1. Psoriatic arthritis (PsA) Clinical features, Diagnosis & Management
PsA-Iraj Salehi-Abari
Psoriatic arthritis (PsA) Clinical features, Diagnosis & Management
Iraj Salehi-Abari MD.,
Internist
Rheumatologist

2. 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

3. 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 = years
Race: Caucasians > non-Caucasians

4. 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

5. 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

6. 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

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

8. 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

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

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

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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

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

21. PsA-Iraj Salehi-Abari

22. PsA-Iraj Salehi-Abari

23. PsA-Iraj Salehi-Abari

24. PsA-Iraj Salehi-Abari

25. 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%

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

27. 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

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

29. 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

30. 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

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

32. 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

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

34. PsA-Iraj Salehi-Abari