Overview of diagnosis and management of Psoriatic arthritis

1. Psoriathic arthritis
Diagnosis and Management
Dr. Nnonyelu Chibueze

2. Introduction
• Psoriatic arthritis is an inflammatory joint
disease associated with psoriasis.
• Psoriasis affects approximately 3% of the U.S.
population, and psoriatic arthritis may
to 30% of patients with psoriasis.
• some patients considered to have psoriatic
because of concurrent psoriasis and joint pain
actually have an unrelated joint condition,
commonly osteoarthritis.

3. The male-to-female ratio for psoriatic arthritis
is 1:1 (other forms of spondyloarthritis
generally have a higher prevalence in men).
Risk factors include obesity, metabolic
syndrome, severe psoriasis, psoriasis involving
the scalp or genitals, or inverse psoriasis.
Psoriatic nail changes are present in more than
80% of patients with psoriatic arthritis.

4. • The genetics of psoriatic arthritis are complex.
HLA-C06 is associated with psoriasis but not
psoriatic arthritis. HLA-B08, -B27, -B38, and -B39
are seen in psoriatic arthritis

5. Clinical subtypes
• 1. Asymmetric oligoarthritis involving four or fewer, typically large, joints. Occasionally, a single
joint may be involved.
• 2. Polyarticular arthritis affecting multiple joints of the hands, which may be symmetrical and
resemble rheumatoid arthritis.
• 3. Distal interphalangeal joint (DIP)–predominant variety, which may occur with the preceding
subtypes or in isolation (Figure 19). Although inflammation in a DIP joint in a patient with
psoriasis strongly suggests psoriatic arthritis, DIP involvement is also common in osteoarthritis, is
occasionally seen in gout, and also occurs in a rare condition called multicentric
reticulohistiocytosis.
• 4. Arthritis mutilans, a more aggressive form of psoriatic arthritis involving the hands. Telescoping
of the digits from substantial joint destruction may occur. Arthritis mutilans is probably a
progressive form of the preceding three subtypes.
• 5. Axial spine involvement with sacroiliitis and spine involvement. This may occur in isolation or in
conjunction with other subtypes. It occurs in up to 50% of patients with psoriatic arthritis, more
commonly among patients with the HLA-B27 gene. Axial psoriatic arthritis involvement may be
distinguished radiographically by asymmetry, skip lesions, and bulkier syndesmophytes.

6. • Eye involvement also develops in psoriatic
arthritis. Conjunctivitis is more common than
uveitis or iritis. Uveitis occurs in up to 8% of
patients with psoriatic arthritis.
• Like ankylosing spondylitis, psoriatic arthritis is
associated with an increased risk for
cardiovascular disease, including myocardial
infarction, valvular disease, and conduction
abnormalities.

7. Diagnosis
• Except for incidental overlap with other conditions, patients
with spondyloarthritis are negative for rheumatoid factor, anti–
cyclic citrullinated peptide, and antinuclear antibodies
• HLA-B27 antigen testing is never diagnostic but can help
determine risk for spondyloarthritis in uncertain situations. A
patient with inflammatory low back pain, uveitis, and
radiographic evidence of bilateral sacroiliitis does not need
HLA-B27 antigen testing because the diagnosis is clear.

8. • Erythrocyte sedimentation rate and C-reactive protein
help confirm an inflammatory process and can be
monitored during therapy.
• In psoriatic arthritis in particular, radiographic findings
classically take the form of erosions of the distal head
of the proximal joint and juxta-articular new bone
formation at the proximal head of the distal joint,
leading to a “pencil-in-cup” appearance across the
joint

9. Treatment
• TNF inhibitors are often given in higher doses for skin disease than for
joint disease, the predominant feature of the disease may drive the
prescribing dose. Weight loss and smoking cessation may positively
affect disease activity.
• For limited disease, such as a single digit with dactylitis or a single
swollen joint, an oral or topical NSAID or a local injection of
glucocorticoids may suffice.
• For more active disease, the ACR suggests initiating a TNF inhibitor,
methotrexate, or an interleukin-17 inhibitor.
• Surgery may be indicated for significant damage to larger joints.

10. Category Medications
Anti-inflammatory agents NSAIDs; oral or intra-articular glucocorticoids
Nonbiologic disease-modifying antirheumatic drugs Methotrexate, leflunomide, sulfasalazine, cyclosporine,
apremilast
Tumor necrosis factor inhibitors Etanercept, adalimumab, infliximab, certolizumab, golimumab
Interleukin-17 inhibitors Secukinumab, ixekizumab, brodalumab
Interleukin-12/interleukin-23 inhibitor Ustekinumab
Interleukin-23 inhibitors Risankizumab, guselkumab
Cytotoxic T-lymphocyte antigen-4 immunoglobulin Abatacept
Janus kinase inhibitor Tofacitinib

11. Thank You