psoriatic arthritis in short

1. Discussion About
“Psoriatic Arthritis”
PRESENTED BY DR. ABDULLAH AL FARUK

2. Psoriatic arthritis
Definition:
Psoriatic arthritis refers inflammatory arthritis that characteristically occurs in individual with psoriasis.
Historic background:
The association between arthritis with psoriasis – 19th century.
In 1970 Psoriatic arthritis included in broader category of spondyloarthities due to similarity with
ankylosing spondiolysis.
Epidemiology:
 Psoriatic arthritis prevalence 5 to 30% among psoriatic patient.
 In white population 1.5-3%
 Patient with psoriasis have an affected first degree relative
 HLA-CW6 gene is directly associated with psoriasis (Juvenile onset/type 1)
 HLA B27 is associated with Psoriatic arthritis.
 Other HLA DR1, DQ3 and B37.

3. Pathology:
Inflammatory synovium in
Psoriatic arthritis like rheumatoid
arthritis. Psoriatic arthritis shows
prominent enthesitis. Some study
shows synovial fibrosis.
Pathogenesis:
Psoriatic arthritis synovium
shows infiltration of T cells, B cells,
Macrophages. NK expresser cell,
plasma cytoid dendritic cell play a key
role in psoriatic arthritis as well
psoriasis.
Types of psoriasis:
1. Plaque psoriasis
2. Guttate psoriasis
3. Inverse psoriasis
4. Pustular psoriasis
5. Erythrodermic psoriasis

4. Clinical Feature:
60to 70 % of cases, Psoriasis preceding joint disease.
15-20 % cases arthritis precedes the onset of psoriasis.
• 0.06% of general population
• Age of onset between 25-45 years of age (average 37 years)
• Male and female ratio is equal.
Symptoms:
Pain and swelling the affecting joint along with enthesitis.
Course of involvement, generally intermittent exacerbation
followed by complete or near complete remission.

5. Wright and Moll classification of Psoriatic arthritis (categorized into 5
patterns)
1.Arthritis involving the DIP :
15% of the cases.
Male are more effected then female; associated with nail
dystrophy.
2.Asymmetrical inflammatory oligo arthritis:
40% of the cases.
Involve most characteristically hands & feet, large joints,
sometimes with joint effusion.
3.Symmetrical polyarthritis:
25% of the cases.
Female are more predominant then male.

6. 4.Psoriatic spondylitis:
Axial involvement similar to ankylosing spondiolysis but typically
unilateral or asymmetrical severity.
5.Arthritis mutilans:
Highly destructive form targeting the fingers and toes.
5% of the cases are involved.
Telescope fingers.

7. Extra articular features of psoriatic arthritis:
•Nail change:
85% patient of psoriatic arthritis and 30% patient of uncomplicated psoriasis.
Pitting
Ridging
Onycholysis
Subungual Hyperkeratosis
May present without skin rash.
•Eye involvement: 7-33% of patient with psoriatic arthritis.
Conjunctivitis.
Uveitis (HLAB27 positive)
•Aortic regurgitation: Only 4%patient involved with psoriatic arthritis. Found only in
long standing case.
•Skin manifestation:
Rash:
Well defined
Erythematous
Scaly black
Involving extensor surface of hand, Scalp, Natal cleft and umbilicus.

8. Diagnosis:
1. Appropriate clinical picture
2. Laboratory and radiological findings
a. Laboratory investigations:
I. CBC: ESR(↑); CRP(↑)
II. RA test
III. Anti-nuclear antibody (will be positive in low titer)
IV. Anti CCP antibody (positive in 10% patient)
V. Serum uric acid ( raised in extensive psoriasis)
VI. HLAB27 (50-70% with axial disease, less than 20% peripheral joints)
VII. X-ray:
SI joint (asymmetrical involvement)
Hand joint ( pencil in cup, small joint ankylosis, marginal erosion)
Sacro-illiac joint
Axial joint (course, asymmetrical, non-marginal, syndesmophyte)
viii. USG or MRI of affecting joints (to see synovial inflammation).

9. Casper’s Criteria:
1. Evidence of current psoriasis.
2. Typical psoriatic maldystrophy.
3. Negative RA factor.
4. Current dactilytis.
5. Radio graphical evidence.
Along with inflammatory arthritis and any 3 of the following confirms psoriatic
arthritis.

10. Management:
Pain management:
NSAIDs
Intra-articular steroid injection
Sprint and prolong rest should be avoided.
Drugs:
 Disease modifying anti rheumatoid drugs(DMARD):
Methotrixate (15-25 mg per week)
Sulfasalazine (2 gm/day)
Cyclosporine
Leflunomide
 Biological agent:
Ustekinumab (IL12/IL23 blockers)
Alefacept (anti T cell)
Other options:
Psoralen + UVA (PUVA)
Retinoic acid & its derivatives.
Acitritin
Aprimelast (phosphodyesterage-4 inhibitor)

11. Indication of systemic treatmenmt in Psoriasis:
1. Repeated failure of topical treatment.
2. Extensive psoriasis in elderly.
3. Severe psoriatic arthopathy.
4. Involving more than 60% of body surface.
Kept in clinician’s mind:
Aggravating factors should be noticed. Such as:
 Trauma
 Infection (β hemolytic streptococcal, HIV)
 Sunlight
 Drugs (Anti-malarial, NSAIDs, β-blockers)
 Psychological factors (anxiety and stress)

12. THANK YOU