsA are less tender than patients with RA, a fact that may explain the misconception that it was a mild disease.4 In addition, the effusions
PROGNOSIS OF PSORIATIC ARTHRITIS
The development of deformities among patients with PsA may be related to the degree of inflammatory activity at presentation. Gladman et al30 demonstrated that patients who presented with five or more swollen joints were at an increased risk for progression of joint deformities compared to patients who did not have such active inflammation. Patients who had been given high levels of medications were also at greater risk for disease progression. While inflammatory activity did not remain in a
ETIOPATHOGENESIS OF PSORIATIC ARTHRITIS
The exact cause or pathogenesis of PsA is unknown. Several factors have been considered to be important. These include genetic, immunologic, and environmental factors.1
GENETIC FACTORS
Most studies document a familial predisposition to both psoriasis and PsA. With the discovery of the HLA system in humans it has become clear that there are genes on the short arm of chromosome 6 which confer susceptibility to PsA. The HLA antigens B13, B17, B38, B39, B27, Cw6, DR4, and DR7 have been implicated.1, 12, 22 Recently, molecular DNA techniques were applied to identify alleles of the HLA-C locus previously poorly detected using serologic techniques.14, 33 The HLA-Cw*0602 allele was
IMMUNOLOGIC FACTORS
The clinical and pathologic features of both psoriasis and PsA support the role of immunologic factors in the pathogenesis of these conditions. The inflammatory nature of the disease, the cellular infiltrates seen both in skin and joint lesions, and the deposition of immunoglobulins in the epidermis as well as the synovial membrane, all support an immune mechanism.18, 57 Autoantibodies (such as antinuclear antibodies), rheumatoid factor, and antibodies against skin antigens, as well as immune
ENVIRONMENTAL FACTORS INFECTION
Both viral and bacterial infections have been proposed as causative agents in PsA.1 Unlike Reiter's disease and ankylosing spondylitis where it has been suggested that gut bacteria may operate through the HLA-B27 molecule, in PsA it has been the streptococcus which has been incriminated and the relation to HLA-B27 is not as clear, since no more than 50% of the patients with PsA carry this antigen. Some investigators believe that guttate psoriasis is initiated by an infectious agent.73 Support
TRAUMA
The role of trauma has been questioned, particularly because of the well-described Koebner's phenomenon among patients with psoriasis. Although there are case reports suggesting a possible role for trauma in the development of PsA in some patients, 1, 66 and there is a retrospective study supporting the role of trauma, 68 there are no prospective studies which can be relied upon to explore the role of trauma in the development of PsA.
MANAGEMENT OF PSORIATIC ARTHRITIS
The management of patients with PsA requires attention to both skin and joint manifestations. It begins with patient education regarding the inflammatory and chronic nature of his or her disease, and the patient's understanding of the risk of progression of joint deformity and damage. Drug therapy will depend on the extent of the skin and joint manifestations.3, 22 In patients whose skin disease is severe, but the joint manifestations are mild, the latter may require only intermittent use of
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Cited by (124)
Incidence and prevalence of psoriatic arthritis in patients with psoriasis stratified by psoriasis disease severity: Retrospective analysis of an electronic health records database in the United States
2022, Journal of the American Academy of DermatologyUS National Health and Nutrition Examination Survey Arthritis Initiatives, Methodologies and Data
2018, Rheumatic Disease Clinics of North AmericaCitation Excerpt :Many people may well ignore back pain or stiffness, which is considered to be a commonly occurring problem, but it is very hard to ignore knee pain or hand swelling because of the functional limitations imposed. Classical RA is usually thought to always be accompanied by significant joint pain; however, for ankylosing spondylitis, psoriasis-related axial arthritis, and SpA in inflammatory bowel disease, it is evident that a percentage of cases with definite and even advanced radiologic disease presents without a significant pain history, and these patients may have substantial functional impairments.244–247 Reanalysis of the relevant NHANES data here could further research in this area, in this instance potentially giving more diagnostic weight to a combination of radiologic findings, target organ impairment, and functional status measures.
308G/A and 238G/A polymorphisms in the TNF-α gene may not contribute to the risk of arthritis among Turkish psoriatic patients
2016, Egyptian RheumatologistCitation Excerpt :The pathogenesis, clinical manifestations and treatments differ from those of rheumatoid arthritis (RA). The risk of developing PsA is 7–42% among psoriatic patients [1]. The disease affect the synovium and enthesis of peripheral and axial joints [2,3].
Golimumab in refractory uveitis related to spondyloarthritis. Multicenter study of 15 patients
2016, Seminars in Arthritis and RheumatismInfection and Spondyloarthropathies
2015, Infection and Autoimmunity
Address reprint requests to: Dr. Dafna Gladman, Centre for Prognosis Studies in the Rheumatic Diseases, The Toronto Hospital, Western Division, 399 Bathurst Street, Suite 1-318, Toronto, Ontario, M5T 2S8, Canada
This work is supported by The Medical Research Council of Canada and The Canadian Arthritis Society.
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From the University of Toronto, Division of Rheumatology; Centre for Prognosis Studies in the Rheumatic Diseases; and the Psoriatic Arthritis Program, the Toronto Hospital, Toronto, Ontario, Canada