Psoriatic arthritis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2]
Overview
Psoriatic arthritis is a systemic, immune- mediated inflammatory arthritis, associated with psoriasis. The etiology is not clearly understood. It may be caused by complex interaction between genetic, immunologic and environmental mechanisms which act as triggers for the disease development. Both psoriatic arthritis and psoriasis have been shown to have strong familial predisposition. Psoriatic arthritis present with pain and stiffness in the affected joints. According to Moll and Wright criteria, joint involvement pattern in psoriatic arthritis include distal arthritis usually involving distal interphalangeal joints, asymmetric oligoarthritis, symmetric polyarthritis, arthritis mutilans, spondylitis, and sacroiliitis. Other symptoms include enthesitis (pain and tenderness at the insertion of tendons and ligaments to the bone), dactylitis ( sausage like finger or toe swelling), psoriatic skin plaques, nail changes (pitting, hyperkeratosis, and nail destruction). The pathophysiology of psoriatic arthritis consists of interactions between cytokines, dendritic cells, and T lymphocytes. Psoriatic arthritis must be differntiated from other inflammatory arthritides including rheumatoid arthritis, ankylosing spondylitis, reactive arthritis, gout, pseudogout, osteoarthritis, arthritis associated with inflammatory bowel disease. The prevalence of psoriatic arthritis in general population ranges from 60 - 250 cases per 100,000 individuals and the prevalence of psoriatic arthritis among psoriasis patients is 11,000 per 100,000 individuals. The mainstay of therapy for psoriatic arthritis NSAIDs, conventional DMARDs (eg, methotrexate, sulfasalazine, cyclosporine) and biologic DMARDs (eg, TNF inhibitors), anti IL therapy (eg, secukinumab, ustekinumab). Other treatment options include physiotherapy, patient education about disease and joint preservation and surgery. Psoriatic arthritis is associated with a number of comorbid conditions due to circulating immunoglobulins, antibodies including metabolic syndrome, increased insulin resistance, atherosclerosis, stroke, hypertension, uveitis, osteoporosis and depression. Patients are monitored regularly for disease activity, drug efficacy, adverse effects and associated comorbid conditions.
Historical Perspective
In 1822, the association between psoriasis and psoriatic arthritis was noticed by Dr. Alibert. In 1948 after the discovery of rheumatoid factor, psoriatic arthritis was considered as a separate entity from rheumatoid arthritis by UK physician Wright.
Classification
According to the severity of the disease, psoriatic arthritis may be classified into mild, moderate, and severe arthritis.
Pathophysiology
The pathogenesis of psoriatic arthritis (PsA) involves prominent T-lymphocytic infiltrate, particularly CD4 cells, are the most common cells.The elevated levels of TNF leads to a high number of osteoclast precursor cells circulating in the blood.
Causes
There are no established causes of psoriatic arthritis. The occurrence of psoriatic arthritis is secondary to a combination of genes, immune mechanisms and exposure to specific external factors or triggers, which increase an individual's risk of developing psoriatic arthritis. These risk factors lead to complex interactions between the genetics, immune system, and the environment.
Differentiating Rheumatoid Arthritis from other Diseases
Psoriatic arthritis must be differentiated from other arthritides including rheumatoid arthritis, reactive arthritis, ankylosing spondylitis, arthritis associated with inflammatory bowel disease, osteoarthritis, gout, and Pseudogout.
Epidemiology and Demographics
The prevalence of psoriatic arthritis in general population ranges from 60 - 250 cases per 100,000 individuals in United states. Incidence of psoriatic arthritis is approximately 6 per 100,000 individuals.
Risk Factors
Multiple risk factors are involved in the Psoriatic arthritis such as genetic factors, immune mechanisms, and environmental factors.
Screening
Various screening tools have been proposed to screen psoriatic arthritis such as The Psoriatic Arthritis Screening and Evaluation tool (PASE), The Psoriasis Epidemiology Screening Tool (PES), and Toronto Psoriatic Arthritis Screen (ToPAS).
Natural History, Complications and Prognosis
Diagnostic study of choice
History and Symptoms
Psoriatic arthritis is a chronic inflammatory arthritis which is progressive. Patients with psoriatic arthritis usually have a positive history of joint pain and stiffness involving both peripheral and axial joints. Common symptoms include joint pain, swelling, morning stiffness, decreased range of motion, fatigue, dactylitis due to inflammation and swelling of the entire digit, enthesopathy,skin lesions, and dystrophic nails.
Physical Examination
Common physical examination findings of patients with psoriatic arthritis include peripheral and axial joint inflammation and tenderness, enthesis, dactylitis, scaly, erythematous papules and plaques on the skin and dystrophic nail changes.
Laboratory findings
X-ray
ECG
Ultrasound
CT
MRI
Other imaging studies
Other diagnostic studies
Treatment
Medical Therapy
Pharmacologic therapy for psoriatic arthritis includes nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs, tumor necrosis factor (TNF) inhibitors, and interleukin 17 (IL-17) inhibitors, interleukin IL-12/23 inhibitors, and topical glucocorticoid injections. Psoriatic arthritis is a chronic inflammatory arthritis which is manifested as peripheral and axial arthritis, dactylitis, enthesitis and skin and nail involvement. Non - pharmacologic therapy including patient education, weight reduction, and physical therapy may also play an important role in disease management. While treating the patients the primary goal is to maximize the long-term health-related quality of life.
Surgical Therapy
Surgery may not be the first-line treatment for patients with psoriatic arthritis. Surgical options, such as the knee surgery, hip replacements, and surgery involving hand joints may be recommended in patients with severe joint damage and deformity.
Primary prevention
There are no established measures for the primary prevention of psoriatic arthritis.
Secondary prevention
There are no established secondary preventive measures for psoriatic arthritis.