Psoriatic Arthritis

1
Psoriatic Arthritis

• Emily Chang
• Morning Report
• August 14, 2009
• August

2
Definition

• Inflammatory arthritis associated with psoriasis
• Usually seronegative for Rheumatoid Factor
• Classified with HLA-B27-associated
  spondyloarthropathies

3
Epidemiology

• Likely in up to 25-34 of patients with presence
  of skin disease
• Overall prevalence 0.04-1.2
• MF although it differs in subsets
• Peak age of onset between 30-55 years

4
CASPAR criteria

• evidence of psoriasis
• current - 2
• history of - 1
• family 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

5
Subtypes

• DIP joint pattern
• oligoarticular (lt5 joints) pattern, usually
  assymetric
• polyarticular (gt5 joints), symmetric in half
• arthritis mutilans
• spondyloarthritis

6
Other Rheum Findings

• enthesitis (inflammation at site of tendon
  insertion)
• tenosynovitis (inflammation of tendon and its
  enveloping sheath)
• dactylitis or sausage digit

7
Extra-articular findings

• skin - psoriasis
• nails - pits and onycholysis
• pitting edema - often asymmetrical
• ocular inflammation - conjunctivitis, iritis

8
How to diagnose those without skin findings

• look for distal joint involvement in asymmetric
  distribution
• look at the nails
• look in ears
• ask about family history
• dactylitis

9
Images
10
Diagnostic Testing

• no diagnostic laboratory testing
• radiologically
• erosive changes and new bone formation in distal
  joints
• lysis of terminal phalanges
• fluffy periostitis and new bone formation at
  sites of enthesitis
• pencil in cup appearance

11
Differential

• Reactive (Reiters) Arthritis
• Rheumatoid Arthritis with concomitant psoriasis
• ankylosing spondylitis
• gouty arthritis

12
Treatment

• NSAIDs 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.

13
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

14
References

• Klippel, John. Primer on the Rheumatic Diseases.
  Edition 12. Atlanta, GA Arthritis Foundation
  2001 584-586.
• Gladman, Dafna. Psoriatic arthritis.
  Dermatologic Therapy. Vol 22. 2009, 40-55.
• www.utdol.com