1. Training on the Modular Approach on the assessment and management of psoriatic arthritis (PsA) for dermatology units
This PsA Assessment initiative is led by the UK PsA Assessment Academy for UK healthcare professionals only, organised and funded by AbbVie.
Available to download at: Prescribing information can be found here or on the website:
AXHUR151220n(1) Date of preparation: December 2017

2. Overview of PsA

3. What is PsA?
Psoriatic arthritis (PsA) is a progressive disorder ranging from mild synovitis to severe progressive erosive arthropathy1
PsA is a complex condition that involves many body areas:
Skin
Fingernails and toenails
Peripheral joints
Axial skeleton (the spine, chest and sacroiliac joint)
Entire digits (dactylitis)
Entheses
1. Pipitone N, et al. Rheumatol 2003; 42:1138–1148.

4. 1. NICE Technology appraisals.TA199, August 2010.
Prevalence of PsA
The prevalence of psoriasis in the general population is estimated at 2–3%, with the prevalence of inflammatory arthritis in people with psoriasis estimated at up to 30%1
At least 20% of people with psoriasis have severe psoriatic arthritis with progressive joint lesions1
1. NICE Technology appraisals.TA199, August 2010.

5. Diagnosis Many patients with PsA remain undiagnosed:
In a study looking at PsA prevalence in Europe and North America of 285 patients given the diagnosis of PsA by a rheumatologist, 117 (41%) had not been previously given the diagnosis 1
PsA can progress notably within the first 2 years of disease onset2
Dual skin and joint involvement can have a negative impact on a patient’s quality of life3
It is, therefore, critical to diagnose and commence treatment early
1. Mease P, Gladman D, Papp K, et al. J Am Acad Dermatol. 2013;69(5):729–735.
2. Gladman DD, et al. Ann Rheum Dis. 2005; 64 :14– Lee S, et al. P & T 2010; 35:

6. Diagnosis
Patients may present to either a dermatology or rheumatology clinic depending on their symptoms
To optimise best practice all patients with psoriasis should be screened for PsA to help prevent irreversible joint damage

7. PsA Assessment Academy
Outside In recommendations are based on the expert opinion of the PsA Assessment Academy

8. Objectives of training
To provide background information on PsA
To explain the new Modular Approach on the assessment of PsA
To ensure all practitioners are proficient in using the assessment tools
To agree a standardised assessment protocol for each clinic

9. PsA Assessment Academy
A group of physician and nurse experts in rheumatology and dermatology were bought together by AbbVie to discuss the assessment of PsA based on the available evidence:
Bruce Kirkham, Consultant Rheumatologist, Guy’s Hospital, London
Philip Helliwell, Consultant Rheumatologist/Senior Lecturer, Leeds University
Eleanor Korendowych, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases, Bath
Kate Gadsby, Rheumatology Consultant Nurse, AbbVie & Honorary Rheumatology Nurse Specialist, Royal Derby Hospital, Derbyshire*
Sue Oliver, Past Chair RCN Rheumatology Forum and RCN Fellow. Independent Nurse Consultant
Liz Parrish, Past Dermatology Lead Nurse/Matron, East Kent University Hospitals NHS Foundation Trust. Independent Nurse Consultant
* Kate Gadsby works predominantly with AbbVie Ltd. But, also has a role within the NHS as an honorary rheumatology nurse specialist at Derby Hospital

10. Academy recommendations
Practical recommendations were put forward that could:
Optimise initial assessment and monitoring of PsA by recommending a standardised approach to assessment
Improve coordination between rheumatology and dermatology services

11. Aligning with existing guidelines
The recommendations were developed to build on and align with existing guidelines issued by the:
British Society of Rheumatology (BSR)
Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)
National Institute for Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)

12. A Modular Approach

13. A Modular Approach
Developed by the Assessment Academy, a Modular Approach was recommended which encourages sharing of knowledge and information, efficient use of time, and prompt referral and treatment of patients.
As part of this approach, it has been suggested that as a minimum:
Dermatology clinics should perform the PASI and the PEST.
Over time the other components of the Modular Approach can be added to clinic practice

15. Applying the Modular Approach to daily clinical practice
Agree a standardised approach for each test in your clinic
All patients should be assessed for PsA
Recommended assessment tools include:
Dermatology Life Quality Index (DLQI)
Psoriasis Area and Severity Index (PASI)
Psoriasis Epidemiology Screening Tool (PEST)

16. Clinical questionnaires

17. Clinical questionnaires
Clinical questionnaires can be useful for the continued management of patients who have PsA
A trained receptionist or nurse can give the patient the questionnaire when the patient first arrives
Clinical questionnaires should be completed periodically by the patient, or as required

18. Dermatology Life Quality Index (DLQI)
The DLQI is a quality of life (QoL) measure that can be used across all skin diseases and measures different aspects of psoriasis to the PASI
The DLQI consists of 10 simple questions relating to ways in which skin disease impairs lives
The DLQI is calculated by summing the score of each question with a maximum of 30. The higher the score, the more quality of life is impaired

19. Dermatology Life Quality Index (DLQI)
Healthcare professional pages
Patient pages
All Outside In materials can be downloaded from

20. Assessing the skin

21. Psoriasis Area Severity Index (PASI)
PASI is an index used to express the severity of psoriasis considering the following:
severity (erythema, induration and desquamation)
percentage of affected area
The body is assessed in four regions:
Head and neck
Arms
Trunk (includes groin and axillae)
Legs (includes buttocks)
All Outside In materials can be downloaded from

22. Psoriasis Area Severity Index (PASI)
Each is assigned a score to reflect extent of affected area, (0 = no skin affected, 6 = all skin affected)
Severity of psoriasis is assessed with scores assigned to each of redness, thickness and scale (0= least severe, 4 = most severe)
For head, arms, trunk and legs specify:
The percentage of area of skin involved
The severity of three clinical signs (erythema, induration and desquamation) on a scale from 0 to 4 (from none to maximum)

23. Psoriasis Area Severity Index (PASI)
The PASI is the main test used in the clinic to assess total body area affected by psoriasis
It can be used to monitor both the patient’s psoriasis and their disease progression and response to treatment over time
The test can be used to help decide the most appropriate treatment

24. Psoriasis Area Severity Index (PASI)
Nails should be visually assessed for pitting during examination

25. Psoriasis Area Severity Index (PASI)
All Outside In materials can be downloaded from

26. PASI score calculation
Area affected was estimated to be 35% which gives an extent score 3
The total extent for the arms is 3 x 0.2 = 0.6
Severity of the plaques on the arms was calculated as 3 for erythema, 2 for scaling and induration as 2
The severity for the arms was calculated as = 7
The total extent multiplied by total severity for the arms is 0.6 x 7 = 4.2

27. PASI score calculation
The calculation of the PASI for this patient is shown below:

28. Assessing the joints

29. Psoriasis Epidemiology Screening Tool (PEST)
PEST should be considered for early detection of PsA
Patients with psoriasis who have not been diagnosed with PsA should complete a PEST questionnaire annually
Patients complete 5 questions scoring 1 point for each question answered in the affirmative
All Outside In materials can be downloaded from

30. Psoriasis Epidemiology Screening Tool (PEST)
The patient is also asked to show on a diagram which joints have caused them discomfort (still, swollen or painful joints)
A total score of 3 or more is indicative of psoriatic arthritis and patients should be referred for further assessment by a rheumatology unit
All Outside In materials can be downloaded from

31. Psoriasis Epidemiology Screening Tool (PEST)
All Outside In materials can be downloaded from

32. Training materials

33. Training materials
A selection of training materials are available on the Outside In website:

34. Summary Agree a standardised approach for each test in your clinic
As a minimum, it has been suggested by the PsA Assessment Academy that:
Dermatology clinics should perform the PASI and the PEST
A total PEST score of 3 or more is indicative of psoriatic arthritis and patients should be referred for further assessment by a rheumatology unit
All patients should be assessed for PsA
PEST should be considered for early detection of PsA