Psoriatic arthritis and the dermatologist: An approach to screening and clinical evaluation (2022)

Table of Contents
Clinics in Dermatology Abstract Introduction Section snippets Why should dermatologists screen for PsA? Overview of PsA Classification and identification of PsA Treatment Conclusions References (53) Semin Arthritis Rheum Arthritis Care Res J Am Acad Dermatol J Am Acad Dermatol Cytokine Lancet Rheum Dis Clin N Am J Am Acad Dermatol J Am Acad Dermatol Diagnosing and treating psoriatic arthritis: an update Br J Dermatol Systematic review of treatments for psoriatic arthritis: 2014 update for the GRAPPA J Rheumatol Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis Ann Rheum Dis A prospective, clinical and radiological study of early psoriatic arthritis: an early synovitis clinic experience Rheumatology Psoriatic arthritis (PSA)—an analysis of 220 patients Q J Med Epidemiology of psoriatic arthritis in the population of the United States J Am Acad Dermatol Diagnosis and management of psoriatic arthritis Drugs Use of etanercept for psoriatic arthritis in the dermatology clinic: the Experience Diagnosing, Understanding Care, and Treatment with Etanercept (EDUCATE) study J Dermatol Treat High prevalence of psoriatic arthritis in patients with severe psoriasis with suboptimal performance of screening questionnaires Ann Rheum Dis Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study) Br J Dermatol Interleukin-9 overexpression and Th9 polarization characterize the inflamed gut, the synovial tissue, and the peripheral blood of patients with psoriatic arthritis Arthritis Rheumatol Psoriatic arthritis and psoriasis: differential diagnosis Clin Rheumatol Familial aggregation of psoriatic arthritis Ann Rheum Dis A strong heritability of psoriatic arthritis over four generations—the Reykjavik Psoriatic Arthritis Study Rheumatology Psoriatic arthritis: epidemiology, diagnosis, and treatment World J Orthoped Is there a psoriasis skin phenotype associated with psoriatic arthritis? Systematic literature review JEADV Cited by (7) Psoriatic arthritis: the role of the nonphysician clinician in the diagnosis and treatment of patients with psoriasis Evaluating standards of care in psoriatic arthritis of the QUANTUM project (qualitative initiative to improve outcomes): results of an accreditation project in Spain Diagnosis and treatment of psoriasis arthropathica: an expert consensus statement in China (2020) Content validity of psoriatic arthritis screening questionnaires: systematic review Recommended articles (6) Videos
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Clinics in Dermatology

Volume 36, Issue 4,

July–August 2018

, Pages 551-560

Abstract

Psoriatic arthritis is a common form of inflammatory arthritis that frequently accompanies psoriasis of the skin—up to 30% of patients with psoriasis are affected. Recognition of the clinical features of psoriatic arthritis is critical, as delayed detection and untreated disease may result in irreparable joint injury, impaired physical function, and a significantly reduced quality of life. Recent epidemiologic studies have also supported that psoriatic arthritis is associated with cardiometabolic and cerebrovascular comorbidities, including coronary heart disease, diabetes mellitus, hypertension, dyslipidemia, and cerebrovascular accidents, further highlighting the importance of identifying affected patients. Dermatologists are poised for the early detection of psoriatic arthritis, as psoriasis predates its development in as many as 80% of patients. In an effort to further acquaint dermatologists and other clinicians with psoriatic arthritis, this review provides a detailed overview, emphasizing its salient clinical features, and discusses classification criteria, validated screening tools, and simple musculoskeletal examination maneuvers that may facilitate earlier detection and treatment of the disorder.

Introduction

Psoriatic arthritis (PsA) is an inflammatory arthritis that commonly accompanies plaque psoriasis of the skin with a prevalence as high as 30% among this patient group.1 The spectrum of psoriatic disease encompasses involvement of the skin, nails, peripheral and axial joints, points of enthesis (sites of tendon insertion into bone and/or ligaments), and dactylitis (“sausage digit”). PsA often leads to a marked reduction in patient quality of life due to physical disability from joint damage, fatigue, cardiovascular (and other) comorbidity, and psychologic stress, particularly when left untreated.[2], [3] In the majority of cases (84%), patients experience skin manifestations before clinical manifestations of arthritis develop. As a result, patients initially seek treatment from dermatologists.1 For this reason, dermatologists represent the first line of care in psoriatic disease diagnosis and intervention. Emerging evidence has shown that delays in PsA diagnosis are associated with worse functional and physical outcomes for patients.4

(Video) Clinical Assessment and Principles of Management of Psoriatic Arthritis

PsA is likely underdiagnosed—as many as 30% of patients with psoriasis have undiagnosed PsA.5 Greater vigilance in screening for PsA in psoriasis patients visiting the dermatology clinic could significantly reduce the rate of undiagnosed PsA and thus improve patient quality of life and outcomes. The focus of this review is to provide an overview of PsA for the dermatologist, and to promote PsA awareness and screening in dermatology clinics. To that end, we review the toolset that the dermatologist has at her or his disposal for PsA screening and diagnosis, including classification criteria, validated screening tools, and musculoskeletal examination maneuvers that may be used in clinic to facilitate earlier detection and treatment of PsA.

Section snippets

Why should dermatologists screen for PsA?

PsA is a systemic, potentially disabling, and destructive disease. Although at one point thought to be a relatively benign and nonprogressive condition compared with rheumatoid arthritis, PsA results in chronic systemic inflammation and has been shown to lead to erosive joint damage in 40% to 57% of patients and significantly affects quality of life.[2], [6]

In addition to the risk of joint damage leading to physical disability and psychological stress, PsA is coprevalent with cardiovascular and

Overview of PsA

PsA is a polygenic disorder that is influenced by genetic, immunologic, and environmental factors. Although the pathogenesis of PsA remains poorly understood, it has been proposed that the process driving PsA is similar to that of plaque psoriasis, in which environmental stressors, such as infection, drug use, or trauma, may trigger a systemic inflammatory reaction in susceptible hosts. The point of enthesis, in which T-cells, dendritic cells, mast cells, macrophages, and neutrophils infiltrate

Classification and identification of PsA

Because PsA is an inflammatory arthritis, it most commonly presents with redness, warmth, swelling, and pain of affected joints, along with stiffness after inactivity for longer than 30 to 60 minutes that improves with activity. By contrast, clinical manifestations of noninflammatory arthritis (eg, osteoarthritis) tend to worsen with activity, particularly toward the end of day (Table 1). Tracking the duration of morning stiffness experienced by a patient over time can be a useful measure of

Treatment

The presence of PsA affects therapeutic decisions in a patient with preexisting plaque psoriasis. Treatments should be tailored to achieve clinical remission, improving patients’ health and quality of life, and limiting the extent of erosive damage.52 Such choices for the psoriatic disease patient can be complex, because patients may present with comorbid and other coprevalent conditions. Potential drug interactions must also be considered. Importantly, some therapies that are effective for

Conclusions

PsA remains underdiagnosed among psoriasis patients. Left untreated, PsA can result in severe morbidity and irreversible physical limitations. Because PsA is often preceded by skin manifestations, dermatologists are well positioned to mitigate the impact of PsA by recognizing the early signs of PsA, monitoring for its development in patients with established plaque psoriasis, and ensuring that patients receive disease-modifying treatments soon after the onset of clinical manifestations. After

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  • Cited by (7)

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