This document summarizes psoriatic arthritis, including its clinical features, patterns, epidemiology and comparison to rheumatoid arthritis. Psoriatic arthritis is an inflammatory arthritis associated with psoriasis that is typically seronegative for rheumatoid factor. It can present as oligoarticular, distal interphalangeal-predominant, polyarticular, spondylitic or arthritis mutilans patterns. Studies show 20% of patients develop deformities within 10 years. Psoriatic arthritis is classified with other seronegative spondyloarthropathies due to characteristics like HLA-B27 positivity and sacroiliitis.

1. Psoria'c
Arthri's
Clinical
Features
and
Epidemiology
Dr.Sree
krishna
paturi

2. Psoria'c
Arthri's
♦ An
inflammatory
arthri's
♦ Associated
with
psoriasis
♦ Usually
seronega've
for
rheumatoid
factor
Definition

3. Psoria'c
Arthri's
Clinical
PaBerns
• Distal
predominant
(Distal
inter-­‐phalangeal
joints
of
fingers
and
toes).
• Oligo-­‐ar'cular
(<5
joints)
oKen
in
an
asymmetric
distribu'on.
• Poly-­‐ar'cular
(≥5
joints),
rheumatoid
arthri's-­‐like.
• Spinal
Involvement.
• ‘Arthri's
Mu'lans’.
Moll & Wright, Seminars Arthritis Rheum 1973;32:181

4. Psoria'c
Arthri's
PaBerns
Oligoarthritis Distal Arthritis
è
è

5. Psoria'c
Arthri's
PaBerns
Polyarticular Pattern

6. Psoria'c
Arthri's
PaBerns
Arthritis Mutilans

7. Psoria'c
Arthri's
PaBerns
Arthritis Mutilans Telescoping

8. Psoria'c
Spondyloarthropathy
➨

9. Psoria'c
Spondyloarthropathy
➨ ➨

10. Dactyli's
in
PsA

11. Edema
in
PsA

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

13. Other
Radiological
Features
of
PsA
Tuft resorption
Periostitis

14. Hidden
Psoriasis

15. PsA
Reported
Series*
Feature Roberts Kammer Gladman Torre-
Alonso
Veale Jones
Year 1976 1979 1987 1991 1994 1994
Site Leeds Boston Toronto Spain Leeds Bath
No. 168 100 220 180 100 100
M/F 67/101 45/55 104/116 99/81 59/52 43/57
Age 40 39 37 39 34 38
J < S ? 30 17 15 ? 18
SI NA 11 26 20 14 16
Asymm ? 53 21 45 43 26
Sym. 78 28 48 42 33 63
Distal 17 10 12 1 16 1
Back ? 2 3 7 4 6
Mutilans 5 7 16 5 2 4
*Includes only series with > 100 Patients

16. Psoria'c
arthri's:
A
dis'nct
en'ty
?
• Dutch
study
found
no
associa'on
between
psoriasis
and
polyarthri's.
• No
associa'on
between
HLA
an'gens
and
seronega've
polyarthri's
with
psoriasis.
• No
radiological
features
in
seronega've
polyarthri's
with
psoriasis.
– van
Romunde
LKJ,
et
al.Rheumatology
Interna'onal
1984;4:55-­‐73.
• ?
fortuitous
associa'on
– Cats
A.
Cu's
1990;46:323-­‐329.

17. Psoria'c
arthri's
• Prevalence
of
psoriasis
in
the
general
popula'on:
0.1-­‐2.8%.
• Prevalence
of
psoriasis
in
arthri's
pa'ents:
2.6-­‐7.0%.
• Prevalence
of
arthri's
in
the
general
popula'on:
2-­‐3%.
• Prevalence
of
arthri's
in
psoria'c
pa'ents:
6-­‐42%.
Epidemiological Evidence

18. Psoria'c
arthri's:
A
dis'nct
en'ty
!
• Previous
popula'on
studies.
• Epidemiological
studies.
• Dutch
study
found
DIP
joints
disease
more
common
in
pa'ents
with
seronega've
polyarthri's
and
psoriasis.
• A
dis'nct
form
of
arthri's,
with
different
paBerns,
associated
with
psoriasis.

19. A
comparison
between
Psoria'c
Arthri's
and
Rheumatoid
Arthri's
Psoriatic
Arthritis
Rheumatoid
Arthritis
DIP Involvement Common Uncommon
Symmetry Less Common Common
Erythema of joint Common Uncommon
Back Involvement Common Uncommon
Skin Lesions Always Uncommon
Nail Lesions Common Uncommon
Dactylitis Common Uncommon
Enthesitis Common Uncommon
Rheumatoid nodules Never Common
Rheumatoid Factor Uncommon Common
HLA-B*27 40-50% 4-8%

20. Assessment
of
Tenderness
RA
N=51
PsA
N=50
Test P Value
Fibromyalgia (N) 29 12 Χ2
=9.99 0.0016
Dolorimeter (Kg)
Tender Points
4.77 6.60 t=5.23 <0.0001
Dolorimeter (Kg)
Control Points
5.99 7.58 t=5.18 <0.0001
Dolorimeter (Kg)
Active Joints
4.19 6.78 t=10.18 <0.0001
Psoriatic Arthritis Vs. Rheumatoid Arthritis
Buskila D, et al. J Rheumatol 1992;19:1115-9.

21. Psoria'c
Arthri's
Classified
with
the
Seronega've
Spondyloarthropathies:
– It
is
usually
seronega've
for
rheumatoid
factor.
– It
may
be
associated
with
a
spondyloarthropathy.
– It
is
associated
with
HLA-­‐B27.
Classification

22. Differen'a'ng
PsA
from
other
SpA
Feature PsA AS ReA IBD
M:F 1:1 9:1 8:1 1:1
Age onset 35-45 20 20 Any
Peripheral 96% 25% 90% Common
Distribution Any Axial
Lower limbs
Lower
limbs
Lower
limbs
Dactylitis 35% Uncommon Common Uncommon
Enthesitis Common Common Common Unommon
Sacroiliitis 40% 100% 80% 20%
HLA-B*27 ~50% >90% 80% 40%

23. Psoria'c
Arthri's
Prevalence
• Exact
prevalence
unknown.
• Es'mated
figures
vary
from
0.1%
in
Rochester
Minnesota
to
1.4%
in
the
Faroe
Islands.
• Recent
Survey
by
Na'onal
Psoriasis
Founda'on
suggests
prevalence
of
1.4%
of
general
popula'on
in
the
US.
• Recent
study
from
Toronto
suggests
a
prevalence
of
2.5%.

24. Psoria'c
Arthri's
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) Toronto 126 31
NPF (2002) US 4.4 m 23

25. Psoria'c
arthri's
♦ PsA
is
much
more
serious
than
previously
recognized.
♦ 20%
of
pa'ents
with
PsA
develop
clinical
deformi'es
and
damage,
resul'ng
in
func'onal
disability.
♦ ≥5
deformi'es
were
detected
in
55%
of
pa'ents
aKer
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.
Clinical Outcome

26. The
University
of
Toronto
Psoria'c
Arthri's
Program
Duration <1 yr 1-5 yr 6-10 yr >10 yr
Visit 1st Last 1st Last 1st Last 1st Last
No Deformities 53% 51% 70% 50% 64% 35% 59% 22%
< 5 deformities 28% 30% 20% 28% 17% 28% 26% 23%
≥5 deformities 19% 19% 10% 22% 19% 37% 15% 55%
Development of Deformities during follow-up
Gladman DD. Baillière’s Clinical Rheumatology1994;8:379.

27. Prognos'c
Indicators
in
PsA
• 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
transi'on
between
damage
states.
Clinical Indicators of Progression
Gladman DD et al. J Rheumatology 1995;22:675.

28. Prognos'c
Indicators
in
PsA
Relative Risk
Variable 1 to 2 2 to 3 3 to 4 Χ2
P value
> 4 Effusions 1.6 1.6 1.6 5.7 0.017
ESR < 15 0.61 0.61 - 6.68 0.01
Rx 1.78 1.78 1.78 7.8 0.005
Steroids 1.55 1.55 1.55 5.46 0.019
Multivariate model for Clinical Indicators
of Clinical Progression*
Gladman DD et al. J Rheumatology 1995;22:675.
*Based on clinical features at presentation

29.
Prognos'c
Indicators
in
PsA
Variable Relative Risk X2
P value
1 to 2 2 to 3 3 to 4
B22 0.19 0.19 0.19 0.002
B27 1.06 1.06 1.06 0.06 0.81
B27xDR7 2.47 2.47 2.47 5.39 0.02
B39 7.05 - - 16.40 <0.001
DR7 0.83 0.83 0.83 0.63 0.43
DQw3 1.63 0.63 1.63 6.86 <0.001
DQw3xDR7 0.54 0.54 0.54 3.09 0.08
> 4 Efusions 1.27 1.27 1.27 1.18 0.28
ESR < 15 0.83 0.83 0.83 1.91 0.17
High Past Rx 2.25 2.25 2.25 8.10 0.004
Steroids 1.58 1.58 1.58 6.73 0.0001
Multivariate Model for Clinical Damage
Gladman DD & Farewell VT. Arthritis Rheum 1995;38:845.
Gladman DD, et al. J Rheumatol 1998;25:730.

30. Prognos'c
Indicators
in
Psoria'c
Arthri's
Factor Relative
Damage Rate
95% CI P value
No. AJ 1.04 1.02,1.07 <0.001
↓ FC 1.86 1.05,2.16 0.027
Male gender 0.65 0.47,0.92 0.013
Current Damage 3.95 2.52,6.20 <0.001
Initial ESR 0.61 0.42,0.90 0.013
Pre Clinic Rx 1.83 1.20,2.79 0.005
Final Multivariate Model for Time Varying Clinical Indicators
Gladman DD, Farewell VT. J Rheumatol 1999;26:2409

31. Outcome
in
Psoria'c
arthri's
♦ PsA
pa'ents
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
popula'on.
♠ Risk
of
death
is
related
to
previously
ac've
and
severe
disease.
Wong K, et al. Arthritis Rheum 1997;40:1868-7.
Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.
Mortality Studies

32. Mortality
in
Psoria'c
Arthri's
Primary Cause N (%)
Circulatory system 17 (36.2)
Myocardial Infarction 13 (27.6)
Cerebrovascular accident 2 ( 4.3)
CHF/arteriosclerosis 2 ( 4.3)
Respiratory system 10 (21.3)
Pneumonia 7 (14.9)
COPD 3 ( 6.4)
Digestive system (liver) 4 ( 8.5)
Malignant neoplasms 8 (17.0)
Injuries/poisoning 7 (14.9)
Other 1 ( 2.1)
Total known cause 47 ( 100)
Primary causes of death in 53 patients

33. Survival in Psoriatic Arthritis
Time Since Clinic Entry (Years)
SurvivalProbability
0 5 10 15 20
0.50.60.70.80.91.0
All patients

34. Mortality
in
Psoria'c
Arthri's
Factor Relative
risk
Confidence
interval
P
value
Prior Medication 1.83 0.93, 3.60 0.079
Radiological damage 3.88 1.32,11.35 0.014
ESR > 15 3.77 1.31,10.83 0.013
Nail changes 0.33 0.14, 0.76 0.009
Prognostic Factors: Final Multivariate Model
Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.

35. Remission
in
Psoria'c
Arthri's
Summary
♦ Remission
occurred
in
17.6%
of
our
PsA
pa'ents.
♦ Male
gender
and
less
ac've
and
severe
arthri's
at
presenta'on
to
Clinic
were
associated
with
remission.
♦ Only
6
(8.7%)
of
the
PsA
pa'ents
sustained
“true
remission”,
♦ 35
(52%)
had
subsequent
flares.
Gladman DD et al. J Rheumatol 2001;28:1045-8.

36. Psoria'c
Arthri's
Prognos'c
Factors
☛ Progression
of
Damage:
✦
High
effusion
count
at
presenta'on
✦
High
joint
count
at
each
visit
✦
High
medica'on
level
at
presenta'on
✦
Low
ESR
is
“protec've”
☛ Death:
8
Elevated
ESR
8
High
prior
medica'on
level
8
Radiological
Damage
☛ Remission
8 Male
Gender
8 Low
joint
count
at
presenta'on

37. Psoria'c
Arthri's
Not
just
skin
and
joints!
• An
inflammatory
arthri's
associated
with
psoriasis.
• More
common
than
previously
thought.
• About
one
fiKh
of
the
pa'ents
have
a
severe
debilita'ng
disease,
although
some
pa'ents
achieve
remission.
• Earlier
studies
sugges'ng
that
PsA
was
a
mild
disease
included
pa'ents
with
early
disease.