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Postgrad Med J: first published as 10.1136/pgmj.58.682.477 on 1 August 1982. Downloaded from

Postgraduate Medical Journal (August 1982) 58, 477-480

Psoriasis and J. N. FORDHAM G. O. STOREY B.Sc., M.R.C.P. M.D., F.R.C.P. Department of , The London Hospital, Whitechapel, London El 2AD

Summary an inflammatory associated with the Ten cases of gouty are described in associa- psoriatic diathesis. Attacks of gout in patients with tion with . Eight were receiving intensive in- psoriasis have been described (Bonim and Kimberg, patient treatment for their skin condition. Diagnosis 1962; Kaplan and Klatskin, 1960; Kuzell et al., 1955; was based on clinical grounds or, in 3 cases, by Leonard, O'Duffy and Rogers, 1978; Moll and of Wright, 1973b; Venkatasubramanian, Blumm and compensated polarizing microscopy (CPM) syno- Riddle, 1980; Zimmer and Demis, 1966). Some of vial fluid. All patients were male and 5 of them had these studies conditions other than psoriasis known to predispose have suffered from being ofa retrospec- The to fit into tive nature and diagnostic criteria for gout have not to hyperuricaemia. patients appeared always been clear. To the best of our knowledge in three groups: five had typical lower limb gout none of these series were urate crystals identified in occurring in conjunction with long-standing extensive the . However, the study of Baker psoriasis; 3 patients had preceding features of inflam- by copyright. matory , one of whom subsequently devel- (1966) failed to find one case of gout in 650 cases of oped typical distal interphalangeal involvement of psoriasis even though he was looking specifically for peripheral ; two patients appeared arthritis. We report here our experience of the study to have coincident gout and psoriasis. ofa large in-patient dermatological population over a We believe that an association of gout with period of 11 years. extensive long-standing psoriasis may exist particu- larly in male patients with an additional cause for The patients hyperuricaemia. Long-term studies of a large popula- tion of psoriatics are required. Previous reports may The patients studied were seen at St John's have underestimated the incidence of gout because of Hospital for Diseases of the Skin between 1969 and http://pmj.bmj.com/ failure to examine synovial fluid for crystals particu- 1980. All were in-patients except patients 4 and 10 larly from those patients with a subacute large who had been referred to the Department of Rheu- arthropathy. matology, Hackney Hospital. Patients satisfied clini- cal and epidemiological criteria for diagnosis of gout Introduction (Bennet and Wood, 1966). Where possible synovial fluid was examined for crystals using compensated The clinical features of gout are usually those of polarizing microscopy (CPM). attacks of acute severely painful com- Details of the cases are shown in the Table. Our on September 24, 2021 by guest. Protected monly affecting the big . Untreated such attacks patients appear to fall into three groups: The largest resolve over 3 to 10 days; prompt treatment with group (cases 1, 2, 3, 4, 5) appeared to develop gouty or non-steroidal anti-inflammatory drugs arthritis complicating longstanding extensive psoria- relieves symptoms over 24 to 48 hr. Urate crystals are sis. Four of the 5 had typical lower limb acute gout, present in the synovial fluid and prolonged hyperuri- and all patients had a good response to non-steroidal, caemia is a prerequisite for gout to occur. Hyperuri- anti-inflammatory drugs (NSAID). Four patients caemia can be due to an inherited metabolic abnor- had causes other than psoriasis for a raised plasma mality as in primary gout, or secondary to an , cases 3 and 5 were receiving as acquired condition. treatment for and cases 1 and 2 had Psoriatic arthritis takes at least 5 different forms, evidence of alcoholic hepatitis. (Moll and Wright, 1973a), all of which are character- The second group (cases 6, 7, 8) had features of a ized by absence of and features of low grade synovitis before the diagnosis ofgout. Case 0032-5473/82/0800-0477 $02.00 © 1982 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.58.682.477 on 1 August 1982. Downloaded from

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Psoriasis and gout 479 7 went on to develop typical terminal interphalangeal swelling of both knees lasting up to 3 months at a involvement of psoriatic arthritis with . time and associated with morning stiffness usually Cases 6 and 8 suffered recurrent bouts of knee less than one hour. This was controlled with a variety effusion associated with morning stiffness. The onset of non-steroidal anti-inflammatory drugs. For the of gout was subacute in two of the three and it was in previous 3 years the psoriasis had become more those with knee involvement in which crystals were extensive and had been treated with identified in synovial fluid (cases 2, 6 and 8). A and subsequently with hydroxyurea. Because ofpoor moderate response to NSAID (in terms oftime taken control he was admitted for further treatment with for relief of pain and swelling) was a feature of this dithranol. Examination showed extensive psoriasis group. involving trunk, legs and scalp, toe and nails Cases 9 and 10 appear to represent the coincidence showed dystrophic changes with pitting. He had of psoriasis with gout. The skin lesion is difficult to bilateral, warm, knee effusions. Serum urate was 0 52 implicate in the pathogenesis of the hyperuricaemia mmol/litre. X-ray of knees showed no abnormality. because the skin involvement was trivial and ofshort Aspiration of the left knee joint synovial fluid duration. Case 10 was associated with a high revealed numerous urate crystals identified by CPM. intake and case 9 was a publican. High alcohol intake The fluid contained 13-3 X 109/litre white cells with may have played a part in the production of 89% polymorphs. Treatment with indomethacin 50 hyperuricaemia in both of these cases. Typical case mg three times daily resulted in regression of pain reports are given. and effusion over one week. The patient had no further joint complaints when seen at 6 months Case 1 follow-up. A 44-year-old salesman with a 5-year history of extensive psoriasis involving all four limbs and trunk Case 9 was admitted to hospital because of worsening of his A 54-year-old publican was referred to hospital skin condition previously controlled with topical because of an acutely painful right first metatarso- by copyright. steroids. He had been seen two years before following phalangeal joint. He had had eight such attacks over a severe attack of pain and swelling of the right first the preceding 20 years involving the same joint and metatarsophalangeal joint and had been found to be usually relieved by bed rest over 2-3 weeks. Over the hyperuricaemic. Following initial treatment with preceding 18 months he had developed a few indomethacin 50 mg 3 times daily he was com- psoriatic plaques over his knees and elbows. Alcohol menced on 100 mg 3 times daily but intake was 34 pints/day. Examination revealed a discontinued this after a few months. Alcohol con- swollen tender right first metatarsophalangeal joint sumption was between 3 to 4 pints of beer per day with redness and a few extensor surface psoriatic over 24 years. Examination revealed widespread plaques. Blood uric acid was 0 55 mmol/litre. He was affecting trunk, legs and arms, with treated with 100 mg 3 times daily http://pmj.bmj.com/ scalp plaques; nail pitting was a feature of some toe and symptoms abated over one day. nails. He was treated with topical dithranol. One week after admission he developed an acutely tender left subtalar swelling with redness of the skin. This took him off his feet. Treatment with indomethacin Discussion 50 mg 3 times daily relieved pain and swelling over This study cannot reflect the incidence of gout in 2 days. Serum urate at this time was 0 5 mmol/ the psoriatic population as a whole. The

patients on September 24, 2021 by guest. Protected litre (normal 02-0A42 mmol/litre). Slide latex test were drawn from a highly selected group with negative; erythrocyte sedimentation rate 75 mm/hr, unusually extensive disease requiring intensive in- neutrophilia. Following discharge the patient has patient treatment. Nor can it prove a causative remained asymptomatic but has a persistently association ofpsoriasis with gout-this would require elevated serum uric acid. long-term study ofa large population ofpatients with psoriasis. However, some of the cases described Case 6 suggest that there is a significant association between the two diseases. This 55-year-old Ugandan Asian had suffered with Mean uric acid levels appear higher in psoriasis psoriasis localized to his scalp for 26 years. Twelve especially when the disease is severe (Baker and years previously he had had an episode of acute pain Wilkinson, 1979). It is of interest that all the patients and swelling of the left first metatarsophalangeal were male and that 5 had other conditions known to joint which confined him to bed. This resolved over 3 predispose to hyperuricaemia. Some had several such weeks with bed rest. Since that time he had recurrent conditions raising the possibility of a cumulative Postgrad Med J: first published as 10.1136/pgmj.58.682.477 on 1 August 1982. Downloaded from

480 J. N. Fordham and G. 0. Storey effect on raising plasma urate. Thus case 10 had Acknowledgments extensive psoriasis being treated with phototherapy We wish to thank the physicians ofSt John's Hospital for Diseases and was coincidentally uraemic and receiving a of the Skin for permission to study and report their cases. for hypertension. Most of our patients required energetic drug treatment-a factor which may have contributed to hyperuricaemia. References Our findings of gout in association with psoriasis BAKER, H. (1966) Epidemiological aspects of psoriasis and arthritis. variance with the of Baker who British Journal of Dermatology, 78, 249. are at study (1966) BAKER, H. & WILKINSON, D.S. (1979) Psoriasis. In: Textbook of failed to find any case of gout in an out-patient study Dermatology (Ed by Rook, A., Wilkinson, D.S. & Ebling, F.J.G.), of 650 cases of psoriasis. This is explicable on the 3rd edn, p. 1334. Blackwell Scientific Publications, Oxford. basis of the highly selected nature of the patients, in BARBER, H.W. (1931) A case ofpsoriatic arthropathy. British Journal the severest form of a of Dermatology, 43, 188. the present study reflecting BENNETT, R.H. & WOOD, P.H.N. (1966) Population studies of the usually mild disease. Other studies (Bonim and rheumatic diseases. In: Proceedings of the 3rd International Kimberg, 1962; Kaplan and Klatskin, 1960; Kuzell et Symposium, Excerpta Medica Foundation, New York. al., 1955; Leonard et al., 1978) have reported a BONIM, J.J. & KIMBERG, D.V. (1962) The syndrome of , association of with The psoriasis and gout. Annals of Internal Medicine, 57, 1018. significant gout psoriasis. KAPLAN, M. & KLATSKIN, G. (1960) Sarcoidosis, psoriasis and gout. study from the Mayo Clinic (Leonard et al., 1978) Syndrome of coincidence? Yale Journal of Biology and Medicine, found that the incidence of gout among hospitalized 3, 2335. psoriatics was 5% compared with 0 18% in a control KUZELL, W.C., SCHAFFARZICK, R.W., NAUGLER, W.E., KOETS, P., group-a highly significant difference. MANKLE, E.A., BROWN, B. & CHAMPLIN, B. (1955) Some observations on 520 gouty patients. Journal ofChronic Diseases, 2, It is well recognized that psoriatic arthritis may 645. mimic gout (Barber, 1931; Sherman, 1952). In LEONARD, D.W., O'DUFFY, I.D. & ROGERS, R.S.II. (1978) Prospec- Wright's study (1959) this was particularly so in the tive analysis of psoriatic arthritis in patients hospitalized for psoriasis. Proceedings ofthe StaffMeetings ofthe Mayo Clinic, 53, subgroup of male patients with distal interphalangeal 511. involvement. The 3 cases in which synovial fluid MOLL, J.M. & WRIGHT, V. (1973a) Psoriatic arthritis. Seminars in

examination revealed uric acid crystals all had a Arthritis and , 3, 55. by copyright. subacute onset and finding of crystals was unex- MOLL, J.M. & WRIGHT, V. (1973b) Familial occurrence of psoriatic pected and emphasizes the importance of looking for arthritis. Annals of the Rheumatic Diseases, 32, 181. SHERMAN, M.S. (1952) Psoriatic arthritis: Observations on clinical crystals even in those patients in whom it is not roentgenographic and pathologic changes. Journal of Bone and clinically diagnosed. Venkatasubramanian and col- Joint Surgery, 34A, 831. leagues (1980) have recently described the associa- VENKATASUBRAMANIAN, K.V, BLUMM, G.G. & RIDDLE, J.M. (1980) Psoriatic arthropathy and crystal-induced synovitis. Jour- tion of psoriatic arthritis with true and pseudo-gout. nal of Rheumatology, 7, 213. This, together with our own findings, raises the WRIGHT, V. (1959) Rheumatism and psoriasis. American Journal of possibility of crystal-induced synovitis being impli- Medicine, 27, 454. cated in some cases of 'psoriatic arthritis'. Failure to WYNEGAARDEN, J.B. & KELLEY, W.N. (1976) Gout and Hyperurica- emia, p. 383. examine fluid for crystals may have led to Grune & Stratton, New York. http://pmj.bmj.com/ synovial ZIMMER, J.G. & DEMIS, D.J. (1966) Associations between gout, underestimation of the association of gout with psoriasis and sarcoidosis with consideration of their pathogenic psoriasis. significance. Annals of Internal Medicine, 64, 786. on September 24, 2021 by guest. Protected