Abstract
Psoriatic arthritis is an inflammatory joint disease that is heterogeneous in presentation and clinical course. Evidence that this disease is distinct from rheumatoid arthritis and other spondyloarthropathies is based on data derived from characteristic clinical features, histopathologic analyses, immunogenetic associations and musculoskeletal imaging. Emphasis has centered previously on a dominant role for the T lymphocyte in the inflammatory process; however, studies provide support for a major contribution from monocyte–macrophages in the initiation and perpetuation of joint and skin inflammation. The occurrence of arthritis in the absence of psoriasis in a minority of patients with psoriatic arthritis, coupled with divergent genetic risk factors, indicates that psoriatic arthritis is distinct from psoriatic skin inflammation. A new terminology, psoriatic disease, has emerged that encompasses the various manifestations of tissue and organ involvement observed in many psoriasis patients, including inflammation in the joint, eye and gut. Moreover, adverse cardiovascular and metabolic outcomes in patients with psoriasis or psoriatic arthritis might be directly linked to the cutaneous and musculoskeletal manifestations of these diseases via subsets of circulating monocytes and tissue macrophages activated by inflammatory cytokine networks that arise in the skin and possibly the joint.
Key Points
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Psoriatic arthritis can be distinguished from rheumatoid arthritis and other forms of spondyloarthropathy on the basis of epidemiological data, clinical manifestations, histopathology, immunogenetic associations and imaging studies
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Psoriasis is a systemic disorder that can involve many tissues in the musculoskeletal system and extra-articular sites, including the gastrointestinal tract and the eye
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Monocyte effector cells (osteoclasts, dendritic cells and macrophages) have been implicated in inflammatory events that occur in psoriatic skin, joints, eye and intestinal tissues
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Adverse metabolic and cardiovascular outcomes in psoriasis patients highlight an important link between cutaneous inflammation, adipocytes and vascular remodeling that might be mediated by subsets of inflammatory monocytes
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Therapies directed at pivotal cytokines (tumor necrosis factor, interleukin-23) or specific subpopulations of monocytes or T lymphocytes might not only limit joint damage and skin inflammation but also lessen adverse metabolic outcomes and cardiovascular events
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References
Alibert J (1818) Precis theorique et pratique sur les maladies de la peau. Paris: Calle et Ravier
Bourdillon C (1888) Psoriasis et Arthropathies [MD thesis]. Paris: A Davy
Blumberg BS et al. (1964) ARA nomenclature and classification of arthritis and rheumatism (tentative). Arthritis Rheum 7: 93–97
Moll JM and Wright V (1973) Psoriatic arthritis. Semin Arthritis Rheum 3: 55–78
Moll JM (1974) Psoriatic spondylitis: clinical radiological and familial aspects. Proc R Soc Med 67: 46–50
O'Neill T and Silman AJ (1994) Psoriatic arthritis. Historical background and epidemiology. Baillieres Clin Rheumatol 8: 245–261
Taylor W et al. (2006) Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum 54: 2665–2673
Fitzgerald O and Dougados M (2006) Psoriatic arthritis: one or more diseases. Best Pract Res Clin Rheumatol 20: 435–450
Hellgren L (1969) Association between rheumatoid arthritis and psoriasis in total populations. Acta Rheumatol Scand 15: 316–326
Ho P et al. (2004) Genetic epidemiology of psoriatic arthritis. Mod Rheumatol 14: 91–100
Baker H (1966) Prevalence of psoriasis in polyarthritic patients and their relatives. Ann Rheum Dis 25: 229–234
Harrison BJ et al. (1997) Presence of psoriasis does not influence the presentation or short-term outcome of patients with early inflammatory polyarthritis. J Rheumatol 24: 1744–1749
Madland TM et al. (2005) Prevalence, disease manifestations, and treatment of psoriatic arthritis in Western Norway. J Rheumatol 32: 1918–1922
Jones SM et al. (1994) Psoriatic arthritis: outcome of disease subsets and relationship of joint disease to nail and skin disease. Br J Rheumatol 33: 834–839
Olivieri I et al. (2002) Fast spin echo-T2-weighted sequences with fat saturation in dactylitis of spondylarthritis. No evidence of entheseal involvement of the flexor digitorum tendons. Arthritis Rheum 46: 2964–2967
Brockbank JE et al. (2005) Dactylitis in psoriatic arthritis: a marker for disease severity. Ann Rheum Dis 64: 188–190
Salvarani C et al. (1997) Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis. J Rheumatol 24: 1106–1110
Tan A et al. (2007) The relationship between the extensor tendon enthesis and the nail in distal interphalangeal joint disease in psoriatic arthritis: a high-resolution MRI and histology study. Rheumatology (Oxford) 46: 253–256
Gladman DD et al. (1999) HLA-C locus alleles in patients with psoriatic arthritis (PsA). Hum Immunol 60: 259–261
Ho P et al. (2007) HLA-Cw6 and HLA-DRB1*07 together are associated with less severe joint disease in psoriatic arthritis. Ann Rheum Dis 66: 807–811
Gonzalez S et al. (1999) The MICA-A9 triplet repeat polymorphism in the transmembrane region confers additional susceptibility to the development of psoriatic arthritis and is independent of the association of Cw*0602 in psoriasis. Arthritis Rheum 42: 1010–1016
Kruithof E et al. (2005) Synovial histopathology of psoriatic arthritis, both oligo- and polyarticular, resembles spondyloarthropathy more than it does rheumatoid arthritis. Arthritis Res Ther 7: R569–R580
Salvador G et al. (2005) p53 expression in rheumatoid and psoriatic arthritis synovial tissue and association with joint damage. Ann Rheum Dis 64: 183–187
van Kuijk AW et al. (2006) Detailed analysis of the cell infiltrate and the expression of mediators of synovial inflammation and joint destruction in the synovium of patients with psoriatic arthritis: implications for treatment. Ann Rheum Dis 65: 1551–1557
Reece RJ et al. (1999) Distinct vascular patterns of early synovitis in psoriatic, reactive, and rheumatoid arthritis. Arthritis Rheum 42: 1481–1484
Veale D et al. (1993) Reduced synovial membrane macrophage numbers, ELAM-1 expression, and lining layer hyperplasia in psoriatic arthritis as compared with rheumatoid arthritis. Arthritis Rheum 36: 893–900
Canete J et al. (2007) Ectopic lymphoid neogenesis in psoriatic arthritis. Ann Rheum Dis 66: 720–726
McGonagle D et al. (1998) Characteristic magnetic resonance imaging entheseal changes of knee synovitis in spondylarthropathy. Arthritis Rheum 41: 694–700
Jevtic V et al. (1995) Distinctive radiological features of small hand joints in rheumatoid arthritis and seronegative spondyloarthritis demonstrated by contrast-enhanced (Gd-DTPA) magnetic resonance imaging. Skeletal Radiol 24: 351–355
McQueen FM et al. (2003) Bone edema scored on magnetic resonance imaging scans of the dominant carpus at presentation predicts radiographic joint damage of the hands and feet six years later in patients with rheumatoid arthritis. Arthritis Rheum 48: 1814–1827
Bollow M et al. (2000) Quantitative analyses of sacroiliac biopsies in spondyloarthropathies: T cells and macrophages predominate in early and active sacroiliitis—cellularity correlates with the degree of enhancement detected by magnetic resonance imaging. Ann Rheum Dis 59: 135–140
Lories RJ et al. (2004) Ankylosing enthesitis, dactylitis, and onychoperiostitis in male DBA/1 mice: a model of psoriatic arthritis. Ann Rheum Dis 63: 595–598
Diarra D et al. (2007) Dickkopf-1 is a master regulator of joint remodeling. Nat Med 13: 156–163
Lories RJ et al. (2007) Evidence for uncoupling of inflammation and joint remodeling in a mouse model of spondylarthritis. Arthritis Rheum 56: 489–497
Frediani B et al. (2002) Ultrasound and clinical evaluation of quadricipital tendon enthesitis in patients with psoriatic arthritis and rheumatoid arthritis. Clin Rheumatol 21: 203–206
McGonagle D et al. (2001) An enthesitis based model for the pathogenesis of spondyloarthropathy. Additive effects of microbial adjuvant and biomechanical factors at disease sites. J Rheumatol 28: 2155–2159
Mease PJ (2004) Recent advances in the management of psoriatic arthritis. Curr Opin Rheumatol 16: 366–370
Scarpa R et al. (2003) Clinical and genetic aspects of psoriatic arthritis “sine psoriasis”. J Rheumatol 30: 2638–2640
Ritchlin C (2006) Newer therapeutic approaches: spondyloarthritis and uveitis. Rheum Dis Clin North Am 32: 75–90
Lowes MA et al. (2007) Pathogenesis and therapy of psoriasis. Nature 445: 866–873
Segre JA (2006) Epidermal barrier formation and recovery in skin disorders. J Clin Invest 116: 1150–1158
Nestle FO et al. (2005) Plasmacytoid predendritic cells initiate psoriasis through interferon-alpha production. J Exp Med 202: 135–143
Boyman O et al. (2007) The pathogenic role of tissue-resident immune cells in psoriasis. Trends Immunol 28: 51–57
Scarpa R et al. (2006) Psoriasis, psoriatic arthritis, or psoriatic disease. J Rheumatol 33: 210–212
Schatteman L et al. (1995) Gut inflammation in psoriatic arthritis: a prospective ileocolonoscopic study. J Rheumatol 22: 680–683
Scarpa R et al. (2000) Microscopic inflammatory changes in colon of patients with both active psoriasis and psoriatic arthritis without bowel symptoms. J Rheumatol 27: 1241–1246
Mielants H et al. (2005) Gut inflammation in the spondyloarthropathies. Curr Rheumatol Rep 7: 188–194
Michaelsson G et al. (1997) Psoriasis patients have highly increased numbers of tryptase-positive mast cells in the duodenal stroma. Br J Dermatol 136: 866–870
Lindqvist U et al. (2006) Patients with psoriatic arthritis have an increased number of lymphocytes in the duodenal mucosa in comparison with patients with psoriasis vulgaris. J Rheumatol 33: 924–927
Queiro R et al. (2002) Clinical features and predictive factors in psoriatic arthritis-related uveitis. Semin Arthritis Rheum 31: 264–270
Paiva ES et al. (2000) Characterisation of uveitis in patients with psoriatic arthritis. Ann Rheum Dis 59: 67–70
Durrani K and Foster CS (2005) Psoriatic uveitis: a distinct clinical entity. Am J Ophthalmol 139: 106–111
Mallbris L et al. (2006) Metabolic disorders in patients with psoriasis and psoriatic arthritis. Curr Rheumatol Rep 8: 355–363
Neimann AL et al. (2006) Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol 55: 829–835
Mallbris L et al. (2006) Psoriasis is associated with lipid abnormalities at the onset of skin disease. J Am Acad Dermatol 54: 614–621
Henseler T and Christophers E (1995) Disease concomitance in psoriasis. J Am Acad Dermatol 32: 982–986
Gelfand JM et al. (2006) Risk of myocardial infarction in patients with psoriasis. JAMA 296: 1735–1741
Zenz R et al. (2005) Psoriasis-like skin disease and arthritis caused by inducible epidermal deletion of Jun proteins. Nature 437: 369–375
Wang H et al. (2006) Activated macrophages are essential in a murine model for T cell-mediated chronic psoriasiform skin inflammation. J Clin Invest 116: 2105–2114
Stratis A et al. (2006) Pathogenic role for skin macrophages in a mouse model of keratinocyte-induced psoriasis-like skin inflammation. J Clin Invest 116: 2094–2104
Massey HM and Flanagan AM (1999) Human osteoclasts derive from CD14-positive monocytes. Br J Haematol 106: 167–170
Zhou LJ and Tedder TF (1996) CD14+ blood monocytes can differentiate into functionally mature CD83+ dendritic cells. Proc Natl Acad Sci USA 93: 2588–2592
McGonagle D et al. (2002) Histological assessment of the early enthesitis lesion in spondyloarthropathy. Ann Rheum Dis 61: 534–537
Taccari E et al. (1987) Phenotypic profile of major synovial cell populations in longstanding psoriatic arthritis. J Rheumatol 14: 525–530
Ritchlin CT et al. (2003) Mechanisms of TNF-alpha- and RANKL-mediated osteoclastogenesis and bone resorption in psoriatic arthritis. J Clin Invest 111: 821–831
Boyle WJ et al. (2003) Osteoclast differentiation and activation. Nature 423: 337–342
Baeten D et al. (2002) Macrophages expressing the scavenger receptor CD163: a link between immune alterations of the gut and synovial inflammation in spondyloarthropathy. J Pathol 196: 343–350
Baeten D et al. (2004) Association of CD163+ macrophages and local production of soluble CD163 with decreased lymphocyte activation in spondylarthropathy synovitis. Arthritis Rheum 50: 1611–1623
Sonoda KH et al. (2003) Immunoregulatory role of ocular macrophages: the macrophages produce RANTES to suppress experimental autoimmune uveitis. J Immunol 171: 2652–2659
Rader DJ and Pure E (2005) Lipoproteins, macrophage function, and atherosclerosis: beyond the foam cell. Cell Metabol 1: 223–230
Gordon S (2007) Macrophage heterogeneity and tissue lipids. J Clin Invest 117: 89–93
Swirski FK et al. (2007) Ly-6Chi monocytes dominate hypercholesterolemia-associated monocytosis and give rise to macrophages in atheromata. J Clin Invest 117: 195–205
Lumeng CN et al. (2007) Obesity induces a phenotypic switch in adipose tissue macrophage polarization. J Clin Invest 117: 175–184
Kanda H et al. (2006) MCP-1 contributes to macrophage infiltration into adipose tissue, insulin resistance, and hepatic steatosis in obesity. J Clin Invest 116: 1494–1505
Fitch E et al.: Pathophysiology of psoriasis. Curr Rheumatol Rep, in press
Clark RA and Kupper TS (2006) Misbehaving macrophages in the pathogenesis of psoriasis. J Clin Invest 116: 2084–2087
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Christopher Ritchlin is a consultant for Abbott, Amgen, Bristol Myers-Squibb, Centocor, Roche and Wyeth, and has received grant/research support from Centocor.
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Ritchlin, C. Psoriatic disease—from skin to bone. Nat Rev Rheumatol 3, 698–706 (2007). https://doi.org/10.1038/ncprheum0670
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DOI: https://doi.org/10.1038/ncprheum0670
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