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Psoriatic Arthritis

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Psoriatic arthritis (PsA)\: in
typical onset 30-50 years, a
Aetiology\: strong genetic association (HLA-B27); immune-mediated in
seronegative (negative for rheumatoid factor and anti-CCP).
Risk factors\: personal or family history of psoriasis or psoriatic arthritis, history of joint trauma.
Symptoms\: joint pain, morning sti
joints, small joints of hands.
Patterns of joint involvement\: asymmetric oligoarthritis (most common), distal interphalangeal dominant, symmetric
polyarthritis, spondylitis, arthritis mutilans.
Clinical

Extra-articular manifestations\: mitral valve prolapse, aortic root dilation, aortic regurgitation, uveitis, urethritis.
Di
deposition disease (CPPD).
Investigations\: RF and anti-CCP (usually negative), in
osteophytes), MRI of SIJ (joint oedema).
Management\: NSAIDs, intraarticular glucocorticoid injections, DMARDs (methotrexate, le
biologics (TNF-a inhibitors, ustekinumab, secukinumab, tofacitinib); pre-biologic screening for infections (TB, HIV, hepatitis
B/C).
Complications\: cardiovascular disease (higher prevalence of obesity, dyslipidaemia), joint erosion (rapid hip joint
deterioration, potential need for arthroplasty).
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A comprehensive topic overview

Introduction

Psoriatic arthritis (PsA) is in
psoriasis and can occur either before, during or after the onset of psoriatic skin changes.
1,2
The typical age of onset is 30-50 years old, with males and females equally a
2

Aetiology

There is a strong genetic association as the majority of patients with PsA have at least one
with psoriasis or psoriatic arthritis.
3
PsA belongs to a group of seronegative in
(HLA-B27) is commonly implicated.
4
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As PsA is a seronegative arthropathy, blood tests for rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP)
are usually negative.

Pathophysiology

PsA results from an immune-mediated in
tends to occur in patients with a genetic predisposition who are exposed to an environmental factor (e.g. joint trauma).

Risk factors

Risk factors for psoriatic arthritis include\:
Personal history of psoriasis
First degree relative with psoriasis or psoriatic arthritis
History of joint trauma

Clinical features

History

Typical symptoms of psoriatic arthritis include\:
Joint pain
Morning sti
Constitutional symptoms\: fatigue, malaise and low-grade fevers
The most common joints involved are the spine, sacroiliac joints (SIJ) and the small joints of the hands.
There are
1
Asymmetric oligoarthritis\: less than four joints a
Distal interphalangeal dominant\: arthralgia of DIPs of
Symmetric polyarthritis\:
Spondylitis\: in
Arthritis mutilans\: a rare and severe destructive arthropathy of the small joints in the hands and toes, coinciding with
severe dactylitis
The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) de
following constellation of articular and extra-articular symptoms\:
5
Peripheral arthritis\: joints of hands, feet, arms, leg
Axial disease\: lower back and neck
Enthesitis\: in
Dactylitis\: in
Skin psoriasis\: plaques on extensor surfaces neck; dystrophic nail changes (hyperkeratosis, pitting, ridging)
In

Clinical examination

Typical clinical
6
Swelling of the a
Tenderness of the a
Reduced range of motion
Achilles tendonitis
Epicondylitis (enthesitis of the elbow)
Dactylitis
Lumbar spine
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Figure 1. The modi
used to assess lumbar spine
measuring the distance between 2 points
while the spine is in neutral alignment
and while the spine is forward

Extra-articular manifestations

The following extra-articular manifestations are associated with seronegative spondyloarthropathies\:
Mitral valve prolapse
Aortic root dilation
Aortic regurgitation
Uveitis
Urethritis

Di

Di
Rheumatoid arthritis (RA)
Reactive arthritis
Sarcoidosis
Ankylosing spondylitis
Calcium pyrophosphate deposition disease (CPPD)

Investigations

Laboratory investigations

Relevant laboratory investigations include\:
Rheumatoid factor (RF)\: a de
likelihood of PsA
Anti-cyclic citrullinated peptide (anti-CCP)\: this
rather than PsA
In
can indicate the degree of joint in

Imaging

Relevant imaging investigations include\:
X-ray of a
bone formation (osteophytes). In advanced disease, there may be “pencil in cup deformity” at the DIP
X-ray of the sacroiliac joints (SIJ)\: usually normal in the initial stages, but it is important to obtain a baseline radiograph
for assessing disease progression
MRI of SIJ\: looking for joint oedema (not routinely performed due to low speci

Diagnosis

The diagnosis for PsA is a clinical diagnosis based on history and examination.
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The CASPAR classi can be used to aid in the diagnosis, but it is intended for research, not clinical practice.
7

Management

Medical management

The goal of management is to control joint in
Management options include\:
Non-steroidal anti-in
e
Intraarticular glucocorticoid injection\: reduce arthralgia but can aggravate skin symptoms (not routinely done)
Disease-modifying antirheumatic drugs (DMARDs)
Typical DMARDs used in the management of psoriatic arthritis include\:
Methotrexate (MTX)\: an antifolate drug that is e
e
8
Le
Sulfasalazine
Biologics
Biologics are monoclonal antibodies that can target speci
Biologics used in the management of psoriatic arthritis include\:
Tumour necrosis factor-alpha (TNF-a) inhibitors\: an e
with axial joint symptoms
Ustekinumab (Stelara®)\: blocks IL-12 and IL-23 which inhibits T cell activation in an alternate in
TNF-a, so considered in those who do not respond to TNF-a inhibitors
Secukinumab (Cosentyx®)\: blocks IL-17 in an which is another potential target for treatment a
not respond to initial therapy
Tofacitinib (Xeljanz®)\: JAK inhibitors are a newer class of biologics that can be considered when the initial treatment
options don’t work
Pre-biologic screening tests
Patients need to be screened for underlying infections that may become reactivated when biologics are initiated.
Pre-biologic assessment should include testing for\:
Tuberculosis\: chest X-ray and interferon-gamma release assay (IGRA) blood test
HIV\: viral serology
Hepatitis B\: viral serology
Hepatitis C\: viral serology

Complications

Complications of psoriatic arthritis include\:
Cardiovascular disease\: PsA is associated with a higher prevalence of obesity and dyslipidaemia, so patients are at an
increased risk for cardiovascular disease
9
Joint erosion\: those with bilateral spondylitis may show rapid joint deterioration of the hip and need arthroplasty
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References

Alinaghi, F., Calov, M., Kristensen, L. E., Gladman, D. D., Coates, L. C., Jullien, D., Gottlieb, A. B., Gisondi, P., Wu, J. J., Thyssen, J.
P., & Egeberg, A. (2019). Prevalence of psoriatic arthritis in patients with psoriasis\: A systematic review and meta-analysis of
observational and clinical studies. J o u r n a l o f t h e A m e r i c a n A c a d e m y o f D e r m a t o l o g y , 8 0 (1).
Gladman, D. D. (2005). Psoriatic arthritis\: epidemiology, clinical features, course, and outcome. A n n a l s o f t h e R h e u m a t i c
D i s e a s e s , 6 4 (suppl_2), ii14–ii17.
Di Lernia, V., Ficarelli, E., Lallas, A., & Ricci, C. (2014). Familial aggregation of moderate to severe plaque psoriasis. C l i n i c a l a n d
E x p e r i m e n t a l D e r m a t o l o g y , 3 9 (7), 801–805.
FitzGerald, O., Haroon, M., Giles, J. T., & Winchester, R. (2015). Concepts of pathogenesis in psoriatic arthritis\: genotype
determines clinical phenotype. A r t h r i t i s R e s e a r c h & T h e r a p y , 1 7 (1).
Coates, L. C., Kavanaugh, A., Mease, P. J., Soriano, E. R., Laura Acosta-Felquer, M., Armstrong, A. W., Bautista-Molano, W.,
Boehncke, W.
-H., Campbell, W., Cauli, A., Espinoza, L. R., FitzGerald, O., Gladman, D. D., Gottlieb, A., Helliwell, P. S., Husni, M.
E., Love, T. J., Lubrano, E., McHugh, N., … Ritchlin, C. T. (2016). Group for Research and Assessment of Psoriasis and Psoriatic
Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis. A r t h r i t i s & R h e u m a t o l o g y .
Korean Academy of Rehabilitation Medicine. M o d i CC BY-NC
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Taylor, W., Gladman, D., Helliwell, P., Marchesoni, A., Mease, P., & Mielants, H. (2006). Classi
arthritis\: Development of new criteria from a large international study. A r t h r i t i s & R h e u m a t i s m , 5 4 (8), 2665–2673.
Black, R. L., O'Brien, W. M., Van Scott, E. J., Auerbach, R., Eisen, A. Z., & Bunim, J. J. (1964). Methotrexate Therapy in Psoriatic
Arthritis. J A M A , 1 8 9 (10).
Gladman, D. D., Ang, M., Su, L., Tom, B. D., Schentag, C. T., & Farewell, V. T. (2008). Cardiovascular morbidity in psoriatic
arthritis. A n n a l s o f t h e R h e u m a t i c D i s e a s e s , 6 8 (7), 1131–1135.

Reviewer

Dr Grainne Murphy
Consultant Rheumatologist

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Contents

Introduction
Aetiology
Risk factors
Clinical features
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