Arthritis, sub-types of arthritis Comprehensive information on Psoriatric Arthritis

1. PSORIATIC ARTHRITIS
POKHREL, BHARAT

2. DEFINITION
Chronic progressive, inflammatory
disorder of the joints and skin
One of the Spondyloarthropathies
Males and females are equally affected

3. EPIDEMIOLOGY
Affects men & women equally
Occurs in 4-6% up to 30% of patients
with known psoriasis
60 – 70%: Skin psoriasis first
15%: Psoriatic arthritis first
15%: Skin and arthritis diagnosed at same
time

4. ETIOLOGY
 Genetic Factors
 Immunologic Mechanisms
 Environmental
 Trauma – Koebner phenomenon: Psoriatic lesions
arising at site of trauma (24-52%); development of
PsA after trauma to joint.
 Bacterial infections - association between guttate
psoriasis and streptococcal pharyngitis; up to 30%
of PsA synovial tissue-derived T cells proliferate
following exposure to group A strep

5. GENETIC FACTORS
Has been known to occur in families
Up to 40% psoriasis or PsA have a
family history in first degree relative
Tends to be concordant among
monozygotic twins more commonly than
dizygotic

6. ROLE OF TNF
Released predominantly by cells of the
monocyte/macrophage lineage
Accumulation of T-cells, infiltration of
synovium: TNF-mediated production of
factors that attract T-cells – monocyte
chemoattractant protein-1 and
macrophage inflammatory protein 3
alpha
Induces lymphocyte and neutrophil
migration into synovium

7. TNF in PsA
 High levels of TNF-α in PsA synovium
 Marked up regulation of TNF-α in PsA synovial
membrane
 Inflammation of synovium, enthesis and bone
 TNF-α transgenic mice – bone destruction
 Promotes release of matrix-degrading
metalloproteinases
 Enhances secretion of pro-inflammatory
cytokines (IL-1, IL-6, IL-8)
 Potentiates osteoclastic bone resorption

9. DIFFERENTIAL DIAGNOSIS
 Rheumatoid Arthritis
 Symmetric
 PIP, MCP, not distal
 Ulnar deviation,
swan neck
deformities
 Rheumatoid
nodules
 Ankylosing Spondylitis
 Strong HLA B27
association
 Male predominance
 Axial skeletal
involvement –
sacroilitis
 Bamboo spine
 Schober test
demonstrating limited
flexion

10. DIFFERENTIAL DIAGNOSIS
 Reactive Arthritis
 1-4 weeks after an
infection
 Infectious agents:
 Shigella
 Salmonella
 Yersinia
 Campylobacter
 Chlamydia
 Triad: urethritis,
conjunctivitis, arthritis
 Keratoderma
Blennorhagicum
 Inflammatory Bowel
Disease Associated
 Crohn’s

11. TYPES OF PSORIATRIC ARTHRITIS
ASYMMETRICAL INFLAMMATORY
OLIGOARTHRITIS
SYMMETRICAL POLYARTHRITIS
DISTAL IPJ ARTHRITIS
PSORIATRIC SPONDYLITIS
ARTHRITIS MUTILANS

13. CASPAR Criteria for the Classification of PsACASPAR Criteria for the Classification of PsA
 Inflammatory articular disease (joint, spine, or
entheseal)
 With ≥3 points from following categories:
− Psoriasis: current (2), history (1), family history (1)
− Nail dystrophy (1)
− Negative rheumatoid factor (1)
− Dactylitis: current (1), history (1) recorded by a
rheumatologist
− Radiographs: (hand/foot) evidence of juxta-articular
new bone formation
 Specificity 98.7%, Sensitivity 91.4%
Taylor et al. Arthritis & Rheum 2006;54: 2665-73

14. MAIN FEATURES OF PSAMAIN FEATURES OF PSA
Helliwell PS & Taylor WJ. Ann Rheum Dis 2005;64(2:ii)3-8
Fitzgerald “Psoriatic Arthritis” in Kelley’s Textbook of Rheumatology, 2009
*Low levels of RF and ACPA can be found in 5-16% of patients; **To a lesser degree than in RA
***Spinal disease occurs in 40-70% of PsA patients

15. HALLMARK CLINICAL FEATURES IN PSA
D a c t y lit is E n t h e s it is
P s o r ia t ic A r t h r it is
Ritchlin C. J Rheumatol. 2006;33:1435–1438.
Helliwell PS. J Rheumatol. 2006;33:1439–1441.

16. DACTYLITIS
ACR Slide Collection on the Rheumatic Diseases; 3rd
edition. 1994.
1
Brockbank J, et al. Ann Rheum Dis. 2005;64:188–190.
2
Veale D, et al. Br J Rheumatol. 1994;33:133–38.
• Diffuse swelling of a digit may be acute, with painful
inflammatory changes, or chronic wherein the digit remains
swollen despite the disappearance of acute inflammation1
• Also referred to as
“sausage digit”1
• Recognized as one
of the cardinal
features of PsA,
occurring in up
to 40% of patients.
• Feet most commonly
affected

17. ENTHESITIS
Entheses are the
regions at which a
tendon, ligament, or
joint capsule attaches
to bone
Inflammation at the
entheses is called
enthesitis
1
McGonagle D. Ann Rheum Dis. 2005;64(Suppl II):ii58–ii60.
2
Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338–343.
3
Salvarani C. J Rheumatol. 1997;24:1106–1140.

18. DIAGNOSTICS
No specific diagnostic tests
Diagnosis made on clinical and
radiological basis: Helps to rule out with
other types of arthritis
Elevation of ESR, C- reactive protein
level : Helps to track the activity of
disease by measuring inflammation

19. RADIOGRAPHIC EVALUATION
Pencil in Cup Deformity

20. TREATMENT
1 – NSAIDS
2 – DMARDS
Methotrexate (MTX) – Drug of choice
Leflunomide
Sulfasalazine
Cyclosporine
TNF α inhibitor
Coordinate b/w Rheumatology and
Dermatology

21. DIETARY CONSIDERATIONS
 For people who have morning stiffness, the optimal time for
taking an NSAID may be after the evening meal and again
upon awakening.
 Taking NSAIDs with food can reduce stomach discomfort.
 Any NSAID can damage the mucous layer and cause
ulcers and GI bleeding when taken for long periods.
 Cyclooxygenase (COX)–2 selective inhibitors are
associated with a lower prevalence of gastric ulcer
formation.

22. PHYSICAL THERAPY IN PSORIATIC
ARTHRITIS
 The rehabilitation treatment program should be
individualized and should be started early in the
disease process. Such a program should consider the
use of the following:
 Rest
 Exercise - Passive, active, stretching, strengthening,
and endurance
 Modalities - Heat, cold
 Orthotics - Upper and lower extremities

23. THANK YOU