1. Department of Rheumatology and Connective Tissue Diseases
Psoriatic arthritis
Department of Rheumatology and Connective Tissue Diseases
Tacjana Barczyńska

2. Psoriatic arthritis (arthritis psoriatica, psoriatic arthritis, PsA)
a chronic inflammatory disease
different phenotypes
seronegative spondyloarthropathy
most often develops in patients with psoriasis
The order of developing:
arthritis or enthesitis
changes in skin and nails
may vary, but usually psoriasis develops earlier than arthritis
The severity of psoriasis typically does not correlate with the degree of joint damage.

3. PsA- epidemiology PsA affects 0,05-0,24% of the Caucasian population
Psoriasis affects 2-3% of the popluation
PsA affects 6-42% (~40%) of patients with psoriasis
Women: Men– 1 :1 (equal sex prevalence)
W- symmetrical polyarthritis
M- type with predominant symptoms of spondyloarthropathy (axial)
The onset of symptoms
usually between years old
may also occur in children

4. Ethiopathogenesis- genetic factors
Epidemiological data:
40% of patients with PsA have first-degree relatives diagnosed with psoriasis or PsA
PsA more often develops in monozygotic twins
PsA identified in both parents- greater risk of developing PsA
Antigens in PsA:
HLA-B27 (axial form)
HLA-Cw6 (predisposes to skin psoriasis and correlates with the development of psoriasis at a younger age)

5. Ethiopathogenesis- immunological mechanisms
Activation and expansion of keratinocytes and synoviocytes
Infiltration by mononuclear cells and angiogenesis
Increased immune, humoral and cellular response
increased proinflammatory cytokine expression, especially TNF in skin and joint fluid

6. Ethiopathogenesis- environmental factors
mechanical injury
bacterial infections (e.g. streptococci)
viral infections (e.g. HIV infection- 10x higher risk of developing PsA)

7. Ethiopathogenesis
Active inflammation in PsA leads to bone remodeling- coexistence of two mechanisms:
resorption- damage to the articular cartilage and bone
creation of new pathological bone structures (e.g. ankylosis)

8. Classification of PsA according to Moll and Wright (1973)
The form
of PsA
The type of affected joints
The frequency %
Symmetrical polyarthritis
≥ 5 peripheral joints
(resembling rheumatoid arthritis with involvement of PIP)
15-25
Asymmetrical
oligoarthritis
≤ 4 peripheral joints (often dactylitis)
>50
The distal
DIP (often nails)
5-10
Spodnylitis predominant (axial)
Joints of the spine and sacroiliac joints (usually asymmetrical changes )
20-40
Arthritis mutilans
PIP i DIP
(advanced destructive changes, digit ‘telescopic’) 5

9. Classification of PsA
PsA classification proposed by Moll and Wright is helpful in the diagnosis of early forms of PsA. However, over time the characteristics of the various types can overlap.
Some authors prefer PsA division into 3 types:
peripheral arthritis
peripheral arthritis with involvement of the spine
type with predominant symptoms of spondyloarthropathy (axial)

10. Clinical presentation of PsA Peripheral arthritis
inflammation of one or more joints
recurrent exudative arthritis of the lower limbs (eg. knee)
symptoms of inflammation (pain, swelling, redness, increased warming and stiffness of the affected joint)
asymmetric joints involvment, especially in the early stages of the disease
when the process involves increasing number of joints- changes may be symmetical

11. Peripheral arthritis
Polyarticular symmetrical form can resemble RA, differentiating elements:
absence of rheumatoid factor and rheumatoid nodules
joint involvement: DIP
changes in the nail plate
Arthritis mutilans- severe deformities
Telescopic fingers
Subluxation

12. Clinical presentation of PsA The axial form
Involvement of joints of the spine and sacroiliac joints:
changes are usually one-sided (unilateral)
inflammatory spinal pain (back pains)
limitation of motion of the spine

13. Fingers inflammation (dactylitis)-
may be the first symptom of PsA
occurs in 40-48% cases of PsA
Dactylitis of toes or fingers (65% only toes)
inflammatory process involves primarily the tendon and tendon sheath of the flexor, and then the remaining structures- PIP and DIP joints, bones and soft tissues, leading to joint destruction
Types of dactylitis:
acute- swelling, redness and pain around the toe or finger
chronic- despite the resolution of active inflammation persists painless swelling of the whole toe or finger

14. Enthesitis
Inflammation of the ligament, tendon or joint capsule at the site of attachment to the bones, revealed pain and swelling.
Location of changes in PsA:
most often- inflammation of the Achilles tendon and plantar fascia
rarely- tendons in the knee, shoulder, elbow

15. Psoriasis 70%- psoriasis precedes the appearance of arthritis
15%- simultaneous occurrence of skin lesions and arthritis
15%- arthritis is the first symptom of the disease, and psoriasis may develop after a few years (psoriatic arthritis sine psoriasis)
Primary eruption- red-brown lump of clear boundaries with silvery scales
Psoriasis - location:
knees, elbows, umbilicus, scalp, natal cleft, external genitalia, but also the trunk, hands and feet

16. Nail psoriasis 80% patients with PsA
20-40% patients with psoriasis and unchanged joint
may be a predictor of PsA, particularly the form with DIP joint involvement
may be the only clinical manifestation of the disease
Psoriatic nail changes:
Nail pits- point depressions in the nail plate
longitudinal or transverse grooves
yellow and white discoloration
,, oil spots”
onycholysis- separation of the nail from its bed

17. Ocular Symptoms conjunctivitis uveits Uveitis
symptoms: pain, redness, blurred vision
can lead to blindness

18. The diagnosis of PsA Personal and family history of psoriasis
Physical examination: evaluation of skin lesions, nail, peripheral joints, sacroiliac, spine, tendon and fingers
Basic laboratory tests, including ESR and CRP
Rheumatoid Factor
Imaging studies of joints and tendon (X-ray, ultrasound, MRI)
Genetic testing: HLA-B27 and HLA-Cw6
Dermatological consultation

19. CASPAR ClASsification criteria for Psoriatic ARthritis (sensitivity 91
CASPAR ClASsification criteria for Psoriatic ARthritis (sensitivity 91.4%, specificity 98.7%)
The diagnosis of PsA is determined:
after fulfilling the mandatory criterion, which is an inflammation of joint, spine or entheseal
and obtaining 3 or more points for 5 of the following additional criteria:
Additional criteria
Points
Notes
1. Symptoms of psoriasis
(A or B or C)
a) Current 2
Confirmed by dermatologist or rheumatologist
b) In a personal history 1
From patient, dermatologist, rheumatologist or primary care physician
c) In a family history (in first or second degree relatives)
From the patient
2. Psoriatic nail dystrophy
Current examination
3. Negative rheumatoid factor
By any method except latex
4. Dactylitis
(a lub b)
Confirmed by rheumatologist
b) In a history
5. Radiological evidence of juxta-artocular new bone on hand or foot x-ray
Excluding osteophytes

20. X-rays of hands and feet
changes present in the DIP joints
asymmetry
rarely periarticular osteopenia
simultaneously destructive lesions (erosions, geodes inflammatory osteolysis) and proliferation of bone (periosteal new bone, often juxta-articular)
osteolytic lesions within the phalanges of the nail provide a picture of the so-called sharpened pencil, and when accompanied by a proliferation of bone tissue damaged joint is similar to ,,pencil in the cup "

21. PsA- axial form
Atypical syndesmofites
Sacroiliitis

22. Differential diagnosisRA
osteoarthritis
gout
Infectious arthritis
Other inflammatory spondyloarthropathies (ankylosing spondylitis, reactive arthritis and arthritis in the course of inflammatory bowel diseases)

23. The active form of PsA: presence of ≥1 tender joint and / or enthesitis and / or inflammation of the finger (dactylitis) and / or inflammatory back pain.
Poor prognosis factors: inflammation of the joints ≥5, elevated acute phase markers (ESR and CRP), progressive damage in X-ray, previous use of GKS, loss of function and reduced quality of life.

24. Synthetic DMARDs
Should be used in patients with active peripheral arthritis and factors of poor prognosis.
Early application -  several weeks to a maximum of one year.
The drug of first choice is methotrexate (at an optimum dose of 25 mg / week).
No synthetic DMARDs demonstrated efficacy in treating tendonitis and axial disease.
Other DMARDs: sulfasalazine, leflunomide and cyclosporine A

25. Glucocorticoids
GKS applied topically can be used for enthesitis and dactylitis.
GKS can be used systemically in the lowest possible doses with caution as the relative potential for exacerbation of skin lesions.

26. TNF-α inhibitors
If despite of the use of synthetic DMARDs within 3-6 months remission or low disease activity is not achieved, consider the inclusion of TNF-α inhibitor in combination with synthetic DMARDs or alone.

27. Axial form of PsA The drug of first choice should be NSAIDs.
In the case of high disease activity (BASDAI ≥ 4) TNF-α inhibitor can be considered, even without prior treatment with synthetic DMARDs.