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Home , Ankylosing spondylitis, Arthritis mutilans, Oligoarthritis, Polyarthritis, Sacroiliitis, Spinal disease

Psoriatic

Ewa Olech, MD Division of University of Nevada School of Las Vegas The Spectrum of Spondyloarthritis Characteristics of the Spondyloarthritis

 Sacroiliac & spinal involvement  Peripheral arthritis   Common spectrum of extra-articular features (especially mucocutaneous, ocular)  Negative  Familial clustering  Association with HLA-B27  Potential infectious trigger HLA-B27 and the Seronegative Spondyloarthritides HLA-B27 Disorder frequency (%) Ankylosing 95% 70% 25% Psoriatic spondylitis 60% Enteropathic arthritis 7% Enteropathic Spondylitis 70% Juvenile 70% Undifferentiated Spondyloarthropathy 70% Acute Anterior 50%

Pattern of Peripheral Synovitis in the Condition Pattern of Involvement Ankylosing • Asymmetric large-joint , primarily lower Spondylitis extremities Reactive • Asymmetric large-joint oligoarthritis, primarily lower Arthritis extremities Enteropathic • Asymmetric large-joint oligoarthritis, primarily lower Arthritis extremities Psoriatic • Oligoarticular disease: Asymmetric large-joint Arthritis oligoarthritis, primarily lower extremities • Polyarticular disease: Symmetric involving large and small resembling RA • DIP joint disease: Associated with nail involvement • : Severely destructive arthritis involving the hands with shortening of the digits Psoriatic Arthritis- Epidemiology

 Prevalence of : 1–2%  20 – 40 % develop arthritis  Prevalence of PsA: 0.04-1.2%  Peak age of onset: between 30-55 years  Highest incidence in patients with extensive skin involvement  Males and females are equally affected  In 70-80 % of PsA, skin symptoms occur first 1Taylor WJ. Curr Opin Rheumatol. 2002;14:98–103. 2Mease P. Curr Opin Rheumatol. 2004;16:366–370. 3Brockbank J, et al. Exp Opin Invest Drugs. 2000;9:1511–1522. 4Kane D, et al. Rheumatology. 2003;42:1460–1468.

Pathogenesis of Ps and PsA

Nograles KE, et al. Clin Pract Rheumatol 2009,5:83-91 Historical Patterns of PsA

 Oligo/ monoarticular disease (~ 30-70%):  Asymmetric, <5 joints, usually large, primarily LEs  Polyarticular disease (~15-45%):  Symmetric, large & small joints, resembling RA  DIP joint disease (~5%):  Associated with nail involvement  Arthritis mutilans (~5%):  Severely destructive arthritis involving the hands with shortening of the digits  Axial (sole in ~5% but with other types in ~40%):  Spondylitis and , usually HLA B27-positive

Moll JMH, Wright V. Semin Arthritis Rheum 1973;3:55-78 Psoriatic arthritis: asymmetric synovitis Psoriatic arthritis: nail changes, rash, and arthritis Psoriatic arthritis: nail changes, rash, and arthritis Psoriatic arthritis: hands

 Morning stiffness >30 min in 50% of patients1  Joint tenderness sometimes less than in RA despite deformities1  Ridging, pitting of nails, onycholysis in up to 90% of pts vs only 40% of pts with psoriasis2,3  in >40% of pts2,4  Eye (conjunctivitis, iritis, or uveitis) in 7– 33% of pts;  uveitis more commonly bilateral and chronic as compared to AS2  Distal extremity swelling with pitting in 20% of pts as the first isolated manifestation of PsA5 1Gladman DD. In: Up To Date. Accessed December 3, 2004. 2Taurog JD. In: Harrison's Online McGrawHill. Accessed January 2,2005. 3Gladman DD. Rheum Dis Clin N Amer. 1998;24:829–844. 4Veale D, et al. Br J Rheumatol. 1994;33:133–38. 5Cantini F, et al. Clin Exp Rheumatol. 2001;19:291–296. Main Features and Their Frequency

Back involvement (50%)1 Skin Skin Involvement

2 In nearly 70% of patients, DIP involvement (39%) cutaneous lesions precede the onset of joint pain, in 20% starts before skin manifestations, and in 10% both are concurrent. 6 Nail psoriasis (80%)4, 5 Dactyilitis (48%)3

2 Enthesopathy (38%) 1Gladman D et al. Arth & Rheum 2007;56:840; 2 Kane. D et al. Rheum 2003;42:1460-1468 3 Gladman D et al. Ann Rheum Dis 2005;64:188–190; 4Lawry M. Dermatol Ther 2007;20:60-67 DIP: Distal interphalangeal 5Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6Yamamoto Eur J Dermatol 2011;21:660-6

Comorbidities in PsA Patients

1 Ocular inflammation PsA patients6-8 (Iritis/Uveitis/ ) • Psychosocial burden • Reactive depression • Higher suicidal ideation • Alcoholism

IBD2  Metabolic Syndrome3-5

• Hyperlipidemia • Hypertension • Insulin resistent • Diabetes • Obesity  Higher risk of Cardiovascular disease (CVD)

1Qieiro et al. Semin Arth Rheum 2002;31:264; 2Scarpa et al. J Rheum 2000;27:1241; 3Mallbris et al. Curr Rheum Rep 2006;8:355; 4Neimann et al. J Am Acad Derm 2006;55:829; 5Tam et al. 2008;47:718; 6Kimball et al. Am J Clin Dermatol 2005;6:383-392; 7Naldi et al. Br J Dermatol 1992;127:212-217; 8Mrowietz U et al. Arch Dermatol Res 2006;298(7):309-319 Main Features of PsA

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

Psoriatic Arthritis

Dactylitis

Ritchlin C. J Rheumatol. 2006;33:1435–1438. Helliwell PS. J Rheumatol. 2006;33:1439–1441. Dactylitis • 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 • One of the cardinal features of PsA, in up to 40% of patients1,2 • Feet most commonly affected1 • Dactylitis involved digits show more radiographic damage1

ACR Slide Collection on the Rheumatic Diseases; 3rd edition. 1994. 1Brockbank J, et al. Ann Rheum Dis. 2005;64:188–190. 2Veale D, et al. Br J Rheumatol. 1994;33:133–38. Dactylitis/ Sausage Digit Definition of Enthesitis

 Entheses - the regions at which a tendon, ligament, or joint capsule attaches to bone1  Enthesitis -inflammation at the entheses1,2  Pathogenesis of enthesitis has yet to be fully elucidated2  Isolated peripheral enthesitis may be the only rheumatologic sign of PsA in a subset of 3 patients 1McGonagle D. Ann Rheum Dis. 2005;64(Suppl II):ii58–ii60. 2Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338–343. 3Salvarani C. J Rheumatol. 1997;24:1106–1140.

How to Diagnose Those Without Skin Findings Look for distal joint involvement in asymmetric distribution Look at the nails Look in ears Ask about family history Look for dactylitis Psoriatic arthritis: nail pitting Psoriatic arthritis: nail dystrophy and arthritis PsA: Radiographic Characteristics

 Erosive arthritis (usually asymmetric)

 Pencil-in-cup deformity

 Bony

 Arthritis mutilans

 Spurs/ periosteal reaction

 Non-marginal asymmetric syndesmophytes

 Asymmetric sacroiliitis Psoriatic Arthritis: Hand Psoriatic Arthritis: Feet Pencil-in-cup Deformity PsA: Progressive Joint Changes Juxta-articular and Ankylosis Arthritis Mutilans Arthritis Mutilans

Pencil-in-cup Gross Osteolysis Spurs/ Periosteal Reaction

Sacroilitis Spinal Involvement: Syndesmophytes Differential Diagnosis

Reactive (Reiter’s) Arthritis with concomitant psoriasis Gouty Arthritis HIV Patients

 Increased incidence  reactive arthritis  psoriasis  psoriatic arthritis  Explosive onset and more severe disease course  Testing for HIV indicated in newly diagnosed severe psoriatic or reactive arthritis Course and Prognosis

20% of patients have a severe an debilitating form of arthritis originally thought to be more benign course than RhA progression of clinical damage occurs in a majority of patients radiologic changes occur over time despite treatment Classification Criteria of PsA

How to diagnose PsA? Classical Description of PsA Using the Diagnostic Criteria of Moll and Wright

 Including 5 clinical patterns:

 Asymmetric mono-/oligoarthritis (~30%)1-4  Symmetric polyarthritis (~45%)1-4  Distal interphalangeal (DIP) joint involvement (~5%)1  Axial (spondylitis and sacroiliitis) (HLA-B27) (~5%)1,3  Arthritis Mutilans (<5%)1,3

• However patterns may change over time and are therefore not useful for classification 5 HLA: Human leucocytes antigen 1. Moll JMH, Wright V. Semin Arthritis Rheum 1973;3:55-78 Patterns may Change Over Time

Clinical subgroups at baseline and follow-up:

Monoarthritis

Oligoarthritis Oligoarthritis

DIP DIP

Polyarthritis Polyarthritis

Spondyloarthritis Spondyloarthritis

Mutilans Mutilans

No clinical evidence of joint disease McHugh et al. Rheum 2003;42:778-783 CASPAR 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 formation  Specificity 98.7%, Sensitivity 91.4% Taylor et al. Arthritis & Rheum 2006;54: 2665-73 Assessment of PsA Disease Severity GRAPPA Disease Severity Table1 THANK YOU