Subclinical joint inflammation in patients with psoriasis without concomitant psoriatic arthritis: a cross-sectional and longitudinal analysis

Derivation of a Multivariable Psoriatic Arthritis Risk Estimation Tool (PRESTO): A Step Towards Prevention

OBJECTIVE

A simple, scalable tool that identifies psoriasis patients at high risk for developing psoriatic arthritis (PsA) could improve early diagnosis. We aimed to develop a risk prediction model for the development of PsA and to assess its performance among patients with psoriasis.

METHODS

We analyzed data from a prospective cohort of psoriasis patients without PsA at enrollment. Participants were assessed annually by a rheumatologist for the development of PsA. Information about their demographics, psoriasis characteristics, comorbidities, medications, and musculoskeletal symptoms was used to develop prediction models for PsA. Penalized binary regression models were used for variable selection while adjusting for psoriasis duration. Risks of developing PsA over 1- and 5-year time periods were estimated. Model performance was assessed by the area under the curve (AUC) and calibration plots.

RESULTS

Among 635 psoriasis patients, 51 and 71 developed PsA during the 1-year and 5-year follow-up periods, respectively. The risk of developing PsA within 1 year was associated with younger age, male sex, family history of psoriasis, back stiffness, nail pitting, joint stiffness, use of biologic medications, patient global health, and pain severity (AUC 72.3). The risk of developing PsA within 5 years was associated with morning stiffness, psoriatic nail lesion, psoriasis severity, fatigue, pain, and use of systemic nonbiologic medication or phototherapy (AUC 74.9). Calibration plots showed reasonable agreement between predicted and observed probabilities.

CONCLUSIONS

The development of PsA within clinically meaningful time frames can be predicted with reasonable accuracy for psoriasis patients using readily available clinical variables.

Arthralgia with risk of progression to psoriatic arthritis: role of clinical assessments and ultrasound as prognostic factors

OBJECTIVES

Referral of patients from dermatology to rheumatology practices due to psoriasis is unnecessary delayed. Many times musculoskeletal symptoms are the first reason for consultation. We aimed to estimate the proportion of ARP-PsA (arthralgia with risk to progression) defined by patients with arthralgia and the presence of psoriasis and/or a family history. Also, identify clinical, laboratory and imaging prognostic factors of PsA progression within the ARP-PsA group over a one year follow-up period.

METHODS

Patients were included in a comprehensive arthralgia evaluation program, with the ARP-PsA criteria defined as arthralgia with Pso and/or a family history of Pso, not referred from dermatology. Baseline characteristics were analysed, and the progression to PsA at one year was assessed. Multivariate analysis identified predictor features for progression.

RESULTS

Of the 1419 patients, 8.4% met ARP-PsA criteria, and 29% of this subgroup developed PsA at one year. Baseline differences between those who developed PsA and those who did not included family history, Pso duration, pain severity, joint count and imaging findings (X-ray and ultrasound). Multivariate analysis revealed the predictive significance of a combination of Pso plus family history of psoriasis disease, synovitis by Power Doppler ultrasound, ultrasound enthesopathy findings and low tender joint count.

CONCLUSION

The frequency of patients ARP-PsA was 8.4%, of whom 29% developed PsA at one year. The main predictor variables for this progression were identified.

Allelic and haplotypic HLA analysis in patients with psoriatic arthritis: Low frequency of common alleles

Introduction

Psoriatic arthritis is a complex disease, and human leukocyte antigens (HLA) are key to its development. Latin America and, specifically, Colombia, has scarce data about patients with psoriatic arthritis.

Objective

To describe the genotypic, allelic and haplotypic frequency of HLA alleles in psoriatic arthritis and associate them with clinical variables.

Materials and methods

We conducted a retrospective study involving adult patients with psoriatic arthritis, evaluated according to CASPAR criteria, between 2012 and 2023. We included healthy donors whose HLA-A, B, C, and DR were genotyped by PCR/SSO in a Luminex 100/200 xMAP™ device. We performed an HLA comparative analysis between healthy donors and psoriatic arthritis patients.

Results

We included 401 healthy controls and 37 patients with psoriatic arthritis, in which we identified 46 genotypes, 75 alleles, and 32 haplotypes. The most frequent HLA were HLA-A*24 (37.1%), HLA-B*35 (20.8%), HLA-C*3 and HLA-C*7 (19.9% each), and HLADR* 4 (30%). Compared to healthy donors, the patient’s genotypic frequency was lower for HLA-A*02, HLA-A*11, HLA-B*35, HLA-DR*01, HLA-DR*07, HLA-DR*13, and HLA-DR*15 (p < 0.05), which means that even though HLA-B*35 was frequent in psoriatic arthritis, it's frequency was lower when compared to that of healthy controls. The frequency of HLA-A*24 and HLA-B*44 was different in cutaneous involvement (p < 0.05), HLA-B*40 and HLA-B*35 in joint involvement (p < 0.05), and HLA-A*26 and HLA-C*16 in extra-articular manifestations (p < 0.05). The allelic frequency of HLA-A*26:01 and HLA-C*16:01 in extra-articular manifestations was also significant. The frequency of HLA-Cw*6 was 6.7% and the allele HLA-B*27 was absent.

Conclusions

The HLA analysis in psoriatic arthritis showed a low frequency of HLA-C*06 and absence of HLA-B*27, different from the information reported for Caucasian population. These results also revealed other alleles of interest. Found differences could be related to the important racial mixing of our population.

Recent advances in nuclear medicine and their role in inflammatory arthritis: focus on the emerging role of FAPI PET/CT

Imaging molecular processes associated with inflammatory disease has been revolutionized by hybrid imaging using positron emission tomography/computed tomography (PET/CT). PET/CT visualizes metabolic activity as well as protein expression and provides a comprehensive whole-body evaluation. It has the potential to reveal inflammation prior to detection of structural changes in inflammatory joint diseases. FAP is a type II transmembrane glycoprotein overexpressed not only in the stroma of tumors but also in the fibrotic processes of certain immune-mediated disorders. The recent introduction of fibroblast activation protein inhibitors (FAPI) labeled by positron emitters and thus suitable for PET/CT allows to investigate FAP expression in vivo. This review will focus on the use of FAPI-PET/CT for the diagnosis and evaluation of treatment response in inflammatory joint diseases.

Skin and Nail Predictors of Psoriatic Arthritis Development: A Holistic Overview Integrating Epidemiological and Physiopathological Data

Dermatological manifestations are considered to be of significant importance in identifying individuals with psoriasis at a higher risk of developing arthritis, as rheumatological involvement typically follows the onset of skin/nail lesions. This review summarizes the literature evidence about dermatological predictors of psoriatic arthritis (PsA) development, also analyzing the underlying physiopathological mechanisms and potential biases. Such an integration between statistical evidence and a mechanism-based approach aims to emphasize the most robust skin/nail risk factors upon which clinicians should focus most in daily clinical practice. Accordingly, psoriasis severity and nail changes due to matrix involvement would result in the most relevant risk factors for PsA occurrence, while other possible predictors (e.g., scalp and inverse psoriasis) do not seem to be supported by a significant pathogenetic link.

Imaging in psoriatic arthritis: established methods and emerging techniques

Psoriatic arthritis (PsA) is a heterogeneous, chronic, inflammatory musculoskeletal disease that can lead to peripheral and axial damage and loss of function. A clear difference between PsA and other forms of inflammatory arthritis is the different forms of bone remodeling seen in PSA which incorporates not only increased bone resorption with bone erosions, osteolysis, and loss of bone mineral density but also increased bone formation with periostitis, syndesmophytes, enthesiophytes, and ankylosis. PsA, if diagnosed late, will lead to significant structural damage, the most severe form of which is known as arthritis mutilans, and loss of physical function. Imaging plays a crucial role in diagnosing and monitoring both peripheral and axial conditions associated with PsA. Radiography is currently the main modality used to monitor structural damage in PsA though commonly used scoring systems do not include bony proliferation as a criterion. Besides, radiography is limited in determining the presence and cause of periarticular soft tissue thickening, which may arise from tendinosis, tenosynovitis, synovial proliferation, bursitis, or enthesitis. Recently, much more attention has been paid to determining the imaging characteristics of PsA, which enables more precise identification of disease and severity assessment. Newer imaging technologies also enable variations in normal bone microstructure to be distinguished from disease-related abnormality. This review discusses the current state of innovative imaging modalities in PsA, specifically concentrating on their roles in PsA diagnosis and treatment, improving the early detection of PsA, and identifying patients with skin psoriasis at risk of developing psoriatic arthritis.

A novel nomogram to predict psoriatic arthritis in patients with plaque psoriasis

OBJECTIVE

To construct a predictive model for Psoriatic Arthritis (PsA) based on clinical and ultrasonic characteristics in patients with plaque psoriasis (PsP).

PATIENTS AND METHODS

Demographic, clinical, and ultrasound data were collected from patients with PsP and PsA between May 2019 and December 2022.

RESULTS

A total of 212 patients with PsP and 123 with PsA in the training cohort, whereas the validation cohort comprised 91 patients with PsP and 49 with PsA. The multivariate logistic regression identified nail psoriasis (odds ratio [OR] 1.88, 95% CI: 1.07-3.29), synovitis (OR 18.23, 95% CI: 4.04-82.33), enthesitis (OR 3.71, 95% CI: 1.05-13.14), and bone erosion (OR 11.39, 95% CI: 3.05-42.63) as effective predictors for PsA. The area under the curve was 0.750 (95% CI, 0.691-0.806) and 0.804 (95% CI, 0.723-0.886) for the training and validation cohorts, respectively. The Hosmer-Lemeshow goodness-of-fit test showed good consistency for both the training cohort (p  =  0.970) and the validation cohort (p  =  0.967). Calibration curves also indicated good calibration for both cohorts. The DCA revealed that the predictive model had good clinical utility.

CONCLUSIONS

We have developed a quantitative, intuitive, and convenient predictive model based on nail psoriasis, synovitis, enthesitis, and bone erosion to assess the risk of PsA in patients with plaque psoriasis.

GRAPPA 2023 Debate: Is Psoriatic Disease Really a Primary Enthesitis That Drives Joint Synovitis? The Enthesitis Hypothesis 25 Years On

The enthesitis hypothesis posits that enthesitis is a primary lesion and that inflammation at the enthesis initiates the musculoskeletal symptoms of psoriatic arthritis (PsA) and spondyloarthropathies (SpA). The hypothesis suggested that inflamed entheseal tissue near the synovium could trigger cytokine-mediated synovitis, that enthesis bone anchorage could explain osteitis, and that the location of entheses at the soft tissue interface could explain dactylitis. Advances in imaging techniques that allow better visualization of enthesitis lesions and the development of animal models have allowed evolution of the concept of enthesitis as a central mechanistic driver of musculoskeletal symptoms in PsA and SpA. A debate between Drs. Dennis McGonagle and Bruce Kirkham at the Group for Research on Psoriasis and Psoriatic Arthritis (GRAPPA) 2023 annual meeting discussed the data supporting and refuting this hypothesis in PsA and SpA, respectively. The major points of this debate are summarized in this article.

Psoriasis as a Systemic Disease

BACKGROUND

Psoriasis was long regarded as an inflammatory disease limited to the skin. Data from dermatologic, rheumatologic and cardiologic research now show it to be a systemic disease, for which the term psoriatic disease is used.

METHODS

This paper is based on a selective literature search with special attention to the findings of clinical trials and other current publications, as well as the recommendations of international guidelines.

RESULTS

Immunologically mediated inflammation of the skin, arteries, bones, and joints is a central feature of psoriatic disease. Other diseases that are known to be associated with psoriatic disease include hypertension, metabolic syndrome, and depression. The main risk factor for the development of psoriatic disease is obesity, which also increases the likelihood of psoriatic arthritis. The main known trigger factors are stress, infection, and, less commonly, medication. Psoriatic disease is characterized by complex genetics and by a characteristic pattern of inflammation that involves elements of both innate and acquired immunity and, in particular, the cytokines interleukin 17 and 23. The inflammatory processes underlying psoriatic disease can now be targeted with modern biologic and other therapies.

CONCLUSION

In view of the complexity of psoriatic disease, structured management is now recommended so that physicians and patients can work together to determine the optimal treatment strategy.

From Psoriasis to Psoriatic Arthritis: Ultrasound Insights Connecting Psoriasis with Subclinical Musculoskeletal Inflammation and the Path to Psoriatic Arthritis

PURPOSE OF REVIEW

This review summarizes the literature about the transition from psoriasis to psoriatic arthritis (PsA), focusing on musculoskeletal ultrasound (MSUS) for detecting subclinical inflammation and its role in diagnosis and triage of high-risk patients.

RECENT FINDINGS

MSUS effectively detects subclinical musculoskeletal inflammation in patients with psoriasis; however, some of these lesions are non-specific and can be found in healthy individuals. Preliminary evidence suggest that subclinical sonographic findings may predict progression to PsA in psoriasis patients. MSUS can also improve referrals' accuracy and its integration in the PsA classification criteria may improve early PsA detection. MSUS is a valuable tool for detecting subclinical abnormalities in psoriasis patients, which indicate an increased likelihood of progressing to PsA. Its integration into referral protocols and clinical use could improve PsA diagnosis. We propose an MSUS-inclusive algorithm for PsA referrals and triage, which requires validation. The potential of early intervention in reducing PsA progression in psoriasis patients with subclinical inflammation remains to be established.

Anatomical pattern of entheseal and synovial fibroblast activation in patients with psoriasis and its risk of developing psoriatic arthritis

OBJECTIVES

To assess the presence and anatomical distribution of activated fibroblasts in the joints and entheses of patients with psoriasis with arthralgia and to test how fibroblast activation visualised by 68gallium-labelled fibroblast activation protein inhibitor-04 (68Ga-FAPI-04)-positron emission tomography (PET)/CT correlates with clinical tenderness, musculoskeletal ultrasound findings and progression to psoriatic arthritis (PsA).

METHODS

We conducted a prospective cohort study in patients with psoriasis and arthralgia who underwent clinical and ultrasound evaluation and whole-body PET/CT imaging with 68Ga-FAPI-04. 68Ga-FAPI-04 uptake at synovial and entheseal sites was assessed by maximal standardised uptake values (SUVmax) and PET/CT Joint Index (JI); logistic regression models were used to investigate its correlation with clinical and ultrasound findings. Survival analyses were performed on patients with at least 6 months of follow-up.

RESULTS

36 patients with psoriasis were enrolled. 68Ga-FAPI-04 uptake was found in 318 (7.9%) joints and 369 (7.3%) entheses in 29 (80.6%) participants, with a mean SUVmax (SD) of 3.2 (1.8) for joints and 2.9 (1.6) for entheses. Large joints and the lower limbs were predominantly affected. A significant positive relationship was found between 68Ga-FAPI-04-PET/CT signal intensity and the 68 tender joint count (SUVmax: p<0.001; PET/CT-JI: p<0.001) and tender entheses count (SUVmax: p<0.001; PET/CT-JI: p=0.002). No correlations were found with ultrasound findings (SUVmax: p=0.969; PET/CT-JI: p=0.720). Patients with relevant synovio-entheseal 68Ga-FAPI-04 uptake showed a statistically significant higher risk of developing PsA (p=0.02), independent of ultrasound findings.

CONCLUSIONS

Patients with psoriasis presenting with arthralgia show localised signs of resident tissue activation in joints and entheses, which are associated with higher risk of developing PsA.

Risk of developing psoriatic arthritis in psoriasis cohorts with arthralgia: exploring the subclinical psoriatic arthritis stage

OBJECTIVE

Subjects with subclinical psoriatic arthritis (PsA), defined as the presence of arthralgia in psoriasis (PsO), are at higher risk of PsA but scant real-world data exist. Our aims were to (1) estimate the probability of PsA development in subclinical PsA, (2) characterise subclinical PsA symptoms and (3) determine the clinical patterns at PsA diagnosis.

METHODS

Patients with PsO, mainly subclinical PsA, were evaluated longitudinally in two European cohorts. The key outcome was new-onset PsA. Musculoskeletal symptoms including inflammatory and non-inflammatory symptoms before PsA diagnosis were collected. Occurrence of PsA was analysed with survival analysis and cumulative incidence functions (CIFs).

RESULTS

384 patients with PsO were included with a mean follow-up of 33.0 (±20.9) months. 311 of 384 (80.9%) had subclinical PsA with a PsA incidence rate of 7.7 per 100 patient-years. Subclinical PsA displayed a higher risk of PsA development compared with PsO (HR=11.7 (95% CI 1.57 to 86.7), p=0.016). The probability of new-onset PsA estimated by the CIF was 9.4% (95% CI 4.7% to 10.6%) at month 12 and 22.7% (95% CI 17.2% to 28.6%) at month 36. 58.9% of cases reported inflammatory symptoms in the months immediately prior to PsA diagnosis but prior non-inflammatory symptoms were evident in 83.9% prior to PsA diagnosis. Peripheral joint swelling was the predominant PsA presentation pattern (82.1%).

CONCLUSIONS

The probability of PsA development among subclinical PsA was relatively high, emphasising the importance of emergent musculoskeletal symptoms when aiming for PsA prevention. Joint swelling was the dominant feature in new-onset PsA, likely reflecting clinical confidence in recognising joint swelling.

Metabolic and molecular imaging in inflammatory arthritis

It is known that metabolic shifts and tissue remodelling precede the development of visible inflammation and structural organ damage in inflammatory rheumatic diseases such as the inflammatory arthritides. As such, visualising and measuring metabolic tissue activity could be useful to identify biomarkers of disease activity already in a very early phase. Recent advances in imaging have led to the development of so-called 'metabolic imaging' tools that can detect these changes in metabolism in an increasingly accurate manner and non-invasively.Nuclear imaging techniques such as 18F-D-glucose and fibroblast activation protein inhibitor-labelled positron emission tomography are increasingly used and have yielded impressing results in the visualisation (including whole-body staging) of inflammatory changes in both early and established arthritis. Furthermore, optical imaging-based bedside techniques such as multispectral optoacoustic tomography and fluorescence optical imaging are advancing our understanding of arthritis by identifying intra-articular metabolic changes that correlate with the onset of inflammation with high precision and without the need of ionising radiation.Metabolic imaging holds great potential for improving the management of patients with inflammatory arthritis by contributing to early disease interception and improving diagnostic accuracy, thereby paving the way for a more personalised approach to therapy strategies including preventive strategies. In this narrative review, we discuss state-of-the-art metabolic imaging methods used in the assessment of arthritis and inflammation, and we advocate for more extensive research endeavours to elucidate their full field of application in rheumatology.

A clinical review of structural damage in psoriatic arthritis for dermatologists: From pathogenesis to ongoing controversies

Psoriatic arthritis (PsA) is a chronic inflammatory disease that often goes unrecognized in patients with psoriasis. As a result, patients may develop significant structural damage before diagnosis and initiation of adequate treatment. Dermatologists are in an unique position to identify early signs and symptoms of PsA. Here, we briefly review the pathogenesis of PsA, differences in PsA presentation within real-world dermatology practice versus rheumatology clinical trials, and imaging modalities that can be used to assess structural damage. We then discuss several ongoing controversies related to prediction, assessment, and treatment of PsA-related structural damage. Debated questions include the following: (1) Does subclinical enthesitis predict progression from psoriasis to PsA?, (2) Does methotrexate inhibit progression of structural damage?, (3) Does structural damage correlate with clinical disease activity?, and (4) Can progression from psoriasis to PsA be prevented? Evidence presented herein suggests that dermatologists, together with rheumatologists, can play important roles in the early diagnosis and treatment of PsA, thereby potentially preventing irreversible structural damage.

Prevalence of Musculoskeletal Symptoms in Patients with Psoriasis and Predictors Associated with the Development of Psoriatic Arthritis: Retrospective Analysis of a US Claims Database

INTRODUCTION

Psoriasis (PsO) is associated with the development of psoriatic arthritis (PsA). Patients with PsO often experience pre-PsA musculoskeletal (MSK) symptoms, leading to potential structural damage and substantial disease burden with impact on function. The objective of this study is to describe prevalence rates and evidence of MSK symptoms, including incidence of comorbid PsA diagnosis, in patients newly diagnosed with PsO and identify factors associated with PsA diagnosis.

METHODS

This retrospective analysis included administrative claims from the Optum Research Database for adult patients with a new PsO diagnosis between January 2008 and February 2019. Eligible patients had ≥ 2 claims for PsO on unique dates, were aged ≥ 18 years at the date of the first claim with a diagnosis of PsO (index date), and had continuous enrollment with medical and pharmacy coverage for 12 months before (baseline period) and ≥ 12 months following the index date. Primary outcomes were incidence of comorbid PsA diagnosis, prevalence of MSK symptoms other than PsA, and evidence of MSK symptoms collected at baseline and assessed in 12-month intervals through 60 months.

RESULTS

Of the 116,203 patients with newly diagnosed PsO, 110,118 were without baseline comorbid PsA. High prevalence rates of MSK symptoms among patients with only PsO were seen at baseline (47.1%), 12 months (48.2%), and 60 months (82.1%). Patient age, baseline MSK symptoms, and baseline MSK symptom-related healthcare utilization were associated with increased hazard of a PsA diagnosis.

CONCLUSION

Increased prevalence rates of MSK symptoms and burden are experienced by patients newly diagnosed with PsO through 60 months of follow-up. Several baseline factors were associated with increased risk of PsA diagnosis.

Identification of circulating microRNA patterns in patients in psoriasis and psoriatic arthritis

OBJECTIVE

miRNAs are small non-coding RNAs that control gene expression. Specific intra- and extracellular miRNA signatures have been identified in various diseases. Whether certain miRNA signatures are associated with psoriasis (PsO) and PsA is currently unknown. We aimed to search for circulating miRNA signatures associated with PsO and PsA patients.

METHODS

Expression of miRNAs was analysed by reverse transcription quantitative real-time PCR (RT-qPCR) in the serum of PsA, PsO patients and healthy controls. Demographic and disease-specific characteristics and imaging data from hand MRI were recorded. In the discovery phase, 192 miRNA assays were analysed in 48 samples (PsA, PsO, controls: each N = 16). For validation, 17 selected miRNAs were measured in the total population.

RESULTS

A total of 141 patients and controls were analysed (51 PsA, 40 PsO, 50 controls). In the discovery phase 51 miRNAs in PsO and 64 miRNAs in PsA were down- or upregulated compared with controls, with 33 miRNAs being changed in both (adj. P < 0.05). The 17 top candidates from discovery were assessed in the validation phase, 9 of them discriminated PsA and PsO from controls [area under the curve (AUC) ≥0.70, all P < 0.05]. Four miRNAs (miR-19b-3p, miR-21-5p, miR-92a-3p and let-7b-5p) were significantly differently regulated between PsO and PsA. A combination of these miRNAs increased the AUC to 0.92 in multivariate regression model to discriminate PsO and PsA.

CONCLUSION

miRNA signatures in PsA and PsO patients differ from controls. Nine miRNAs were differentially regulated in PsA and PsO patients, five of them previously reported to be involved in bone and cartilage metabolism, indicating an intimate association of psoriatic inflammation and bone/cartilage changes.

[From conventional to cutting edge imaging in rheumatology]

Imaging instruments, such as conventional X‑ray, ultrasound and magnetic resonance imaging (MRI) are now fully established and highly valued in the care of rheumatology patients. However, the information provided by these imaging modalities in their current form is of limited utility for the prognostic prediction of individual patient outcomes. This article illuminates an important part of the development of imaging and shows that the vision of personalized medicine is becoming increasingly more tangible due to the further development of high-resolution imaging techniques, molecular imaging and artificial intelligence.

Imaging in inflammatory arthritis: progress towards precision medicine

Imaging techniques such as ultrasonography and MRI have gained ground in the diagnosis and management of inflammatory arthritis, as these imaging modalities allow a sensitive assessment of musculoskeletal inflammation and damage. However, these techniques cannot discriminate between disease subsets and are currently unable to deliver an accurate prediction of disease progression and therapeutic response in individual patients. This major shortcoming of today's technology hinders a targeted and personalized patient management approach. Technological advances in the areas of high-resolution imaging (for example, high-resolution peripheral quantitative computed tomography and ultra-high field MRI), functional and molecular-based imaging (such as chemical exchange saturation transfer MRI, positron emission tomography, fluorescence optical imaging, optoacoustic imaging and contrast-enhanced ultrasonography) and artificial intelligence-based data analysis could help to tackle these challenges. These new imaging approaches offer detailed anatomical delineation and an in vivo and non-invasive evaluation of the immunometabolic status of inflammatory reactions, thereby facilitating an in-depth characterization of inflammation. By means of these developments, the aim of earlier diagnosis, enhanced monitoring and, ultimately, a personalized treatment strategy looms closer.

Application of clinical and molecular profiling data to improve patient outcomes in psoriatic arthritis

Achieving a good outcome for a person with Psoriatic Arthritis (PsA) is made difficult by late diagnosis, heterogenous clinical disease expression and in many cases, failure to adequately suppress inflammatory disease features. Single-centre studies have certainly contributed to our understanding of disease pathogenesis, but to adequately address the major areas of unmet need, multi-partner, collaborative research programmes are now required. HIPPOCRATES is a 5-year, Innovative Medicines Initiative (IMI) programme which includes 17 European academic centres experienced in PsA research, 5 pharmaceutical industry partners, 3 small-/medium-sized industry partners and 2 patient-representative organizations. In this review, the ambitious programme of work to be undertaken by HIPPOCRATES is outlined and common approaches and challenges are identified. It is expected that, when completed, the results will ultimately allow for changes in the approaches to diagnosing, managing and treating PsA allowing for better short-term and long-term outcomes.

EULAR points to consider for the definition of clinical and imaging features suspicious for progression from psoriasis to psoriatic arthritis

BACKGROUND

The transition from psoriasis (PsO) to psoriatic arthritis (PsA) and the early diagnosis of PsA is of considerable scientific and clinical interest for the prevention and interception of PsA.

OBJECTIVE

To formulate EULAR points to consider (PtC) for the development of data-driven guidance and consensus for clinical trials and clinical practice in the field of prevention or interception of PsA and for clinical management of people with PsO at risk for PsA development.

METHODS

A multidisciplinary EULAR task force of 30 members from 13 European countries was established, and the EULAR standardised operating procedures for development for PtC were followed. Two systematic literature reviews were conducted to support the task force in formulating the PtC. Furthermore, the task force proposed nomenclature for the stages before PsA, through a nominal group process to be used in clinical trials.

RESULTS

Nomenclature for the stages preceding PsA onset, 5 overarching principles and 10 PtC were formulated. Nomenclature was proposed for three stages towards PsA development, namely people with PsO at higher risk of PsA, subclinical PsA and clinical PsA. The latter stage was defined as PsO and associated synovitis and it could be used as an outcome measure for clinical trials evaluating the transition from PsO to PsA. The overarching principles address the nature of PsA at its onset and underline the importance of collaboration of rheumatologists and dermatologists for strategies for prevention/interception of PsA. The 10 PtC highlight arthralgia and imaging abnormalities as key elements of subclinical PsA that can be used as potential short-term predictors of PsA development and useful items to design clinical trials for PsA interception. Traditional risk factors for PsA development (ie, PsO severity, obesity and nail involvement) may represent more long-term disease predictors and be less robust for short-term trials concerning the transition from PsO to PsA.

CONCLUSION

These PtC are helpful to define the clinical and imaging features of people with PsO suspicious to progress to PsA. This information will be helpful for identification of those who could benefit from a therapeutic intervention to attenuate, delay or prevent PsA development.

Psoriatic Arthritis: Development, Detection and Prevention: A Scoping Review

Psoriatic arthritis is a heterogenous chronic inflammatory disease that develops over time in some patients with psoriasis. The course of the disease is variable, with a broad clinical spectrum. The management of PsA has changed tremendously over the last decade, thanks to earlier diagnosis, a multidisciplinary approach and progress in pharmacological therapies. Therefore, screening for risk factors and the early signs of arthritis is highly important and recommended. Currently, research is focused on finding soluble biomarkers and developing imaging techniques that can improve the prediction of psoriatic arthritis. Among imaging modalities, ultrasonography seems to be the most accurate in detecting subclinical inflammation. Early intervention is based on the assumption that it is possible to prevent or delay psoriatic arthritis if systemic treatment for psoriasis can be administered early enough. This review article provides an overview of the current perspectives and evidence regarding the diagnosis, management and prevention of psoriatic arthritis.

The role of ultrasound in screening subclinical psoriatic arthritis in patients with moderate to severe psoriasis

OBJECTIVE

To identify patients in the subclinical psoriatic arthritis (Sub-PsA) phase by ultrasound (US) and provide a solution to screen them.

METHODS

A total of 490 participants with moderate-to-severe psoriasis were evaluated. Among them, 384 participants without arthritis symptoms were enrolled into the silent psoriasis group and 106 participants with arthritis symptoms, called prodromal/active PsA phase, were enrolled into the clinical PsA group. Another 80 non-psoriasis participants were enrolled into the control group. Each participant received clinical assessments and US examinations of 60 joints, 38 tendons, and 40 entheses. We compared the incidences of synovio-enthesitis, synovitis, tenosynovitis, erosion, and dactylitis detected on US among the three groups. Subsequently, on the basis of significant US findings, we distinguished Sub-PsA from psoriasis alone (PsO) in the silent psoriasis group and analyzed the clinical characteristics, mainly including basic clinical characteristics, body surface area (BSA), and Psoriasis Area and Severity Index (PASI) score.

RESULTS

Only synovio-enthesitis significantly differed between the control group and the silent psoriasis group (1.3% vs. 16.1%, p < 0.001). The knee was the most commonly involved site of synovio-enthesitis (79.0%). Taking synovio-enthesitis as the standard, 16.1% of silent psoriasis participants and 12.7% of all psoriasis participants were in the Sub-PsA phase. Furthermore, there were no differences in BSA and PASI among the three phases of PsO, Sub-PsA, and prodromal/active PsA.

CONCLUSIONS

Since the psoriasis patients in Sub-PsA phase was as high as 12.7% in all patients with moderate-to-severe psoriasis, US-detected synovio-enthesitis was recommended routinely for screening them regardless of arthritis symptoms, especially in the lower limbs.

KEY POINTS

• Synovio-enthesitis on ultrasound was significantly associated with subclinical psoriatic arthritis, especially in the lower limbs. • Routine ultrasound evaluation could help screen psoriasis patients in the subclinical psoriatic arthritis phase, which was as high as 12.7% in all psoriasis patients.

Efficacy of guselkumab, a selective IL-23 inhibitor, in Preventing Arthritis in a Multicentre Psoriasis At-Risk cohort (PAMPA): protocol of a randomised, double-blind, placebo controlled multicentre trial

INTRODUCTION

Psoriatic arthritis (PsA) is a complex, immune-mediated disease associated with skin psoriasis that, if left untreated, can lead to joint destruction. Up to 30% of patients with psoriasis progress to PsA. In most cases, psoriasis precedes synovio-entheseal inflammation by an average of 5-7 years, providing a unique opportunity for early and potentially preventive intervention in a susceptible and identifiable population. Guselkumab is an effective IL-23p19 inhibitor Food and Drug Administration (FDA-approved for treatment of moderate-to-severe psoriasis and PsA. The Preventing Arthritis in a Multicentre Psoriasis At-Risk cohort (PAMPA) study aims to evaluate the efficacy of guselkumab in preventing PsA and decreasing musculoskeletal power Doppler ultrasound (PDUS) abnormalities in a population of patients with psoriasis who are at-increased risk for PsA progression.

METHODS AND ANALYSIS

The PAMPA study is a multicentre, randomised, double-blind, placebo-controlled, interventional, preventive trial comparing PDUS involvement and conversion to PsA in patients with psoriasis at-increased risk for progression treated with guselkumab compared with non-biological standard of care. The study includes a screening period, a double-blind treatment period (24 weeks) and an open-label follow-up period (72 weeks). At baseline, 200 subjects will be randomised (1:1) to receive either guselkumab 100 mg (arm 1) or placebo switching to guselkumab 100 mg starting at week 24 (arm 2). Arm 3 will follow 150 at-risk psoriasis patients who decline biological therapy and randomisation. Changes from baseline in the PDUS score at week 24 and the difference in proportion of patients transitioning to PsA at 96 weeks will be examined as the coprimary endpoints.

ETHICS AND DISSEMINATION

Ethics approval for this study was granted by the coordinating centre's (NYU School of Medicine) Institutional Review Board (IRB). Each participating site received approval through their own IRBs. The findings will be shared in peer-reviewed articles and scientific conference presentations.

TRIAL REGISTRATION NUMBER

NCT05004727.

Looking beyond the Skin: Pathophysiology of Cardiovascular Comorbidity in Psoriasis and the Protective Role of Biologics

Psoriasis is a chronic systemic inflammatory disease associated with a higher incidence of cardiovascular disease, especially in patients with moderate to severe psoriasis. It has been estimated that severe psoriasis confers a 25% increase in relative risk of cardiovascular disease, regardless of traditional risk factors. Although the underlying pathogenic mechanisms relating psoriasis to increased cardiovascular risk are not clear, atherosclerosis is emerging as a possible link between skin and vascular affection. The hypothesis that the inflammatory cascade activated in psoriasis contributes to the atherosclerotic process provides the underlying basis to suggest that an anti-inflammatory therapy that improved atherosclerosis would also reduce the risk of MACEs. In this sense, the introduction of biological drugs which specifically target cytokines implicated in the inflammatory cascade have increased the expectations of control over the cardiovascular comorbidity present in psoriasis patients, however, their role in vascular damage processes remains controversial. The aim of this paper is to review the mechanistic link between psoriasis and cardiovascular disease development, as well as analyzing which of the biological treatments could also reduce the cardiovascular risk in these patients, fueling a growing debate on the modification of the general algorithm of treatment.

Follow-Up Comparison of Fluorescence Optical Imaging With Musculoskeletal Ultrasound for Early Detection of Psoriatic Arthritis

Objectives

Early diagnosis of psoriatic arthritis (PsA) is crucial for a patient outcome but hampered by heterogenous manifestation and a lack of specific biomarkers. We recently showed that fluorescence optical imaging (FOI) can differentiate between patients with confirmed and suspected PsA. This study aims to follow-up (FU) patients with confirmed and suspected PsA focusing on patients with a change from suspected to confirmed PsA by the use of FOI in comparison with musculoskeletal ultrasound (MSUS).

Methods

Follow-up examination of patients included in the study performed by Erdmann-Keding et al. in which FOI of both hands was performed in a standardized manner using three predefined phases (p1–p3) and PrimaVista Mode (PVM). The comparison was drawn to grayscale–power Doppler (GS/PD) MSUS of the clinically dominant hand (wrist, MCP, PIP, DIP 2–5) from dorsal or palmar.

Results

Patients with a change from suspected to diagnosed PsA showed an increased prevalence of joints with pathological enhancement in FOI (p = 0.046) with an unchanged joint distribution pattern, especially with a dominant involvement of DIP joints. Compared to the baseline, these patients were three times more common to show enhancement in FOI p3 at FU. Newly detected pathologic joints by FOI (PVM, p2) and MSUS at FU were positively associated with the change of diagnosis from suspected to confirmed PsA (FOI: AUC 0.78; GSUS: AUC 0.77).

Conclusion

Fluorescence optical imaging appears to be a helpful tool to detect early PsA and to distinguish between acute and chronic disease stages. It could thereby become a suitable tool as a screening method to select psoriasis patients with an indication for further rheumatological evaluation.

Does biologic therapy impact the development of PsA among patients with psoriasis?

OBJECTIVE

To examine the association of biologic therapy use for psoriasis with incident psoriatic arthritis (PsA) diagnosis.

METHODS

A retrospective cohort study was conducted in the OptumInsights Electronic Health Record Database between 2006 and 2017 among patients with psoriasis between the ages of 16 and 90 initiating a therapy for psoriasis (oral, biologic or phototherapy). The incidence of PsA was calculated within each therapy group. Multivariable Cox models were used to calculate the HR for biologic versus oral or phototherapy using biologics as a time-varying exposure and next in a propensity score-matched cohort.

RESULTS

Among 1 93 709 patients with psoriasis without PsA, 14 569 biologic and 20 321 cumulative oral therapy and phototherapy initiations were identified. Mean age was lower among biologic initiators compared with oral/phototherapy initiators (45.9 vs 49.8). The incidence of PsA regardless of therapy exposure was 9.75 per 1000 person-years compared with 77.26 among biologic users, 61.99 among oral therapy users, 26.11 among phototherapy users and 5.85 among those without a prescription for one of the target therapies. Using a multivariable adjustment approach with time-varying exposure, adjusted HR (95% CI) for biologic users was 4.48 (4.23 to 4.75) compared with oral or phototherapy users. After propensity score matching, the HR (95% CI) was 2.14 (2.00 to 2.28).

CONCLUSIONS

In this retrospective cohort study, biologic use was associated with the development of PsA among patients with psoriasis. This may be related to confounding by indication and protopathic bias. Prospective studies are needed to address this important question.

Development of a Predictive Model for Screening Patients with Psoriasis at Increased Risk of Psoriatic Arthritis

Introduction

This study aimed to develop a predictive model based on ultrasound variables which can be used to screen patients with psoriasis who are prone to progress to psoriatic arthritis (PsA) in clinical practice.

Methods

This is a cross-sectional study conducted in a single center from October 2018 to November 2020. All subjects (non-PsA group, PsA group, and control group) underwent an ultrasound examination and their ultrasound abnormalities were recorded. On the basis of statistical analysis and clinical experts’ advice, several variables were selected for modelling. We used logistic regression to establish the prediction model. To assess the discrimination and accuracy of this model, internal validation and external validation were performed.

Results

A total of 852 patients with psoriasis but without PsA, 261 patients with PsA, and 86 healthy volunteers were included. Ultimately, the predictive model consisted of six variables, namely hand joint power Doppler (PD) signals (grade 0: OR 2.94, 95% CI 1.94–4.47; grade ≥ 1: OR 109.30, 95% CI 14.35–832.27; P < 0.001), wrist joint synovial thickening (grade 1: OR 1.29, 95% CI 0.69–2.43; grade 2: OR 4.30, 95% CI 1.92–9.65; grade 3: OR 11.05, 95% CI 1.01–120.64; P = 0.001), knee joint PD signals (grade 0: OR 1.01, 95% CI 0.56–1.80; grade ≥ 1: OR 14.77, 95% CI 3.99–54.69; P < 0.001), toe joint PD signals (grade 0: OR 1.18, 95% CI 0.78–1.79; grade ≥ 1: OR 5.74, 95% CI 2.84–11.63; P < 0.001), quadriceps tendon and patellar tendon enthesitis (OR 1.95, 95% CI 1.36–2.78, P < 0.001), Achilles tendon and plantar aponeurosis enthesitis (OR 1.63, 95% CI 1.14–2.32, P = 0.007). C-index for the predictive model was 0.80 (95% CI 0.76–0.83). After bootstrapping validation (1000 times), it was confirmed to be 0.79. The external validation showed the accuracy of the predictive model is 0.87 (95% CI 0.69–0.95).

Conclusion

This study succeeded in developing a predictive model with a high degree of accuracy to predict the risk of PsA in patients with psoriasis.

Psoriatic arthritis often occurs in the population of patients with psoriasis. It brings a huge burden and pain to patients. At present, the diagnosis for psoriatic arthritis is very challenging. Numerous research studies have begun to focus on identifying patients with psoriasis at increased risk of psoriatic arthritis. Among a lot of modalities, ultrasound has been considered as a sensitive and convenient tool for screening early psoriatic arthritis. Our study successfully established a predictive model based on ultrasound variables to screen patients with psoriasis at high risk of transiting to psoriatic arthritis. After internal and external validation, it showed great accuracy and generalizability. We recommend that clinicians perform ultrasound screening of patients with psoriasis in clinical routine and get their risk value of transiting to psoriatic arthritis by using this model. For those patients with a high risk of progression to psoriatic arthritis, clinicians should refer them to a rheumatology department as soon as possible so that they could have access to early and effective management which might bring them good clinical and imaging outcomes.

Musculoskeletal pain in psoriasis - relation to inflammation and additional value of ultrasound in psoriatic arthritis classification

OBJECTIVE

To investigate and compare clinical features and ultrasound signs of inflammation in joints and entheses in patients with psoriasis (PsO) with and without musculoskeletal pain, and the additional value of ultrasound in classification of psoriatic arthritis (PsA). Furthermore, to explore the association between such findings and patient-reported outcomes (PROs) and the performance of screening-questionnaires for identifying patients with PsA.

METHODS

Patients with PsO (n = 126) recruited from a nationwide survey were evaluated at one of four rheumatology departments. The evaluation included clinical examination, laboratory tests, radiography, greyscale (GS) and colour Doppler (CD) ultrasound of 48 joints and 12 entheses, PROs, and four screening-questionnaires for PsA. Patients were classified with Classification for PsA (CASPAR), ultrasound-modified CASPAR, and ultrasound-only criteria.

RESULTS

When subgroups of self-reported pain (63%), no pain (29%) and diagnosed PsA (9%) were compared, patients with pain had higher tenderness-related clinical scores (tender joints, entheses and fibromyalgia points) and ultrasound GS sum-scores, compared with 'no pain' patients. PROs were negligibly-moderately correlated with pain-related clinical scores (Spearman's rho = 0.11-0.59, all patients), and negligibly-weakly with ultrasound sum-scores (rho = 0.01-0.34). More patients could be classified as PsA when ultrasound synovitis/enthesitis was included as entry criterion (ultrasound-modified CASPAR, 66% of all patients) compared with conventional CASPAR (35%) or ultrasound-only criteria (52%). Sensitivities of screening-questionnaires were low for fulfilment of CASPAR (0.23-0.66), ultrasound-modified CASPAR (0.17-0.57), and ultrasound-only (0.20-0.57) criteria.

CONCLUSION

Self-reported pain in PsO is related to ultrasound inflammation. Ultrasound-modified CASPAR criteria identified almost twice as many patients as conventional CASPAR criteria. Screening-questionnaires showed limited value.

Predictors, Risk Factors, and Incidence Rates of Psoriatic Arthritis Development in Psoriasis Patients: A Systematic Literature Review and Meta-Analysis

Background

Agreement on how to identify psoriasis (PsO) patients at risk of developing psoriatic arthritis (PsA) is lacking.

Objective

To identify predictors, risk factors and incidence rate (IR) of PsA development in PsO patients through a systematic literature review (SLR) and meta-analyses (MA).

Methods

MEDLINE, Embase, and Cochrane databases were searched. Cohort studies were used to assess the predictors, while case–control studies for PsA risk factor determination.

Results

We screened 4698 articles for eligibility, and 110 underwent a full reading and 26 were finally included. Among skin and nail phenotypes, PsO severity and nail pitting were selected as predictors of PsA development. Furthermore, PsO patients with arthralgia (pooled RR 2.15 [1.16; 3.99]) and/or with imaging-MSK inflammation (pooled RR 3.72 [2.12; 6.51]) were at high risk of PsA. Higher categories of BMI and a family history of PsA were other predictors. In outpatient-based cohort studies, the IR of PsA per 100 patient-years varied from 1.34 to 17.4.

Limitations

Despite the strength of the overall results, the heterogeneity and the number of the cohort studies could be considered a limitation.

Conclusions

This study provides a tentative profile of the PsO patient at risk of PsA and will help the design of PsA prevention trials.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00378-w.

Early Origins of Psoriatic Arthritis: Clinical, Genetic and Molecular Biomarkers of Progression From Psoriasis to Psoriatic Arthritis

Greater than 90% of patients with psoriatic arthritis (PsA) first develop their arthritis on a background of known psoriasis (Pso). Thus, having skin/nail Pso certainly is an important risk factor for PsA but as PsA develops in <30% of those affected with Pso, the presence of Pso alone is insufficient as a means of identifying which patients with Pso will develop PsA. It is hoped that with further molecular assessment of Pso patients who do not have any evidence of inflammatory musculoskeletal disease compared to those with early PsA features, that the “at risk” profile of Pso patients destined to develop PsA can be refined such that disease prevention studies can be designed and a new era of treatment for PsA can emerge. In this article, the early stages in the development of PsA are outlined and what is currently known about clinical features, genetic factors and soluble or tissue biomarkers associated with the development of PsA in patients with Pso is reviewed in detail. Finally, proposals are outlined regarding the approaches required in order to address this important research area.

Digital Approaches for a Reliable Early Diagnosis of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disease that develops in up to 30% of patients with psoriasis. In the vast majority of cases, cutaneous symptoms precede musculoskeletal complaints. Progression from psoriasis to PsA is characterized by subclinical synovio-entheseal inflammation and often non-specific musculoskeletal symptoms that are frequently unreported or overlooked. With the development of increasingly effective therapies and a broad drug armamentarium, prevention of arthritis development through careful clinical monitoring has become priority. Identifying high-risk psoriasis patients before PsA onset would ensure early diagnosis, increased treatment efficacy, and ultimately better outcomes; ideally, PsA development could even be averted. However, the current model of care for PsA offers only limited possibilities of early intervention. This is attributable to the large pool of patients to be monitored and the limited resources of the health care system in comparison. The use of digital technologies for health (eHealth) could help close this gap in care by enabling faster, more targeted and more streamlined access to rheumatological care for patients with psoriasis. eHealth solutions particularly include telemedicine, mobile technologies, and symptom checkers. Telemedicine enables rheumatological visits and consultations at a distance while mobile technologies can improve monitoring by allowing patients to self-report symptoms and disease-related parameters continuously. Symptom checkers have the potential to direct patients to medical attention at an earlier point of their disease and therefore minimizing diagnostic delay. Overall, these interventions could lead to earlier diagnoses of arthritis, improved monitoring, and better disease control while simultaneously increasing the capacity of referral centers.

Translational Research Studies Unraveling the Origins of Psoriatic Arthritis: Moving Beyond Skin and Joints

Patients with psoriatic arthritis (PsA) are suffering from a decreased quality of life despite currently available treatments. In the latest years, novel therapies targeting the IL-17/IL-23 and TNF pathways improved clinical outcome. Despite this, remission of disease is not achieved in a considerable group of patients, continuous treatment is very often required to reach clinical remission, and prevention of PsA in patients with psoriasis (PsO) is currently impossible. A better understanding of PsA pathogenesis is required to develop novel treatment strategies that target inflammation and destruction more effectively and at an early stage of the disease, or even before clinically manifest disease. The skin is considered as one of the sites of onset of immune activation, triggering the inflammatory cascade in PsA. PsO develops into PsA in 30% of the PsO patients. Influenced by environmental and genetic factors, the inflammatory process in the skin, entheses, and/or gut may evolve into synovial tissue inflammation, characterized by influx of immune cells. The exact role of the innate and adaptive immune cells in disease pathogenesis is not completely known. The involvement of activated IL-17A+ T cells could implicate early immunomodulatory events generated in lymphoid organs thereby shaping the pathogenic inflammatory response leading to disease. In this perspective article, we provide the reader with an overview of the current literature regarding the immunological changes observed during the earliest stages of PsA. Moreover, we will postulate future areas of translational research aimed at increasing our knowledge on the molecular mechanisms driving disease development, which will aid the identification of novel potential therapeutic targets to limit the progression of PsA.

Epidemiology, Comorbidity and Risk Factors for Psoriatic Arthritis: a Health Insurance Claims Database Analysis

Psoriatic arthritis is a frequent manifestation of psoriasis, and has a high level of impact on physical functioning, work ability and quality of life. However, there have been few studies of the epidemiology, development of and risk factors for concomitant psoriatic arthritis in patients with psoriasis. This study analysed data from a German public health insurance database of > 2 million individuals. Factors influencing the development of psoriatic arthritis were determined by descriptively analysing comorbidities and Cox regression modelling. The prevalences of psoriasis and psoriatic arthritis were 2.63% and 0.29% in adults (18+ years) and, respectively, 0.30% and 0.01% in children (0–17 years). The proportion of adult patients with incident psoriasis who developed concomitant psoriatic arthritis within five years after diagnosis of psoriasis (mean 2.3 years) was 2.6%. Cardiovascular diseases are the most frequent comorbidity in patients with psoriasis with or without concomitant psoriatic arthritis. Depression and neurosis/stress disorder were identified as indicators for the development of psoriatic arthritis.

A clinical perspective on risk factors and signs of subclinical and early psoriatic arthritis among patients with psoriasis

Psoriasis is a chronic, immune-mediated disease that includes a broad spectrum of systemic manifestations, complications, and comorbidities. Approximately 20%-30% of patients with psoriasis eventually develop psoriatic arthritis, and up to half of those without psoriatic arthritis experience subclinical musculoskeletal abnormalities. Recognition of early musculoskeletal inflammatory signs in patients with psoriasis is important to understand the extent and severity of this systemic disease, assess the risk of structural joint damage, and ensure timely and effective treatment of the complete spectrum of psoriatic disease. Delayed or ineffective treatment can lead to decreased quality of life, irreversible musculoskeletal damage, and loss of function. In this review, we highlight features of subclinical or early psoriatic arthritis among patients with psoriasis of which dermatologists should be aware. Recent knowledge of features of preclinical psoriatic arthritis in patients with psoriasis is presented. We briefly discuss important risk factors, clinical features, and other characteristics of patients likely to progress from psoriasis to psoriatic arthritis that should be known by dermatologists. Screening tools commonly used in the dermatology clinic to detect psoriatic arthritis are also critically reviewed. Finally, we provide expert commentary for dermatologists concerning the treatment of patients with psoriasis and subclinical signs of early psoriatic arthritis.

Musculoskeletal Imaging for Dermatologists: Techniques in the Diagnosis and Management of Psoriatic Arthritis

Psoriatic arthritis is an inflammatory condition affecting up to 30% of patients with psoriasis. Patients may experience irreversible joint damage if not treated early, and diagnostic delays of even 6 months are associated with radiographic progression and impaired function. Therefore, early detection and intervention are of critical importance in patients with psoriatic arthritis. Given that psoriasis often precedes symptoms of psoriatic arthritis, dermatologists are uniquely positioned to identify patients with psoriatic arthritis early in their disease course, before permanent damage has occurred. Several screening tools have been developed to help dermatologists identify patients who may have psoriatic arthritis, but these tools may not capture patients with subclinical disease or quantify the type and severity of the underlying tissue insult, which is often the presenting sign of psoriatic arthritis. In these cases, a combination of clinical assessment and musculoskeletal imaging (e.g., ultrasound) is required. This review summarizes three common musculoskeletal imaging techniques used in the diagnosis and management of patients with psoriatic arthritis: conventional radiography, ultrasound, and magnetic resonance imaging. Further understanding of musculoskeletal imaging will assist dermatologists in making treatment decisions and allow them to have a more active role in the detection of psoriatic arthritis.

Imaging in psoriatic arthritis: Status and recent advances

The heterogeneous nature of psoriatic arthritis (PsA), encompassing several domains, with varied presentations brings about considerable challenges in disease evaluation. Prompt diagnosis and targeted therapy have resulted in disease remission being accepted as an attainable goal in PsA. Imaging has played a pivotal role in early diagnosis, better understanding of pathogenesis, monitoring of disease, and as an outcome measurement tool in clinical trials in PsA. Conventional radiography has been the cornerstone of assessing structural damage. With the advent of ultrasound and magnetic resonance imaging, better delineation of the various structures involved in the disease process is possible, thus enabling sensitive assessment of inflammatory and structural pathologies together. In this review, imaging modalities used in routine assessment and clinical trials in PsA will be discussed in detail, focusing on advances over the past 5 years.

A 12-point recommendation framework to support advancement of the multidisciplinary care of psoriatic arthritis: A call to action

OBJECTIVE

Making a differential diagnosis of psoriatic arthritis (PsA) is not straightforward. This is partly because of its heterogeneous presentation and partly because many patients with PsA are initially diagnosed with psoriasis and treated in primary care or by dermatologists, with referral to rheumatologists being delayed. Once diagnosed, optimal disease control requires frequent specialist monitoring, adjustment or switching of therapies, and management of comorbidities and concomitant diseases, as well as attention to patients' overall well-being. Given the breadth of expertise that diagnosis and management of PsA requires, we sought to define a collaborative, structured framework that supports the optimisation of multidisciplinary care for patients with PsA in Europe.

METHODS

An expert panel comprising four rheumatologists, three dermatologists, two specialist nurses and one psychologist-from Spain, the United Kingdom, The Netherlands, Germany, France and Italy-met face-to-face to take part in a modified Delphi exercise.

RESULTS

The result of this exercise is a set of recommendations that are based on combining published evidence with the panel's extensive clinical experience. Recommendations can be implemented in a number of ways, but the central call-to-action of this framework is the need for improved collaboration between dermatologists (or primary care physicians) and rheumatologists. This could occur in a variety of different formats: standard referral pathways, multidisciplinary physician meetings to discuss patient cases, or 'one stop', combined clinics.

CONCLUSION

We anticipate that when the majority of patients with PsA receive regular multidisciplinary care, improved patient outcomes will follow, although robust research is needed to explore this assumption.

Distal phalangeal bone erosions observed by HR-pQCT in patients with psoriatic onycholysis

OBJECTIVES

PsA prevalence among skin psoriasis is ∼30%. Nail psoriasis, especially onycholysis, is present in >70% of PsA and the risk of developing PsA is more than doubled in patients with nail involvement. We hypothesized that onycholysis may be associated with early bone erosions of the DIP joint without harbouring PsA symptoms.

METHODS

We compared tendon thickness, assessed by US, and bone erosions, assessed by high-resolution peripheral quantitative CT, of the DIP joint in patients with psoriatic onycholysis without PsA (ONY) with those in patients with cutaneous psoriasis only (PSO). We used patients with PsA as reference (PsA group), and healthy age-matched controls (CTRL). Differences between groups were assessed by analysis of variance tests followed by post hoc analysis using the Scheffe method.

RESULTS

Mean (s.e.m.) age of the 87 participants (61% males) was 45.2 (1.3) years. The mean extensor tendon thickness was significantly larger in ONY than in PSO patients. In the PsA group, 68% of patients exhibited erosions of three different shapes: V-, Omega- and U-shape. Association with erosions was greater in the ONY group than in the PSO group (frequency: 57 vs 14%; P < 0.001; mean number of erosions: 1.10 (0.35) vs 0.03 (0.03); P < 0.001).

CONCLUSION

Onycholysis was associated with significant enthesopathy and bone erosions in our cohort. These data support the pathogenic role of enthesopathy in PsA. Onycholysis may be considered as a surrogate marker of severity in psoriasis.

TRIAL REGISTRATION

ClinicalTrails.gov, https://clinicaltrials.gov, NCT02813720.

Medical imaging examination in psoriasis and early psoriatic arthritis patients: an updated systematic review and meta-analysis

Psoriatic arthritis appears in one in four skin psoriasis patients. Early detection of the presence of joint involvement and early interception of its developments may minimize long-term functional disability, and the radiological methods may be a perfect choice. To summarize and compare different imaging methods for diagnosing early-stage psoriatic arthritis and determine the necessity of joint examination in all psoriasis patients, several electronic databases, including MEDLINE and EMBASE, were searched for English language studies. A specific selection criterion followed the retrieval of studies. Thirteen studies were finally enrolled in the meta-analysis, eight of which compared the bone changes presentat on medical imaging examination between psoriasis patients without psoriatic arthritis and healthy people; three studies focused on differences between psoriatic arthritis patients and free joint involvement psoriasis patients shown on medical imaging tests. Medical imaging examination, including ultrasound (US), high-resolution peripheral quantitative CT scans (HR-pQCT), and magnetic resonance imaging (MRI), can be good choices for detecting the start of asymptomatic joint inflammation in psoriasis patients, which is essential to early detection and interception of joint damage to lower joint deformities and improve the future quality of life for patients. Additionally, the examination for psoriasis patients with arthralgia is also highly recommended.

Similar Impact of Psoriatic Arthritis and Rheumatoid Arthritis on Objective and Subjective Parameters of Hand Function

OBJECTIVE

The objective of this study was to compare the impact of psoriatic disease (psoriatic arthritis [PsA] and psoriasis) and rheumatoid arthritis (RA) on objective and subjective parameters of hand function.

METHODS

Hand function was determined in this cross-sectional study by 1) vigorimetric grip strength, 2) the Moberg Picking-Up Test used for assessing fine-motor skills, and 3) self-reported hand function (Michigan Hand Questionnaire). Mixed-effects linear regression models were used to test the relation of hand function with disease group, age, and sex.

RESULTS

Two hundred ninety-nine subjects were tested, 101 with RA, 92 with PsA, and 106 nonarthritic controls (51 with psoriasis and 55 healthy controls [HCs]). Regression analysis showed that hand function was influenced by age, sex, disease group, and hand dominance (P < 0.001 for all). The impact of PsA and RA on hand function was comparable and generally more pronounced in women. Both PsA and RA led to significantly enhanced age-related loss of grip strength, fine-motor skills, and self-reported hand function in patients with PsA and RA compared with HCs. In addition, patients with psoriasis showed significant impairment of hand function compared with HCs.

CONCLUSION

RA and PsA have a comparable impact on the decline of strength, fine-motor skills, and self-reported function of the hand. Unexpectedly, patients with psoriasis also show impaired hand function that follows a similar pattern as observed in patients with PsA.

Dermatologists' Role in the Early Diagnosis of Psoriatic Arthritis: Expert Recommendations

Psoriatic arthritis is a common type of inflammatory arthritis found in up to 40% of patients with psoriasis. Because skin involvement usually precedes joint involvement, dermatologists play a key role in early detection. Early diagnosis is important for reducing the risk of irreversible structural damage, attenuating the deterioration of physical function, and improving patients' quality of life. This consensus statement was drafted by a group of 9 dermatologists and 1 rheumatologist to provide simple recommendations to help dermatologists screen for psoriatic arthritis in patients with psoriasis. The experts offer consensus-based guidelines that draw on a review of available scientific evidence and on experience acquired in routine clinical practice.

Comparison of the Heel Enthesitis MRI Scoring System (HEMRIS) with clinical enthesitis and local metabolic activity on PET-CT

OBJECTIVE

To compare the Heel Enthesitis MRI Scoring model (HEMRIS) with clinical and PET/CT outcomes in patients with cutaneous psoriasis (Pso), psoriatic arthritis (PsA) or ankylosing spondylitis (AS).

METHODS

This prospective, observational study included 38 patients with Pso, PsA and AS. Patients were included regardless of presence or absence of clinical heel enthesitis. MRI-scans of both ankles and a whole-body 18F-FDG PET/CT were acquired. MRIs were assessed for enthesitis by two independent and blinded observers according to the HEMRIS. A physician, blinded for imaging results, performed clinical evaluations of enthesitis at the Achilles tendon and plantar fascia.

RESULTS

In total, 146 entheses were scored according to the HEMRIS and clinically assessed for enthesitis (6 entheses were clinically affected). In Achilles tendons with clinical enthesitis, the HEMRIS structural damage score was significantly higher, compared to Achilles tendons without clinical enthesitis (respective median scores 1.0 and 0.5; p=0.04). In clinically unaffected entheses, HEMRIS abnormalities occurred in 44/70 (63%) of Achilles tendons and in 23/70 (33%) of plantar fascia. At the Achilles tendon, local metabolic activity measured on PET/CT was weakly associated with the structural (rs=0.25, p=0.03) and total HEMRIS (rs=0.26, p=0.03).

CONCLUSION

This study revealed a high prevalence of subclinical HEMRIS abnormalities and discrepancy between HEMRIS and clinical and PET/CT findings. This may suggest that the HEMRIS is a sensitive method for detection of inflammatory and structural disease of enthesitis at the Achilles tendon and plantar fascia, although the clinical significance of these MRI findings remains to be determined in longitudinal studies.

Recent Advances in Imaging for Diagnosis, Monitoring, and Prognosis of Psoriatic Arthritis

Psoriatic arthritis (PsA) is an inflammatory condition characterized by a strong heterogeneity and multifaceted behavior. PsA manifests in two types—axial and peripheral—which may be present at the same time. Peripheral manifestations can be further divided into the articular (arthritis) and extra-articular (i.e., enthesitis and dactylitis) subgroups. In such a complex disease, imaging is often required to characterize the type of involvement and to evaluate the radiological damage and progression of PsA. In addition, imaging plays a pivotal role in clinical practice; that is, for axial involvement. Conventional radiology has been the main standard of reference for many years. However, in recent years, there has been growing interest in different imaging modalities, such as ultrasonography (US) and magnetic resonance imaging (MRI). All these techniques play a role in the diagnosis and follow-up of patients with PsA and cover all the types of the disease. US and MRI have good sensitivities and specificities for detecting synovitis, and this may be helpful for differential diagnosis with other musculoskeletal diseases and useful in the early or preclinical phases of the disease. However, US is not useful in the diagnosis of axial PsA. In addition, other modalities have been investigated in the field of PsA imaging. Computed tomography (CT), in particular, dual energy-CT and high-resolution peripheral CT (HRpQ-CT) might play an important role in the assessment of bone damage, erosions, and new bone formation. Regarding advanced functional imaging, FDG PET/CT is another interesting technique for exploring disease activity.

Defining Pre-Clinical Psoriatic Arthritis in an Integrated Dermato-Rheumatology Environment

In excess of three quarters of patients with psoriatic arthritis (PsA) have preceding psoriasis (PsO), which offers a clinical biomarker for the recognition of early PsA. Numerous surveys have shown a remarkably high frequency of clinically occult musculoskeletal symptoms in psoriasis patients. Imaging studies, particularly ultrasound, show a high prevalence of subclinical enthesitis and other inflammatory changes in psoriasis subjects. Since a serum biomarker, such as the case of anti-citrullinated protein antibodies (ACPA) in rheumatoid arthritis, neither exists nor seems biologically plausible at this point, this article explores how integration of rheumatological and dermatological assessment can be facilitated for the early recognition of potential PsA. Given that scalp disease is a PsA predictor, but may be managed in the community, then a particular need to access this group is needed. An integrated approach between rheumatology and dermatology can involve joint clinics, parallel clinics with discussion of relevant cases or virtual contact between specialties. Early therapy evaluation and integrated strategies have considerable implications for minimizing suffering and joint damage in PsA.

Imaging in the diagnosis and management of peripheral psoriatic arthritis

Psoriatic arthritis is a heterogenous disease affecting peripheral and axial joints, tendons, ligaments, and their insertions, in addition to the skin and the nails. The complexity of the involved structures has puzzled clinicians trying to understand the underlying pathology that leads to symptoms in order to choose the appropriate medications with different modes of actions. Imaging, mainly ultrasound and magnetic resonance imaging, allows of accurate detection of inflammatory changes in the musculoskeletal structures, which helps to avoid false positive and negative assessments. The linking of different anatomical structures' involvement using imaging also provides insights into the pathogenesis of psoriatic arthritis. In this review, ultrasound and magnetic resonance imaging will be discussed in depth with regard to their use in the field of peripheral psoriatic arthritis, with a focus on the literature from the last 4 years and recent advances.

Innovative Imaging Technique for Visualization of Vascularization and Established Methods for Detection of Musculoskeletal Inflammation in Psoriasis Patients

Psoriasis (PsO) is one of the common chronic inflammatory skin diseases. Approximately 3% of the European Caucasian population is affected. Psoriatic arthritis (PsA) is a chronic immune-mediated disease associated with PsO characterized by distinct musculoskeletal inflammation. Due to its heterogeneous clinical manifestations (e.g., oligo- or polyarthritis, enthesitis, dactylitis, and axial inflammation), early diagnosis of PsA is often difficult and delayed. Approximately 30% of PsO patients will develop PsA. The responsible triggers for the transition from PsO only to PsA are currently unclear, and the impacts of different factors (e.g., genetic, environmental) on disease development are currently discussed. There is a high medical need, recently unmet, to specifically detect those patients with an increased risk for the development of clinically evident PsA early to initiate sufficient treatment to inhibit disease progression and avoid structural damage and loss of function or even intercept disease development. Increased neoangiogenesis and enthesial inflammation are hypothesized to be early pathological findings in PsO patients with PsA development. Different disease states describe the transition from PsO to PsA. Two of those phases are of value for early detection of PsA at-risk patients to prevent later development of PsA as changes in biomarker profiles are detectable: the subclinical phase (soluble and imaging biomarkers detectable, no clinical symptoms) and the prodromal phase (imaging biomarkers detectable, unspecific musculoskeletal symptoms such as arthralgia and fatigue). To target the unmet need for early detection of this at-risk population and to identify the subgroup of patients who will transition from PsO to PsA, imaging plays an important role in characterizing patients precisely. Imaging techniques such as ultrasound (US), magnetic resonance imaging (MRI), and computerized tomography (CT) are advanced techniques to detect sensitively inflammatory changes or changes in bone structure. With the use of these techniques, anatomic structures involved in inflammatory processes can be identified. These techniques are complemented by fluorescence optical imaging as a sensitive method for detection of changes in vascularization, especially in longitudinal measures. Moreover, high-resolution peripheral quantitative CT (HR-pQCT) and dynamic contrast-enhanced MRI (DCE-MRI) may give the advantage to identify PsA-related early characteristics in PsO patients reflecting transition phases of the disease.

Patient-Centered Care in Psoriatic Arthritis-A Perspective on Inflammation, Disease Activity, and Psychosocial Factors

Psoriatic arthritis (PsA) is a seronegative spondyloarthropathy characterized by skin lesions, dactylitis, and enthesitis. Patients with PsA suffer from a variety of psychosocial difficulties and nonspecific symptoms early on in the disease course and continue to experience progressive disease due to delays in diagnosis and treatment. Symptoms initially viewed as somatization could lead to undertreatment and promote psychological distress, poor coping, and negative patient-provider relationships. Pain and fatigue are important complaints that affect the patient's perception and may need to be addressed with a multidisciplinary approach. Maladaptive cognitive responses can lead to a negative illness perception and impact patient beliefs and concerns over treatment, as well as nonadherence. An underlying inflammatory component in affective disorders has been examined, though whether and how it may interact mechanistically in PsA warrants interest. Cognitive behavioral therapy represents a nonpharmacological treatment modality that can be combined with cytokine-targeted therapy to address both somatic and psychological complaints. Future directions for research include: (1) Elucidating nonspecific manifestations (e.g., subclinical stage, differential with functional syndromes) of PsA and how they impact diagnosis and management; (2) characterizing immune-mediated components of mood disorders in PsA; and (3) whether a bidirectional approach with abrogating inflammation and psychotherapeutic support leads to improved outcomes.

Clinicians' perspectives of shared care of psoriatic arthritis and psoriasis between rheumatology and dermatology: an interview study

OBJECTIVE

Shared care between rheumatologists and dermatologists is advocated for patients with psoriasis and psoriatic arthritis, but care provided by rheumatologists and dermatologists is often siloed, leading to inconsistencies in patient care and outcomes. This study aimed to describe rheumatologists' and dermatologists' perspectives on shared care.

METHODS

Face-to-face semi-structured interviews were conducted with 15 rheumatologists and 12 dermatologists across 27 centers in Australia. Transcripts were thematically analyzed.

RESULTS

Five themes were identified: uncertainties in disciplinary tensions (lacking expertise to make diagnosis, hesitation managing outside of scope, doubting screening tools, defaulting to own disciplinary priorities, hampered by lack of evidence), working in fragmented care (frustration with working in silos, striving to coordinate with primary care, persevering despite inequities in access to care, overwhelmed by managing comorbidities, under-resourced for complexity), building trusting relationships (establishing a culture of collaboration, seeking reliable cross-specialty help, depending on unique skills), prioritizing efficiency (minimizing burden for patients, avoiding resource overuse, deferring to pragmatic decisions), and strengthened by integrated care models (improving the timeliness and accuracy of care, centering on patient goals and understanding, enhancing cross-specialty partnerships, providing opportunities for education and training).

CONCLUSIONS

Rheumatologists and dermatologists endeavor to provide comprehensive care to their patients in disjointed healthcare settings but are hampered by a lack of training and a sense of feeling overburdened in the management of comorbidities. Interdisciplinary models are perceived to improve the care of patients but are limited by financial barriers to implementation and concerns about wasting health resources and improperly burdening patients. Key Points • Rheumatologists and dermatologists perceive that shared care models improve the care for their patients with psoriatic arthritis and psoriasis by improving the timeliness and accuracy of management, making the patient the center of care, and enhancing shared care relationships between specialties. • Screening tools to detect psoriatic arthritis may be under-utilized by dermatologists due to doubt about the accuracy of instruments and competing priorities in time-limited consultations. • Management of comorbid disease is challenging for rheumatologists and dermatologists due to a need to prioritize their specialty area and a sense of feeling overburdened while working in fragmented healthcare systems.