sign in sign up
<<
Home , Rheumatology

Peripheral joint involvement in psoriatic patients M.L. Acosta Felquer1, O. FitzGerald2

1Rheumatology Section, Medical Services, ABSTRACT associated with features including joint Italiano de Buenos Aires, Peripheral joint involvement is a com- fusion and deformities, asymmetrical Instituto Universitario Escuela de mon, potentially debilitating feature of , and dactylitis (7, 8). Medicina, Hospital Italiano de Buenos (PsA). Joint involve- In the last few years much interest has Aires, CABA, Buenos Aires, Argentina. 2Department of Rheumatology, ment is commonly symmetrical and focused on the development of new St Vincent’s University Hospital, polyarticular similar to rheumatoid ar- biological markers in rheumatic diseas- Dublin, Ireland. thritis (RA) but it can also be oligoar- es. Biomarkers can be used in clinical Maria Laura Acosta Felquer, MD ticular, asymmetrical or occasionally practice in a number of ways includ- Oliver FitzGerald, MD, FRCPI, monoarticular. Involvement of the distal ing diagnosis and prognosis but they FRCP(UK) interphalangeal joints is a feature which can also be used to predict response to Please address correspondence to: distinguishes PsA from RA. Articular in- treatment. Biomarkers have been de- Prof. Oliver FitzGerald, volvement in PsA can be severe with a scribed but not yet proven as predict- Department Rheumatology, mutilating found in about ing early psoriatic arthritis in PsO pa- St. Vincent’s University Hospital, 5%. These patients are characterised tients such as CD16 and dendritic cell Elm Park, clinically by digital shortening and on Dublin 4, Ireland. specific transmembrane protein (DC- E-mail: [email protected] radiographs by erosion on both sides of STAMP) (9). DC-STAMP is expressed Received and accepted on August 26, 2015. the joint and/or osteolysis. Treatments on the surface of osteoclast precursors targeting joint disease frequently re- (OCPs) which stimulate the formation Clin Exp Rheumatol 2015; 33 (Suppl. 93): S26-S30. duces symptoms and signs resulting in of resorbing osteoclasts (OCs) prevention of damage progression. (10). The use of biomarkers and also © Copyright Clinical and Experimental Rheumatology 2015. imaging could help identify Introduction PsA in patients with PsO, thus opening Key words: psoriatic arthritis, Psoriatic arthritis (PsA) is a multifac- up the possibility of early intervention peripheral joint involvement eted disease that includes features of improving patient outcome. peripheral joint and axial involvement, enthesitis, dactylitis and extra-articular Peripheral joint disease manifestations such as skin and nail Peripheral joint involvement in PsA can disease. This manuscript focuses on be quite variable. Patients can present peripheral joint involvement in PsA. with a mono-arthritis, an oligoarthri- tis when there are ≤4 joints involved, Epidemiology or they may present with polyarticular The exact prevalence of PsA in pa- involvement (>4 joints). The joints in- tients with (PsO) is unclear, volved may be symmetrically distrib- and varies widely between 13.8% and uted as in (RA) 36% in the published literature depend- or they may be asymmetrical. As de- ing on the classification criteria used scribed in the original description of (1, 3). Haroon et al., found that 29% of PsA by Moll and Wright, 5 clinical pat- psoriatic patients attending dermatol- terns of joint involvement may be ob- ogy had undiagnosed PsA (4), served in PsA patients (see Table I) (11). In other studies, the reported incidence Their first publication on the frequency of PsA has varied from 3.4 to 8 per of patterns identified asymmetric -oli 100.000 (5, 6). goarthritis as the most frequent clinical Genetic studies have shown that PsO subgroup among PsA (12). However, and PsA patients have a genetic predis- during the past decades a number of position. The primary genotype linked publications, while confirming the var- to PsO is HLA-Cw6. HLA-B27 was ied clinical patterns in PsA, have report- Competing interests: O. FitzGerald has more associated with the early develop- ed that is the most frequent received honoraria and grant/research support from Abbvie, BMS, Celgene, ment of PsA and with specific disease pattern observed with an estimated fre- Janssen, Novartis, Pfizer, and UCB; features such as symmetrical sacroiliitis quency of about 60% (13-18). Yet other M.L. Acosta Felquer has declared no and enthesitis, whereas HLA-B08 and publications suggest that the pattern of competing interests. its component alleles were positively joint involvement changes over time.

S-26 Peripheral joint involvement in PsA patients / M.L. Acosta Felquer & O. FitzGerald

Table I. Arthritis subgroups in PsA. don et al., found AM in 6% of 610 PsA patients. They also found that mutilans Moll and Wright subgroups for PsA (11) Veale subgroups (15) cases have earlier age of onset of PsA, Distal interphalangeal joint predominant arthritis (DIP) 5% Asymmetrical (35%) poor function and more prevalent nail Asymmetrical oligoarticular arthritis 70% Symmetrical polyarthritis (60%) disease (28). Most patients with AM Symmetrical polyarthritis 15% Predominant spondylitis (5%) had psoriasis before the diagnosis of ar- 5% thritis with mean age of psoriasis diag- Predominant spondylitis 5% nosis at 25.6 years and of PsA diagnosis at 30.9 years (29). Based on data availa- Thus, some patients with oligoarticular- helpful to distinguish PsA. It is also bility on 244 patients, 49% were males, onset disease could develop polyarticu- possible indeed that both RA and PsO with a mean (SD) age of 44.7±14.7 lar disease over time and other patients may co-exist as both are common con- years (27). Osteolysis is the defining with polyarticular-onset disease may ditions. In this setting, the pattern of radiographic feature and according become oligoarticular with treatment symmetrical small joint involvement, to a review of the literature, the most (19). Most reported series of PsA are a strongly positive common radiographic changes were based on patients with established dis- or CCP antibody and the absence of the presence of bone resorption (45%), ease with very few studies addressing musculoskeletal features thought more pencil-in-cup change (17%), the clinical presentation and progres- typical of PsA should point towards the (21%), total joint erosion (13%), and sion of in an inception cohort. Kane et diagnosis of RA. subluxation (9%). al., described the clinical presentation and radiological outcomes of 129 early Asymmetrical oligoarthritis Dactylitis or “sausage digit” PsA patients and they reported that 60% This is characterised by asymmetric in- Dactylitis should be included in this had polyarticular and 40% oligoarticu- volvement and ≤4 joints involved. Dis- section as or joint involve- lar at presentation (16). tal Interphalangeal (DIP) joints, large ment is frequently a component of this The subset classification and indeed the joints and feet can all be involved. This feature. (For Enthesitis, see Chapter necessity to define some of these subsets pattern has male preponderance (15, on Enthesitis) Dactylitis is considered remain controversial. It could be argued 23) and a reported frequency of about a hallmark feature of PsA but it can that with the pattern of joint involvement 30–40% (18, 24). also sometimes occur in other spon- changing or evolving over time, that a dyloarthropathies, , or simpler division into peripheral joint DIP joint involvement (tuberculosis, syphilis). The disease, predominant spondylitis and This may be symmetric or asymmetric, reported prevalence among PsA pa- the classic arthritis mutilans phenotype may affect a few joints or many, and tients is between 30–50% (30, 31, 32). may be more appropriate. commonly leads to progressive ero- Defined as the diffuse swelling of a sive bony lesions. Predominant DIP digit (finger or toe), dactylitis relates Symmetrical polyarthritis joint disease was considered a classic to a combination of tenosynovitis, en- This is defined by a cut-off of >4 in- form of joint involvement in PsA but thesitis and synovitis and can be acute volved joints, commonly affecting the a few studies have suggested that DIP or chronic. Acute dactylitis is defined as small joints of hands and feet in addi- involvement is not a separate category the presence of painful swelling of an tion to larger, weight-bearing joints. but can occur across all of the PsA sub- entire digit (33, 34). and chronic dactyl- Symmetrical polyarthritis accounts for groups (15, 25). itis is defined as a persistent swelling in 60% of disease at presentation. This the absence of pain. Tender inflamma- pattern is often difficult to distinguish Arthritis mutilans tory dactylitis in PsA is associated with from RA with the presence of skin pso- This is recognised as the most severe erosive disease and radiologic progres- riasis, nail dystrophic change and the destructive form of PsA and is charac- sion in the affected digits (35). Distri- presence of a negative rheumatoid fac- terised by digital shortening with se- bution is asymmetric and studies report tor helpful in diagnosis of PsA. Patients vere osteolysis on imaging, leading to that Dactylitis is found more commonly with this clinical pattern are predomi- irreversible deformity and loss of func- in the toes as compared to fingers (78% nantly female and 50% of joints (group- tion (26). The Group for Research and vs. 42%, respectively) (36). ing together the small joints of hands Assessment of Psoriasis and Psoriatic On clinical examination, dactylitis is and feet) are involved as matched pairs Arthritis (GRAPPA) developed a con- commonly asymmetric compared to (i.e. symmetric) (20, 15, 21, 22). sensus definition and suggested that the contralateral digit. Diagnosis can be Some patients with PsA may have low “involvement of just 1 joint with ar- more challenging when symmetrically grade positive rheumatoid factor or thritis mutilans (AM) as being sufficient involved. The Leeds dactylometer in- indeed CCP antibody with the clinical to be included in the AM group” (27). strument, measures the circumference phenotype, in particular, the presence The frequency ranges between 1 and of the digit compared to the contralat- of other disease features such as dac- 5% according the different publications eral digit and has been shown to be tylitis, enthesitis or axial involvement, (28, 18). A recent publication from Ja- sensitive to change (37). Haroon et al.

S-27 Peripheral joint involvement in PsA patients / M.L. Acosta Felquer & O. FitzGerald reported a positive association of dacty- Table II. Comparison of the clinical, laboratory and radiographic features in psoriatic arthri- litis in cross-sectional study of PsA pa- tis (PsA) as compared to rheumatoid arthritis (RA), undifferentiated tients with both HLA B 27 and HLA B (USpA) and (OA). 08. This important observation likely re- PsA RA USpA OA flects the association of HLA-B27 with enthesitis on the one hand and HLA- Psoriasis + – – – B08 with synovitis on the other (8). Symmetrical + ++ + ++ Asymmetrical ++ + ++ + Siegel et al. summarised new studies DIP involvement + – + + in an animal model highlighting the Spinal disease + – + + importance of the interleukin 23/Th17 Enthesitis + – + – Dactylitis + – + – pathway and mechanical stress in patho- Nail dystrophy + – – – genesis of dactylitis (38). HIV association + – ? – RF/CCP – + – – Differential diagnosis Erosions + ++ + + Periostitis ++ + + + There are currently no diagnostic crite- Sacroiliitis + – + – ria for PsA with the diagnosis usually HLA class I II I – considered when a patient with PsO presents with typical musculoskeletal Table III. Differentiating immuno-histologic features in psoriatic arthritis (PsA), spondylo- features in the absence of rheumatoid arthropathy (SpA) and rheumatoid arthritis (RA) (41, 44). factor. Classification criteria, such as the CASPAR criteria, are available but SpA vs. RA PsA vs. RA should not be used for diagnosis. Clas- Increased in SpA/PsA Vascularity Vascularity sification criteria are best used when Neutrophils Neutrophils trying to ensure patient uniformity CD163+ macrophages when recruiting PsA patients to studies Increased in RA Lining layer thicknessCD83+ Lining layer thickness or clinical trials. dendritic cells CCP+ Because of the wide range of clinical CCP+ CD68 macrophages presentations, the differential diagnosis MHC/HC gp-39+ MHC/HC gp-39+ of PsA is extensive and at times chal- lenging. RA and undifferentiated spon- A few studies have compared the im- resorption and pencil-in-cup type de- dyloarthropathy (USpA) are inflamma- muno-histologic features of PsA with formity which results from a combina- tory conditions characterised by dif- those of other tion of new bone formation and oste- ferent clinical, laboratory and imaging and with RA. Earlier studies have high- olysis (16). Radiographic examination hallmarks. In some patients, features lighted the thinner lining layer, with should include AP views of hands and can overlap and it may be difficult to fewer macrophages trafficking into the feet in patients with peripheral joint in- be sure of the correct diagnosis. Fur- tissue as compared with RA. Table III volvement. thermore, a patient may have more than summarises the differences observed in Ultrasonography (US) and MRI are one diagnosis for example seropositive studies which compared PsA with both more sensitive than radiographs to de- RA and PsO or osteoarthritis (OA) with RA and other forms of peripheral SpA tect inflammatory and destructive joint DIP involvement and PsO. We sum- (41, 44). Hyper-vascularity and an in- changes in patients with PsA and they marised clinical, laboratory and radio- crease in neutrophils were associated are also useful for entheseal or teno- logical findings PsA compared to RA, with PsA. synovial involvement (45). USpA and OA in Table II. Gutierrez et al. demonstrated that Imaging grey-scale US and power Doppler Synovial During the last decades, advances in (PD) allow a detailed assessment of Synovial tissue in PsA is characterised imaging have been very helpful in the the structural changes and were sensi- by a sub-lining infiltrate with T cells assessment and management of pa- tive in detecting abnormal blood flow and B cells, vascular proliferation and tients with PsA. at multiple sites in patients with PsA. also by expression of pro-inflammatory On plain , there are both US also is useful for detection of joint cytokines, including IL-1, interferon-γ, non-specific features, but there are also effusions, synovial proliferation, ero- tumour necrosis factor (TNF)-α, IL-6, some more specific findings which are sions and hyperaemia. In patients with IL-12, IL-15, IL-17 and IL-18. Other useful, and should prompt the rheu- dactylitis, US can detect a combination studies demonstrated that RANK ligand matologist to think about PsA. The of tenosynovitis, synovitis and soft tis- is overexpressed whereas osteoprote- features which are helpful in differen- sue oedema (46, 4). gerin (OPG) is down regulated. This tiating PsA from other inflammatory Magnetic resonance imaging (MRI) upregulation of activated osteoclasts include fewer erosions allows visualisation of , results in bone resorption (39-43). than in RA, new bone formation, bony articular and entheseal lesions and

S-28 Peripheral joint involvement in PsA patients / M.L. Acosta Felquer & O. FitzGerald therefore, can be helpful in the detec- including , leflunomide, The Minimal Disease Activity (MDA) tion of enthesitis, dactylitis, synovitis, or sulfasalazine for 3 or 6 months, as measure was used as the therapeutic tar- bony changes (such as erosions or bone the first step for the treatment of periph- get. At 48 weeks, ACR20 was achieved oedema) and for detection of subclini- eral arthritis. These drugs have demon- by 62% of tight control treated patients cal arthritis. In a study by McQueen and strated efficacy for peripheral arthritis as compared to 45% of those receiving colleagues, MRI could not distinguish but not for axial disease, enthesitis or standard care. More biologic and com- between peripheral PsA and RA when dactylitis bination was used in the tight synovitis and erosions were evaluated In 2014, the Group for Research and control arm (54). (For more details see (47). Assessment of Psoriasis and Psoriatic Treat-to-target chapter) In another comparative study of 10 PsA Arthritis (GRAPPA) published a litera- and 10 RA conventional and dynamic ture review for treatment of peripheral References contrast-enhanced MRI of swollen arthritis in PsA. There are limited data 1. IBRAHIM G, WAXMAN R, HELLIWELL PS: The prevalence of psoriatic arthritis in peo- MCPs was not able to differentiate be- for efficacy of nb-DMARDs, specifical- ple with psoriasis. Arthritis Rheum 2009; 61: tween RA and PsA on the basis of en- ly methotrexate (MTX), where results 1373-8. theseal-related disease but a subgroup from 2 randomised controlled trials 2. SALVARANI C, LO SCOCCO G, MACCHIONI P of PsA patients had diffuse extra-capsu- (RCTs) suggested its potential efficacy. et al.: Prevalence of psoriatic arthritis in Ital- ian psoriatic patients. J Rheumatol 1995; 22: lar enhancement (30%) or diffuse bone On the other hand, the use of anti-tu- 1499-503). oedema (20%). The RA patient group mour necrosis factor (TNF) blockers 3. ZACHARIAE H: Prevalence of joint disease had a greater degree of MCP synovi- in peripheral arthritis is supported with in patients with psoriasis: implications for tis and tenosynovitis than PsA patients much higher levels of evidence from therapy. Am J Clin Dermatol 2003; 4: 441-7. 4. HAROON M, KIRBY B, FitzGERALD O: High There were no significant differences RCTs and from observational studies. prevalence of psoriatic arthritis in patients in either the total number of erosions , , , with severe psoriasis with suboptimal per- or the presence of peri-articular bone golimumab, and certolizumab pegol formance of screening questionnaires. Ann oedema between the groups (48). Mi- have demonstrated significant improve- Rheum Dis 2013; 72: 736-40. 5. SAVOLAINEN E, KAIPIAINEN-SEPPÄNEN O, cro CT is a high-resolution imaging ments in peripheral joint scores and in KRÖGER L, LUOSUJÄRVI R: Total incidence technique designed to visualise the composite, largely joint-related scores and distribution of inflammatory joint diseas- bone architecture. Micro CT also can (ACR20, DAS28CRP, PsARC) com- es in a defined population: results from the be helpful in differentiating the struc- pared with placebo. Other biological Kuopio 2000 arthritis survey. J Rheumatol 2003; 30: 2460-8. tural changes of peri-articular bone in DMARDs, specifically ustekinumab, 6. SÖDERLIN MK, BÖRJESSON O, KAUTIAINEN patients with PsA and RA. Finzel et al., abatacept, brodalumab (development H, SKOGH T, LEIRISALO-REPO M: Annual in- found that the number of erosions in programme recently on-hold), and cidence of inflammatory joint diseases in a population based study in southern Sweden. MCP joints in both groups was similar secukinumab, have also demonstrated Ann Rheum Dis 2002; 61: 911-5. but they were less severe and smaller in statistically significant improvements 7. CHANDRAN V, RAYCHAUDHURI SP: Geoepi- size and depth in PsA. The shape of the compared to placebo. To date, only demiology and environmental factors of pso- erosions was different in PsA compared ustekinumab has been licensed for ap- riasis and psoriatic arthritis. J Autoimmun 2010; 34: J314.21. to RA, being Omega shaped in PsA proval to treat PsA. Apremilast, a small 8. HAROON M, WINCHESTER R, GILES JT, HEF- and more tubular shaped in RA. Osteo- molecule that specifically inhibits phos- FERNAN E, FitzGERALD O: Certain class I phytes were increased in number, ex- phodiesterase 4, was superior to place- HLA alleles and haplotypes implicated in tent and size in PsA as compared with bo in a series of 4 Phase III studies and susceptibility play a role in determining spe- cific features of the psoriatic arthritis pheno- RA and could in some cases affect the has been approved by both FDA and type. Ann Rheum Dis (2014). entire circumference of bone to form EMEA (52). (for details, see chapter on 9. CHIU YH, RITCHLIN CT: Biomarkers to diag- a bony “corona” (49). Whether any of treatment). nose early arthritis in patients with psoriasis. these changes are sufficiently sensitive Early intervention in psoriatic arthritis, Psoriasis Forum Summer 2012; 18: 2-10. 10. CHIU YH, MENSAH KA, SCHWARZ EM et al.: or specific to be useful in diagnosis or as well as the treating-to-target (T2T) Regulation of human osteoclast development management is yet to be proven. have received particular attention in the by dendritic cell-specific transmembrane past few years. T2T is defined as a strat- protein (DC-STAMP). J Bone Miner Res Treatment egy in which the treatment is gradually 2012; 27: 79-92. 11. MOLL JM, WRIGHT V: Psoriatic arthritis. PsA is a progressive disease with 47% escalated in order to reach or maintain Semin Arthritis Rheum 1973; 3: 55-78. developing erosive disease within 2 a therapeutic target such as remis- 12. WRIGHT VMJ: Psoriatic arthritis. In: WRIGHT years of diagnosis (16). Clinical fea- sion or low disease activity (53). The V, MOLL JM (Eds.) Seronegative polyarthri- tis. Amsterdam: North Holland Publishing tures associated with radiographic pro- TIght COntrol of PsA (TICOPA) study Co (1976). gression include polyarticular disease, was the first study using a T2T strat- 13. HELLIWELL P, MARCHESONI A, PETERS M, dactylitis and an elevated erythrocyte egy in early PsA (disease duration <24 BARKER M, WRIGHT V: A re-evaluation of sedimentation rate (50, 51, 1). month). Patients were DMARD-naive the osteoarticular manifestations of psoriasis. Br J Rheumatol 1991; 30: 339-45. Published guidelines recommend tradi- and divided in two groups, the first re- 14. JONES SM, ARMAS JB, COHEN MG, LOVELL tional non-biologic disease-modifying ceiving an intensive treatment strategy CR, EVISON G, MCHUGH NJ: Psoriatic arthri- anti-rheumatic drug (nb-DMARDs) and the second received standard care. tis: outcome of disease subsets and relation-

S-29 Peripheral joint involvement in PsA patients / M.L. Acosta Felquer & O. FitzGerald

ship of joint disease to nail and skin disease. psoriatic arthritis with tumor necrosis fac- 42. RITCHLIN CT, HAAS-SMITH SA, LI P, HICKS Br J Rheumatol 1994; 33: 834-9. tor inhibitors: longer-term outcomes includ- DG, SCHWARZ EM: Mechanisms of TNF-al- 15. VEALE D, ROGERS S, FitzGERALD O: Clas- ing enthesitis and dactylitis with golimumab pha- and RANKL-mediated osteoclastogen- sification of clinical subsets in psoriatic ar- treatment in the Longterm Extension of a esis and bone resorption in psoriatic arthritis. thritis. Br J Rheumatol 1994; 33: 133-8. Randomized, Placebo-controlled Study (GO- J Clin Invest 2003; 111: 821-31. 16. KANE D: A prospective, clinical and radio- REVEAL). J Rheumatol 2012; (Suppl. 89): 43. VANDOOREN B, CANTAERT T, NOORDEN- logical study of early psoriatic arthritis: an 90-3. BOS T, TAK PP, BAETEN D: The abundant early synovitis experience. Rheumatol- 31. GLADMAN DD, CHANDRAN V: Observational synovial expression of the RANK/RANKL/ ogy 2003; 42: 1460-8. cohort studies: lessons learnt from the Univer- Osteoprotegerin system in peripheral spon- 17. REICH K, KRÜGER K, MÖSSNER R, AUGUS- sity of Toronto Psoriatic Arthritis Program. dylarthritis is partially disconnected from TIN M: Epidemiology and clinical pattern of Rheumatology (Oxford) 2011; 50: 25-31. . Arthritis Rheum 2008; 58: psoriatic arthritis in Germany: a prospective 32. OLIVIERI I, SCARANO E, PADULA A, GIASI 718-29. interdisciplinary epidemiological study of V, PRIOLO F: Dactylitis, a term for different 44. KRUITHOF E, BAETEN D, DE RYCKE L et al.: 1511 patients with plaque-type psoriasis. Br digit diseases. Scand J Rheumatol 35: 333- Synovial histopathology of psoriatic arthri- J Dermatol 2009; 160: 1040-7. 40. tis, both oligo- and polyarticular, resembles 18. KUMAR R, SHARMA A, DOGRA S: Prevalence 33. MEASE PJ, GARG A, GLADMAN DD, HELLI- spondyloarthropathy more than it does rheu- and clinical patterns of psoriatic arthritis in WELL PS: Development of simple clinical matoid arthritis. Arthritis Res Ther 2005; 7: Indian patients with psoriasis. Indian J Der- criteria for the definition of inflammatory R569-80. matol Venereol Leprol 80: 15-23. arthritis, enthesitis, dactylitis, and spondyli- 45. WIELL C, SZKUDLAREK M, HASSELQUIST M 19. McHUGH NJ, BALACHRISHNAN C, JONES tis: a report from the GRAPPA 2012 annual et al.: Ultrasonography, magnetic resonance SM: Progression of peripheral joint disease in meeting. J Rheumatol 2013; 40: 1442-5. imaging, radiography, and clinical assessment psoriatic arthritis: a 5-yr prospective study. 34. GLADMAN DD, ZIOUZINA O, THAVANE- of inflammatory and destructive changes in Rheumatology (Oxford) 2003; 42: 778-83. SWARAN A, CHANDRAN V: Dactylitis in fingers and toes of patients with psoriatic ar- 20. HELLIWELL PS, HETTHEN J, SOKOLL K et psoriatic arthritis: prevalence and response thritis. Arthritis Res Ther 2007; 9: R119. al.: Joint symmetry in early and late rheu- to therapy in the biologic era. J Rheumatol 46. GUTIERREZ M, FILIPPUCCI E, DE ANGELIS R, matoid and psoriatic arthritis: comparison 2013; 40: 1357-9. FILOSA G, KANE D, GRASSI W: A sonograph- with a mathematical model. Arthritis Rheum 35. BROCKBANK JE, STEIN M, SCHENTAG CT, ic spectrum of psoriatic arthritis: ‘the five tar- 2000; 43: 865-71. GLADMAN DD: Dactylitis in psoriatic ar- gets’. Clin Rheumatol 2010; 29: 133-42. 21. GLADMAN DD: Psoriatic arthritis. Dermatol thritis: a marker for disease severity? Ann 47. McQUEEN F, LASSERE M, ØSTERGAARD Ther 2004; 17: 350-63. Rheum Dis 2005; 64: 188-90. M: Magnetic resonance imaging in psoriatic 22. KRUEGER GG: Clinical features of psoriatic 36. PAYET J, GOSSEC L, PATERNOTTE S et al.: arthritis: a review of the literature. Arthritis arthritis. Am J Manag Care 2002; 8: S160-70. Prevalence and clinical characteristics of Res Ther 2006; 8: 207. 23. HELLIWELL PS, PORTER G, TAYLOR WJ: Pol- dactylitis in spondylarthritis: a descriptive 48. MARZO-ORTEGA H, TANNER SF, RHODES yarticular psoriatic arthritis is more like oli- analysis of 275 patients. Clin Exp Rheumatol LA et al.: Magnetic resonance imaging in goarticular psoriatic arthritis, than rheumatoid 2012; 30: 191-6. the assessment of metacarpophalangeal joint arthritis. Ann Rheum Dis 2007; 66: 113-7. 37. HELLIWELL PS, FIRTH J, IBRAHIM GH, MEL- disease in early psoriatic and rheumatoid ar- 24. DÖNMEZ S, PAMUK ÖN, AKKER M, AK R: SOM RD, SHAH I, TURNER DE: Development thritis. Scand J Rheumatol 38: 79-83. Clinical features and types of articular in- of an assessment tool for dactylitis in patients 49. FINZEL S, ENGLBRECHT M, ENGELKE K, volvement in patients with psoriatic arthritis. with psoriatic arthritis. J Rheumatol 2005; STACH C, SCHETT G: A comparative study of Clin Rheumatol 2015; 34: 1091-6. 32: 1745-50. periarticular bone lesions in rheumatoid ar- 25. TORRE ALONSO JC, RODRIGUEZ PEREZ A, 38. SIEGEL EL, ORBAI A-M, RITCHLIN CT: thritis and psoriatic arthritis. Ann Rheum Dis ARRIBAS CASTRILLO JM, BALLINA GARCIA Targeting extra-articular manifestations in 2011; 70: 122-7. J, RIESTRA NORIEGA JL, LOPEZ LARREA C: PsA: a closer look at enthesitis and dactylitis. 50. GLADMAN DD, FAREWELL VT, NADEAU C: Psoriatic arthritis (PA): a clinical, immu- Curr Opin Rheumatol 2015; 27: 111-7. Clinical indicators of progression in psoriatic nological and radiological study of 180 pa- 39. Van KUIJK AWR, REINDERS-BLANKERT arthritis: multivariate relative risk model. tients. Br J Rheumatol 1991; 30: 245-50. P, SMEETS TJM, DIJKMANS BAC, TAK PP: J Rheumatol 1995; 22: 675-9. 26. HADDAD A, CHANDRAN V: Arthritis muti- Detailed analysis of the cell infiltrate and the 51. PUNZI L, PIANON M, ROSSINI P, SCHIAVON F, lans. Curr Rheumatol Rep 2013; 15: 321. expression of mediators of synovial inflam- GAMBARI PF: Clinical and laboratory mani- 27. FitzGERALD O, MEASE PJ, HELLIWELL PS, mation and joint destruction in the synovium festations of elderly onset psoriatic arthritis: CHANDRAN V: GRAPPA 2013 Annual Meet- of patients with psoriatic arthritis: implica- a comparison with younger onset disease. ing, rheumatology updates: psoriatic arthritis tions for treatment. Ann Rheum Dis 2006; Ann Rheum Dis 1999: 58: 226-9. (PsA) biomarker project, arthritis mutilans, 65: 1551-7. 52. COATES LC, KAVANAUGH A, RITCHLIN CT: PsA-peripheral spondyloarthritis epidemiol- 40. COSTELLO P, BRESNIHAN B, O’FARRELLY Systematic review of treatments for psori- ogy project. J Rheumatol 2014; 41: 1244-8. C, FitzGERALD O: Predominance of CD8+ T atic arthritis: 2014 update for the GRAPPA. 28. JADON DR, SHADDICK G, TILLETT W et al.: lymphocytes in psoriatic arthritis. J Rheuma- J Rheumatol 2014; 41: 2273-6. Psoriatic arthritis mutilans: characteristics tol 1999; 26: 1117-24. 53. SOLOMON DH, BITTON A, KATZ JN, RADNER and natural radiographic history. J Rheumatol 41. VEALE D, YANNI G, ROGERS S, BARNES L, H, BROWN EM, FRAENKEL L: Review: treat 2015. BRESNIHAN B, FITZGERALD O: Reduced to target in rheumatoid arthritis: fact, fiction, 29. CHANDRAN V, GLADMAN DD, HELLIWELL synovial membrane macrophage numbers, or hypothesis? Arthritis Rheumatol 2014; 66: PS, GUDBJÖRNSSON B: Arthritis mutilans: a ELAM-1 expression, and lining layer hyper- 775-82. report from the GRAPPA 2012 annual meet- plasia in psoriatic arthritis as compared with 54. COATES LC: Treating to target in psoriatic ar- ing. J Rheumatol 2013; 40: 1419-22. rheumatoid arthritis. Arthritis Rheum 1993; thritis. Curr Opin Rheumatol 2015; 27: 107- 30. KAVANAUGH A, MEASE P: Treatment of 36: 893-900. 10.

S-30