Overview
According to the National Psoriasis Foundation's 2001 Benchmark Survey, [1]psoriatic arthritis (PA) is a specific type of arthritis that has been diagnosed in approximately 23% of those who have psoriasis. [2] PA can occur in any age group; however, in most patients, it manifests itself in patients from 30-50 years of age. On average, PA appears about 10 years after the first signs of psoriasis occur, but in about 1 of 7 people with PA, arthritis symptoms occur before any skin lesions appear. Most patients with PA also have psoriasis; patients rarely have PA without psoriasis.
See the psoriatic arthritis images below.
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[IMG]file:///C:/Users/USER/AppData/Local/Temp/msohtmlclip1/01/clip_image001.jpg[/IMG]Anteroposterior radiograph of the abdomen shows fusion of the sacroiliac joints. Courtesy of Bruce M. Rothschild, MD.
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[IMG]file:///C:/Users/USER/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg[/IMG]Posteroanterior radiograph of the hands shows wrist fusion. Courtesy of Bruce M. Rothschild, MD.
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See Psoriasis: Manifestations, Management Options, and Mimics, a Critical Images slideshow, to help recognize the major psoriasis subtypes and distinguish them from other skin lesions.
Stamm et al used the following 9 instruments in their analysis: Arthritis Impact Measurement Scale Short Form; Bath Ankylosing Spondylitis Disease Activity Index; Disabilities of the Arm, Shoulder, and Hand Questionnaire; Dermatology Quality of Life Index; Dougados Functional Index; Health Assessment Questionnaire (HAQ); HAQ-S (HAQ adapted for spondylarthropathies); PsA-specific Quality of Life Instrument; and Short Form 36 Health Survey. [3] They found that the impact of environmental factors, attitudes toward individuals with health problems, and loss of leisure time may represent important aspects that are not addressed through the instruments currently used to assess function in PA.
Prasad et al studied 472 psoriatic patients, 40 of whom had PA. They found that the duration of skin lesions and duration of arthropathy correlate with each other. [4] PASI scores also correlate with arthropathy.
Setty et al noted that the quality of life of patients with PA appeared similar to that of patients with rheumatoid arthritis (RA). [5] The available data on mortality in PA are conflicting, leaving unanswered questions concerning mortality. Rohekar et al found that overall, 10.2% of patients in the Toronto PA cohort developed cancer. [6] The most frequent cancers were cancers of the breast, lung, and prostate. The incidence of malignancy in the large PA cohort did not differ from that in the general population. This finding differs from that reported in Gelfand's study, in which the odds ratio of psoriasis patients developing lymphoma was higher. [7]
Mullan et al noted that early changes in serum type II collagen biomarkers predicted radiographic progression at 1 year in patients with inflammatory PA after biologic treatments. [8]
Types of PA
Five types of PA have been defined; these types can coexist, but they tend to occur separately in most cases:
· Arthritis involving primarily the small joints of the fingers or toes (asymmetrical oligoarthritis) — 55-70%
· Asymmetrical arthritis, which involves the joints of the extremities — 30-50%
· Symmetrical polyarthritis, which resembles RA — 15-70%
· Arthritis mutilans, which is a rare but deforming and destructive condition — 3-5%
· Arthritis of the sacroiliac joints and spine (psoriatic spondylitis) — 5-33%. Gladman et al noted that the definition of axial disease in PA ranges from isolated unilateral grade 2 sacroiliitis to criteria similar to the criteria used for making a diagnosis of ankylosing spondylitis. [9] Depending on the criteria used, the prevalence of axial disease varies from 25% to 70% of patients with psoriatic arthritis.
Preferred examination
PA is diagnosed and assessed with radiography, which is the cornerstone in assessing and monitoring inflammatory arthritides such as PA. Radiographic findings are reproducible and allow for the serial monitoring of patients. Although magnetic resonance imaging (MRI) is more sensitive, the cost of this modality makes it a second-line means for monitoring patients with PA.[10, 11, 12, 13]
Classic presentation
Classic, but not wholly pathognomonic, associations of PA include the following:
· Nail involvement such as pitting and separation from the nail bed (onycholysis), as well as yellow-pink discoloration (the oil-drop sign)
· Sausage digits (dactylitis)
· Inflammation at the sites of ligamentous and tendinous insertions (enthesopathy)
· An absence of rheumatoid factor (RF)
Psoriasis is mostly a disease of the skin wherein some stimulus leads to a hyperproliferation of skin cells, which then results in an increase in the turnover of such cells. Patients develop papules and plaques with micalike scales; such plaques have a predilection for the sacrum, elbows, and scalp. PA can lead to joint swelling and, in the most severe case, sausagelike digits. Perioperative management of tumor necrosis factor antagonists in patients with psoriasis and other inflammatory disorders has been recorded.[14] Synovitis can manifest as edema, joint effusion, or tendinitis (see Images below).
[IMG]file:///C:/Users/USER/AppData/Local/Temp/msohtmlclip1/01/clip_image003.jpg[/IMG]Dorsal view of the hands shows psoriatic rash and sausage swelling on the right second finger. Courtesy of Bruce M. Rothschild, MD.
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[IMG]file:///C:/Users/USER/AppData/Local/Temp/msohtmlclip1/01/clip_image004.jpg[/IMG]Left, typical appearance of psoriasis with silvery scaling on a sharply marginated and reddened area of the skin overlying the shin. Right, thimblelike pitting of the nail plate in a 56-year-old woman who has had psoriasis for the past 23 years. Nail pitting, transverse depressions, and subungual hyperkeratosis often occur in association with psoriatic disease of the distal interphalangeal joint. Courtesy of Ali Nawaz Khan, MBBS.
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Symmetrical polyarthritis with joint pain and joint swelling furnishes a single pattern of clinical manifestations that often indicates erosive progressive disease. [15] Unlike RA, PA regularly involves distal interphalangeal joints.
Andersson lesion (erosive diskovertebral lesion) can be the initial sign of pathology in axial PA. [16]
A haplotype epidemiologic association with PA involves the expression of both class I and class II human leukocyte antigen (HLA) alleles, including HLA-B13, HLA-B17, HLA-B27, HLA-B38, HLA-B39, HLA-Cw6, HLA-DR4, and HLA-DR7. HLA-27 is present in 60% of individuals with the disease, as compared with 8% of the general population.
Prognosis
Factors that portend a worse prognosis for patients with PA include the following:
· A strong family history of psoriasis
· Disease onset younger than age 20 years
· Expression of HLA-B27, HLA-Cw6, or HLA-DR4 alleles
· Polyarticular disease
· Erosive disease
· Extensive skin involvement
Systemic involvement can occur with ocular changes (30%), conjunctivitis, episcleritis, and keratoconjunctivitissicca. Aortic valve disease has also been described. Because of the high skin turnover, hyperuricemia and gout can coincide with psoriasis. An association with human immunodeficiency virus (HIV) infection has also been identified; in such cases, both the psoriatic eruption and PA can be severe. Celiac disease has also been reported. [17, 18, 19, 20, 21]
Bone anabolic changes can continue in PA patients, even when they are on treatment with tumor necrosis factor inhibitors (eg, infliximab) or methotrexate. [22]
Differential diagnosis
Differential diagnosis includes ankylosing spondylitis and rheumatoid arthritis of the hands and spine. Enteropathic arthritis (arthritis of inflammatory bowel disease) should also be considered, and spotted bone disease has been reported in a patient with psoriatic arthritis. [23]
Patient education
For patient education resources, see the Skin Conditions & Beauty Center, as well as Types of Psoriasis, Psoriatic Arthritis, and Psoriasis Medications.


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student name :Faris Abdulrhman Aldiqsi
ID# : 100115