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Psoriatic Arthritis

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Topic updated on 09/13/17 1:38pm

Snapshot
  • A 40-year-old woman presents to the physician's office for joint stiffness in her hands. She reports stiffness every morning in only her right hand and left foot. She recently started an intensive topical regimen of topical steroids and calcipotriene for a psoriasis flare up a week ago. Although the topical regimen is helping with her psoriatic skin lesions, her joint stiffness has not improved. She is started on a systemic medication for her skin lesions and joint stiffness.
Introduction
  • Clinical definition
    • seronegative spondyloarthritis associated with skin psoriasis
  • Epidemiology
    • incidence
      • < 1% of population
      • 20-30% of patients with psoriasis
    • demographics
      • peak incidence in 30-50 years of age
    • risk factors
      • scalp psoriasis
      • nail lesions in psoriasis
  • Etiology
    • idiopathic
  • Pathogenesis
    • ↑ interferon-α, IL-6, tumor necrosis factor-α, and other inflammatory markers recruit T-cells into the skin and joints
    • osteoclasts are exposed to inflammatory molecules in the psoriatic joint, triggering osteoclast activation and causing osteolysis
  • Associated conditions
    • skin psoriasis
    • other HLA-B27 autoimmune diseases
Presentation
  • Symptoms
    • asymmetric joint involvement 
      • often distal interphalangeal joint (DIP)
      • spine can be involved
    • joint pain
    • joint stiffness in the morning
  • Physical exam
    • swelling in the affected joints
      • in particular, hands > feet
    • dactylitis
      • inflammation of entire digit causing the finger to look like a sausage
    • psoriatic lesions
      • sharply demarcated pink plaque with silvery scale
      • pitting nails
    • uveitis
    • sacroiliitis
Imaging
  • Radiographs
    • indication
      • to confirm diagnosis
    • recommend views
      • affected joints
    • findings
      • bone proliferation and bone resorption
      • pencil-in-cup deformity of DIP, demonstrating erosive changes
Studies
  • Labs
    • negative rheumatoid factor
    • positive HLA-B27
Differential
  • Ankylosing spondylitis
  • Rheumatoid arthritis
    • metacarpal phalangeal joint involvement, not DIP
Treatment
  • Conservative
    • weight loss
      • indications
        • for patients who are overweight
        • may reduce disease activity in psoriatic arthritis
  • Medical
    • treatment for skin psoriasis, review here
    • nonsteroidal anti-inflammatory drugs (NSAIDs)
      • indication
        • first-line therapy for mild joint symptoms
    • disease-modifying antirheumatic drugs (DMARDs)
      • indication
        • if patients have > 5 joints involved, radiographic damage, or elevated inflammatory markers
      • drugs
        • methotrexate
        • leflunomide
        • sulfasalazine
        • apremilast
        • tumor necrosis factor-α inhibitors
        • anti-interleukin agents
          • ustekinumab
          • secukinumab
Complications
  • Cardiovascular disease
  • Joint deformities


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