Psoriatic arthritis (PsA) Clinical features, Diagnosis & Management PsA-Iraj Salehi-Abari Psoriatic arthritis (PsA) Clinical features, Diagnosis & Management Iraj Salehi-Abari MD., Internist Rheumatologist Salehiabari@sina.tums.ac.ir

PsA-Iraj Salehi-Abari Definition: A systemic disease with arthritis Related to Psoriasis Arthritis could be started: After Psoriasis Along with Psoriasis or Before Psoriasis

PsA-Iraj Salehi-Abari Epidemiology: Prevalence: 1-2/1000 Incidence: 6/100,000 Sex: F = M PsA/ Psoriasis: 14% PsA/ Early undifferentiated arthritis: 13% Psoriasis: peak age of onset = 5-15 years PsA: peak age of onset = 30-55 years Race: Caucasians > non-Caucasians

An arthritis in a patient with Psoriasis: PsA-Iraj Salehi-Abari An arthritis in a patient with Psoriasis: . Psoriatic arthritis . Psoriasis coexistent with: . Rheumatoid arthritis . Osteoarthritis . IBD related arthritis . Gouty arthritis

Patterns of arthritis: PsA-Iraj Salehi-Abari Patterns of arthritis: DIP arthritis + nail lesions: I Asymmetric oligoarthritis: II Symmetric polyarthritis: III Arthritis mutilans: IV Axial involvement: V Sacroiliitis Spondylitis

DIP arthritis + Nail lesions: PsA-Iraj Salehi-Abari DIP arthritis + Nail lesions: Classic pattern: 20-25% > 20 pits in a nail + (Dactylitis or DIP arthritis) is characteristic of PsA

Asymmetric oligoarthritis: PsA-Iraj Salehi-Abari Asymmetric oligoarthritis: Reactive arthritis like: 30-50% Enthesitis Dactylitis Post-traumatic arthritis

Symmetric polyarthritis: PsA-Iraj Salehi-Abari Symmetric polyarthritis: Rheumatoid arthritis like: 30-50% DIP involvement RF positivity: 10% Bony ankylosis of DIP, PIP: Claw or Paddle deformities

PsA-Iraj Salehi-Abari Arthritis Mutilans: Rare (5%) but Characteristic Telescoping digit: “doigt en lorgnette” “opera-glass finger”

PsA-Iraj Salehi-Abari Axial involvement: Sacroiliitis: 35% Spondylitis: 30% Enthesitis: 40%

PsA-Iraj Salehi-Abari Axial involvement: Ankylosing spondylitis like (5%) but Asymmetric sacroiliitis Asymmetric spondylitis Spotty syndesmophytes Cervical: C1-C2 subluxation

PsA-Iraj Salehi-Abari Pattern variability: More than one pattern: sometimes Change the pattern: Common Pattern I & IV: most specific Pattern III: most common Pattern IV: can occur with any pattern Pattern V: is usually associated with II & III

Soft tissue inflammation: PsA-Iraj Salehi-Abari Soft tissue inflammation: Enthesitis: Plantar fasciitis Achilles tendinitis Pelvic Tenosynovitis: Trigger finger Extensor carpi ulnaris Dactylitis: 50% Finger > toe

Nail psoriasis severity index: PsA-Iraj Salehi-Abari Nail psoriasis severity index: Severity of Psoriatic nail correlates with: The extent and severity of skin disease The extent and severity of joint disease More common with DIP arthritis

Accessory articular features: PsA-Iraj Salehi-Abari Accessory articular features: PPP: Palmoplantar pustulosis with arthritis SAPHO syndrome: Synovitis Acne Pustulosis Hyperostosis Osteitis RS3PE: Remitting seronegative symmetric synovitis with pitting edema

Psoriatic arthritis but no psoriasis: PsA-Iraj Salehi-Abari Psoriatic arthritis but no psoriasis: Psoriatic arthritis sine psoriasis: DIP arthritis Asymmetric arthritis Nail lesions Dactylitis Family history of psoriasis Presence of HLA-Cw6 Hidden (Occult) Psoriasis with arthritis: Umbilicus, scalp, anus, and ears

Systemic manifestations: PsA-Iraj Salehi-Abari Systemic manifestations: Ocular inflammation GI involvement: Ileitis/ Colitis Cardiac involvement Renal involvement Are same as ReA

Radiographic findings: PsA-Iraj Salehi-Abari Radiographic findings: Radiologic damage: In 2/3 patients at first visit to PsA clinics Erosion + new bone formation in distal joints Lysis of the terminal phalanges Fluffy periostitis and new bone formation at the site of enthesitis

Radiographic findings: PsA-Iraj Salehi-Abari Radiographic findings: Gross destruction of isolated joints “Pencil in-cup” appearance Joint lysis + Joint ankylosis Unilateral sacroiliitis Jug-handle syndesmophyte

“Pencil in-cup” appearance PsA-Iraj Salehi-Abari “Pencil in-cup” appearance

PsA-Iraj Salehi-Abari

PsA-Iraj Salehi-Abari

PsA-Iraj Salehi-Abari

PsA-Iraj Salehi-Abari

PsA-Iraj Salehi-Abari Lab. Data: No diagnostic Lab. Tests Elevated WBC and ESR: 1/3 Anemia: AOCD, IDA RF & ANA: similar to normal population Hyperuricemia: 20%

PsA-Iraj Salehi-Abari Lab. Data: U/A: may be hematuria Synovial fluid: Inflammatory Pseudoseptic joint

Differential diagnosis: PsA-Iraj Salehi-Abari Differential diagnosis: Reactive arthritis; Oligoarticular Rheumatoid arthritis; Polyarticular Ankylosing spondylitis; Axial Gouty arthritis; Acute monoarticular Erosive osteoarthritis; Arthritis mutilan

Pathogenesis: Unknown PsA-Iraj Salehi-Abari Pathogenesis: Unknown Psoriatic arthritis Immunologic Factors Genetic Factors Environmental Factors

PsA-Iraj Salehi-Abari Genetic Factors: (+) Family history: 40% 55 times: in first d. relatives Concordance rate for PsA >>> Ps Concordance in monozygotic twins >> dizygotic HLA & non HLA genes: HLA-B27, HLA-DR4, B13, B17, B57,… CARD15, MICA, IL-1 family gene, IL-13

PsA-Iraj Salehi-Abari Immunologic Factors: Antibodies Cytokines: TNF-a, IL-1, IL-6, IL-8, IL-10, INF-g, Adhesion molecules T-Cells (+) CD4 T cells injection to SCID mice  Ps Fibroblasts

Environmental Factors: PsA-Iraj Salehi-Abari Environmental Factors: Trauma: Koebner Ph. Infections: Bacterial: Strep. Viral: HIV . Are trigger factors

The Classification of Psoriatic Arthritis (CASPAR): PsA-Iraj Salehi-Abari The Classification of Psoriatic Arthritis (CASPAR): . At least one of below: . Arthritis . Enthesitis . Inflammatory LBP plus . At least 3 points of below: . Skin psoriasis: Ph. Ex.: 2p, Hx.: 1p, FH: 1p . Nail lesions (onycholysis, pitting): 1p . Dactylitis: 1p . Negative RF: 1p . New bone formation in X-Ray: 1p

PsA-Iraj Salehi-Abari Treatment: NSAIDs + MTX Leflunomide, sulfasalazine, Cyclosporine Biologic (Anti-TNF) Etanercept Adalimumab Infliximab PUVA

PsA-Iraj Salehi-Abari