Psoriatic ArthritisEmily Chang

Morning ReportAugust 14, 2009

August

Definition

Inflammatory arthritis associated with psoriasis

Usually seronegative for Rheumatoid Factor

Classified with HLA-B27-associated spondyloarthropathies

Epidemiology

Likely in up to 25-34% of patients with presence of skin disease

Overall prevalence 0.04-1.2%

M=F although it differs in subsets

Peak age of onset between 30-55 years

CASPAR criteriaevidence of psoriasis

current - 2history of - 1family history of - 1

psoriatic nail dystrophy (onycholysis, pitting, hyperkeratosis)

negative rheumatoid factor

dactylitis, either current or history of

radiological evidence of juxta-articular new bone formation

Subtypes

DIP joint pattern

oligoarticular (<5 joints) pattern, usually assymetric

polyarticular (>=5 joints), symmetric in half

arthritis mutilans

spondyloarthritis

Other Rheum Findings

enthesitis (inflammation at site of tendon insertion)

tenosynovitis (inflammation of tendon and its enveloping sheath)

dactylitis or “sausage digit”

Extra-articular findings

skin - psoriasis

nails - pits and onycholysis

pitting edema - often asymmetrical

ocular inflammation - conjunctivitis, iritis

look for distal joint involvement in asymmetric distribution

look at the nails

look in ears

ask about family history

dactylitis

How to diagnose those without skin

findings

Images

Diagnostic Testing

no diagnostic laboratory testing

radiologically:

erosive changes and new bone formation in distal joints

lysis of terminal phalangesfluffy periostitis and new bone formation at sites of enthesitis“pencil in cup” appearance

Differential

Reactive (Reiter’s) Arthritis

Rheumatoid Arthritis with concomitant psoriasis

ankylosing spondylitis

gouty arthritis

TreatmentNSAIDs if disease is mild.

PT, OT, splinting devices

If erosive disease, treat aggressively with DMARDs (MTX, Sulfasalazine, CsA).

If skin disease is the major issue, should be managed by a dermatologist.

Early referral to rheumatology for initiation of DMARDs to prevent progression.

Course and Prognosis

20% of patients have a severe an debilitating form of arthritis

originally thought to be more benign course than RhA

progression of clinical damage occurs in a majority of patients

radiologic changes occur over time despite treatment

References

Klippel, John. Klippel, John. Primer on the Rheumatic Primer on the Rheumatic

Diseases.Diseases. Edition 12. Atlanta, GA: Arthritis Edition 12. Atlanta, GA: Arthritis

Foundation; 2001: 584-586.Foundation; 2001: 584-586.

Gladman, Dafna. Gladman, Dafna. Psoriatic arthritisPsoriatic arthritis. .

Dermatologic Therapy. Vol 22. 2009, 40-55.Dermatologic Therapy. Vol 22. 2009, 40-55.

www.utdol.com