This document discusses psoriatic arthritis (PsA), including its clinical manifestations, patterns, imaging, diagnosis, and treatment. PsA is a chronic inflammatory arthritis occurring in 7-42% of psoriasis patients, typically presenting as painful, stiff joints. Five patterns are recognized: oligoarticular disease in 70% of cases affecting distal joints; asymmetric DIP involvement in 10% of cases; arthritis mutilans deforming fingers and toes in 5% of cases; symmetric polyarthritis resembling rheumatoid arthritis in 15% of cases; and psoriatic spondyloarthritis in 5% presenting with axial inflammation. Treatment involves NSAIDs, DMARDs like methotrexate, and biological agents

2. Psoriatic arthritis (PsA) is a chronic
inflammatory arthropathy of the peripheral
joints and axial skeleton, occurring in 7% to
42% of patients with psoriasis.

3. Pathogenesis of psoriasiS

5. CLINICAL MANIFESTATIONS
 Typically, patients present with pain and
stiffness of the affected joints, which tend to
be less tender than the affected joints in
patients with RA. Morning stiffness lasting for
over 30 minutes is seen in more than 50% of
patients.
 Five distinct patterns of PsA are recognized
and are listed as follows:

6.  Oligoarticular (four or fewer inflamed joints) disease
that constitutes 70% of all cases of PsA is
characteristically asymmetric and affects a distal
interphalangeal (DIP), proximal interphalangeal (PIP),
and metacarpophalangeal (MCP) joints, knees, ankles,
and feet

7.  Asymmetric involvement of DIP joints of
the hands and feet is sometimes referred
to as “classic” psoriatic arthropathy, but
this pattern appears in as few as 10% of
cases. Digits affected often have
characteristic psoriatic nail changes.

8. Arthritis mutilans is a particularly disabling
form occurring in approximately 5% of all cases
of PsA. The deformity, most striking in the
fingers and toes, is caused by osteolysis of the
affected joints

9. Symmetric polyarthritis (resembling RA) is
usually rheumatoid factor-negative, and
constitutes approximately 15% of all cases of
PsA. Constitutional symptoms such as
morning stiffness and fatigue are common
and tend to parallel the activity of joint
disease.

10. Psoriatic spondyloarthritis occurs in up to 5% of patients with
PsA and presents with clinical and radiographic features of
axial and sacroiliac inflammation. These may be
indistinguishable from those of reactive arthritis Re. A, and
their involvement tends to be asymmetric

11. Enthesopathy includes
plantar fasciitis, epicondylitis,
Achilles tendinitis, and
enthesitis of the ligamentous
insertions around the pelvic
bones

12. Extra-articular manifestation.
• Conjunctivitis and uveitis occur in up to one-third of
patients with PsA. Psoriatic skin lesion and nail dystrophy.
• Nail changes alone may not be diagnostic, but greater
than 20 pits is suggestive and more than 60 can be
diagnostic of PsA. Nail involvement correlates closely
with skin and arthritic changes, especially of the DIP
joints. Fungal and bacterial infections can also cause
hyperkeratosis and onycholysis, and should be ruled out
before attributing the nail changes to psoriasis

16. DAPSA (Disease Activity in Psoriatic
Arthritis) Score
DAPSA = TJ + SJ + CRP +
Activity + Pain =
Disease Activity:
0-4 Remission
5-14 low
15-28 moderate
>28 high Disease Activity

17. D.D
The cutaneous lesions of reactive arthritis(Re.A)
often resemble pustular psoriasis.
ReA usually affects large joints and infrequently
involves the DIP joints or produces sausage digits.
The incidence of HLA-B27 is higher in ReA.
In radiographs, ReA may demonstrate periostitis of
the plantar surfaces of the calcaneus, metatarsal
bones, or ankles. In PsA, periostitis is usually limited
to the long bones

18. Psoriatic arthritis should be differentiated from gout
by the absence of monosodium urate crystals in the
synovial fluid. Hyperuricemia may occur in up to 20%
of patients with skin psoriasis, but is uncommon
during acute flares of PsA. In contrast to monarticular
PsA, acute gouty arthritis usually resolves completely
in 1 to 2 weeks, even if left untreated. Occasionally,
the two conditions may coexist

19. Imaging

21. TREATMENT:
Non steroidal anti-inflammatory drugs
(NSAIDS) [and the selective cyclooxygenase-2
(COX-2) inhibitor] are effective in controlling
mild inflammation of PsA. DMARDs are used
soon after the diagnosis is made. Combining
two DMARDs (usually MTX with cyclosporin) can
be effective even in patients unresponsive to
either drug alone

22. MTX is the most widely used DMARD in Ps A,
because it is effective for skin and arthritic
symptoms, fast acting, and well tolerated
Cyclosporin A works well for skin and joint
disease .
Sulfasalazine, leflunomide, azathioprine,
mycophenolate mofetil, and antimalarials, have
been used with modest effectiveness in Ps A.

23. Biological agents
Physical therapy is used as an adjunct to drug
therapy to help preserve joint range of motion and
minimize muscle weakness.
Reconstructive surgery is of value in patients with
end-stage joint destruction.

24. BAD PROGNOSTIC MARKERS
1- Presence of more than 5 swollen and tender joints.
2-Radiographic changes
3-Elevated inflammatory markers esp. crp. 4-Extraarticlar manifestations esp.
dactilitis
Use leflunomide instead

25. REACTIVE ARTHRITIS

26. Reactive arthritis :is an inflammatory arthritis usually following
sexually acquired or gastrointestinal infection which occur before the
onset of arthritis by 1-4 weeks .
• The arthritogenic bacteria causing ReA are salmonella,
yersinia,helicobacteror klebsiela.
• ReA may be just arthritis but sometimes the full picture of Rieter’s
disease may occure.
• Rieter’s syndrome typically occure in young men with acute onset
of arthritis ,conjunctivitis and urethritis .
• Treatment by rest, NSAID, corticosteroid, methotrexate, azathioprine
and antibiotic for arthritis.

28. Characterized by axial and/or peripheral joint
involvemen(mainly knees and ankles), enthesitis, anterior
uveitis, mucocutaneous inflammation (urethritis ,cervicites),
occasional aortitis and heart block, seronegativity for
rheumatoid factor, and familial aggregation with a strong
association with human leukocyte antigen (HLA)B27.
Therapy that is targeted

29. Therapy that is targeted at the intestinal
inflammation, such as with sulfasalazine, 6-
mercaptopurine, and/or azathioprine. Nonsteroidal
anti-inflammatory drugs (NSAIDs) should be used with
caution because they may sometimes exacerbate
intestinal disease. Anti-tumor necrosis factor (anti-
TNF) agents appear to be very effective for all
musculoskeletal symptoms of IBD.