1. Psoriatic Arthritis Clinical Features and Epidemiology
Dafna D. Gladman MD, FRCPC
Director, Psoriatic Arthritis Program,
University Health Network
Centre for Prognosis Studies in the Rheumatic Diseases
Toronto Western Hospital
Toronto Western Hospital

2. Psoriatic Arthritis Definition An inflammatory arthritis
Associated with psoriasis
Usually seronegative for rheumatoid factor

3. Psoriatic Arthritis Clinical Patterns
Distal predominant (Distal inter-phalangeal joints of fingers and toes).
Oligo-articular (<5 joints) often in an asymmetric distribution.
Poly-articular (5 joints), rheumatoid arthritis-like.
Spinal Involvement.
‘Arthritis Mutilans’.
Moll & Wright, Seminars Arthritis Rheum 1973;32:181

4. Psoriatic Arthritis Patterns 
Oligoarthritis
Distal Arthritis

5. Psoriatic Arthritis Patterns
Polyarticular Pattern

6. Psoriatic Arthritis Patterns
Arthritis Mutilans

7. Psoriatic Arthritis Patterns
Arthritis Mutilans
Telescoping

8. Psoriatic Spondyloarthropathy

9. Psoriatic Spondyloarthropathy 

10. Dactylitis in PsA

11. Edema in PsA

12. Heel Lesions in PsA Achilles Tendon Spur
Achilles Tendon Insertion Erosion
Plantar Spur

13. Other Radiological Features of PsA
Periostitis
Tuft resorption

14. Hidden Psoriasis

15. PsA Reported Series*
*Includes only series with > 100 Patients

16. Psoriatic arthritis: A distinct entity ?
Dutch study found no association between psoriasis and polyarthritis.
No association between HLA antigens and seronegative polyarthritis with psoriasis.
No radiological features in seronegative polyarthritis with psoriasis.
van Romunde LKJ, et al.Rheumatology International 1984;4:55-73.
? fortuitous association
Cats A. Cutis 1990;46:

17. Psoriatic arthritis Epidemiological Evidence
Prevalence of psoriasis in the general population: %.
Prevalence of psoriasis in arthritis patients: %.
Prevalence of arthritis in the general population: 2-3%.
Prevalence of arthritis in psoriatic patients: 6-42%.

18. Psoriatic arthritis: A distinct entity !
Previous population studies.
Epidemiological studies.
Dutch study found DIP joints disease more common in patients with seronegative polyarthritis and psoriasis.
A distinct form of arthritis, with different patterns, associated with psoriasis.

19. A comparison between Psoriatic Arthritis and Rheumatoid Arthritis

20. Assessment of Tenderness
Psoriatic Arthritis Vs. Rheumatoid Arthritis
Buskila D, et al. J Rheumatol 1992;19:

21. Psoriatic Arthritis Classification
Classified with the Seronegative Spondyloarthropathies:
It is usually seronegative for rheumatoid factor.
It may be associated with a spondyloarthropathy.
It is associated with HLA-B27.

22. Differentiating PsA from other SpA

23. Psoriatic Arthritis Prevalence
Exact prevalence unknown.
Estimated figures vary from 0.1% in Rochester Minnesota to 1.4% in the Faroe Islands.
Recent Survey by National Psoriasis Foundation suggests prevalence of 1.4% of general population in the US.
Recent study from Toronto suggests a prevalence of 2.5%.

24. Psoriatic Arthritis Prevalence among people with psoriasis
Author (yr)
Centre
No. Ps. Pts.
% PsA
Leczinsky (1948)
Sweden
534 7
Vilanova (1951)
Barcelona
214 25
Little (1975)
Toronto
100 32
Scarpa (1984)
Napoli
180 34
Stern (1985)
Boston
1285 20
Zaneli (1992)
Winston-Salem
459 17
Barisic-Drusko (1994)
Osijek region
553 10
Salvarani (1995)
Regio Emilia
205 36
Shbeeb (2000)
Mayo Clinic
1056
6.25
Brockbank (2001)
126 31
NPF (2002) US
4.4 m 23

25. Psoriatic arthritis Clinical Outcome
PsA is much more serious than previously recognized.
20% of patients with PsA develop clinical deformities and damage, resulting in functional disability.
5 deformities were detected in 55% of patients after 10 years of follow-up.
Gladman DD et al. Quart J Med 1987;62:127.
Torre Alonso et al. Brit J Rheumatol 1991;30:245.

26. The University of Toronto Psoriatic Arthritis Program
Development of Deformities during follow-up
Gladman DD. Baillière’s Clinical Rheumatology1994;8:379.

27. Prognostic Indicators in PsA
Clinical Indicators of Progression
Progression of damage defined by a change in damage state:
State 1 = 0 damaged joints
State 2 = 1-4 damaged joints
State 3 = 5-9 damaged joints
State 4 =  10 damaged joints
Analysis by model for rate of transition between damage states.
Gladman DD et al. J Rheumatology 1995;22:675.

28. Prognostic Indicators in PsA
Multivariate model for Clinical Indicators
of Clinical Progression*
*Based on clinical features at presentation
Gladman DD et al. J Rheumatology 1995;22:675.

29. Prognostic Indicators in PsA
Multivariate Model for Clinical Damage
Gladman DD & Farewell VT. Arthritis Rheum 1995;38:845.
Gladman DD, et al. J Rheumatol 1998;25:730.

30. Prognostic Indicators in Psoriatic Arthritis
Final Multivariate Model for Time Varying Clinical Indicators
Gladman DD, Farewell VT. J Rheumatol 1999;26:2409

31. Outcome in Psoriatic arthritis
Mortality Studies
PsA patients are at an increased risk of death.
Overall risk is 1.62 that of Ontario Residents.
1.66 for women, 1.59 for men
Causes of Death are similar to general population.
Risk of death is related to previously active and severe disease.
Wong K, et al. Arthritis Rheum 1997;40:
Gladman DD, et al. Arthritis Rheum 1998;41:

32. Mortality in Psoriatic Arthritis
Primary causes of death in 53 patients

33. Survival in Psoriatic Arthritis
0.5
0.6
0.7
0.8
0.9
1.0
Survival Probability
All patients 5 10 15 20
Time Since Clinic Entry (Years)

34. Mortality in Psoriatic Arthritis
Prognostic Factors: Final Multivariate Model
Gladman DD, et al. Arthritis Rheum 1998;41:

35. Remission in Psoriatic Arthritis
Summary
Remission occurred in 17.6% of our PsA patients.
Male gender and less active and severe arthritis at presentation to Clinic were associated with remission.
Only 6 (8.7%) of the PsA patients sustained “true remission”,
35 (52%) had subsequent flares.
Gladman DD et al. J Rheumatol 2001;28:

36. Psoriatic Arthritis Prognostic Factors
Progression of Damage:
High effusion count at presentation
High joint count at each visit
High medication level at presentation
Low ESR is “protective”
Death:
Elevated ESR
High prior medication level
Radiological Damage
Remission
Male Gender
Low joint count at presentation

37. Psoriatic Arthritis Not just skin and joints!
An inflammatory arthritis associated with psoriasis.
More common than previously thought.
About one fifth of the patients have a severe debilitating disease, although some patients achieve remission.
Earlier studies suggesting that PsA was a mild disease included patients with early disease.

38. Psoriatic Arthritis Program
Dr. Dafna Gladman - Director
Cathy Schentag MsC
Research Associate
CPSRD, TWH
Nicole Anderson, BSc
Research Assistant
CPSRD, TWH
Fawnda Pellett, BSC
Research Technologist
CPSRD, TWH
Vern Farewell, PhD
Biostatistician
MRC, Cambridge, UK
Janice Husted, PhD
Epidemiologist
Waterloo, Ontario
Richard Cook, PhD
Biostatistician
Waterloo, Ontario
Research Fellows, Rheumatology Residents, Students,Patients

39. Psoriatic Arthritis Program - Support
Ontario Ministry of Health
Medical Research Council / Canadian Institutes of Health Research
The Arthritis Society
Centre for Prognosis Studies in The Rheumatic Diseases
University of Toronto / University Health Network Arthritis Centre of Excellence
Krembil Foundation
PsA Patients