Epidemiology and clinical pattern of psoriatic arthritis in Germany: a prospective interdisciplinary epidemiological study of 1511 patients with plaque-type psoriasis

Prevalence of psoriatic arthritis among patients with plaque psoriasis: a Brazilian retrospective study

BACKGROUND

Psoriatic arthritis is the most frequent and impactful comorbidity among psoriatic patients and appears in most cases after skin disease. Dermatologists play a key role in its early diagnosis and treatment.

OBJECTIVE

To determine the prevalence of psoriatic arthritis and associated variables among patients with plaque psoriasis seen at a reference center for treating psoriasis.

DESIGN AND SETTING

Retrospective cross-sectional study conducted among 300 patients at an outpatient clinic in a university center in Juiz de Fora, MG, Brazil.

METHODS

Standardized records of 300 patients with plaque psoriasis were examined. Demographic data and medical variables relating to psoriasis (Psoriasis Area and Severity Index (PASI), family history, age at onset and disease progression) and psoriasis arthritis (CASPAR criteria) were evaluated. Laboratory and radiographic tests in the medical records were reviewed.

RESULTS

Seventy-three (24.3%) of these 300 patients with plaque psoriasis had psoriatic arthritis. Asymmetric oligoarthritis (58.9%) was the most common clinical form, followed by polyarthritis (20.5%), distal interphalangeal arthritis (15.2%) and spondyloarthritis (5.4%). Dactylitis was present in 21.9% and enthesitis in 35.6% of patients. Compared with patients without arthritis, patients with arthritis had higher average age, higher frequency of positive family history of psoriasis, longer duration of evolution and higher PASI rates.

CONCLUSION

Psoriatic arthritis is often underdiagnosed. Since dermatologists perform the initial approach, these professionals need to be trained to diagnose this comorbidity and treat it, together with rheumatologists.

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.

Quality of psoriasis care in Germany - results from the nationwide health care studies PsoHealth 2004-2017

BACKGROUND

In the study series PsoHealth first data from 2004/05 showed a poor quality of health care for psoriasis in Germany. Most patients lacked sufficient care and only a minor proportion received systemic drugs. Since 2007, a national psoriasis programme has been conducted.

OBJECTIVES

(1) To analyse the quality of health care for psoriasis in the most recent PsoHealth4 survey 2016/17, (2) to compare health care quality indicators with prior assessments since 2004/05.

MATERIALS AND METHODS

The recent cross-sectional PsoHealth4 survey was conducted 2016/17, and three preceding studies were performed in 2004/05, 2007 and 2013/14, each including at least 1500 patients. The common set of quality indicators included disease severity (PASI and proportion of patients with PASI > 20, indicating high severity), quality of life (DLQI and proportion of patients with DLQI > 10, indicating strong impairments in quality of life), systemic therapy and inpatient treatment of the last five years.

RESULTS

Between December 2015 and December 2017, n = 1827 patients from 93 dermatological centres were included in the most recent survey (mean age: 50.8 ± 14.6 years, 45.2% female). 7.3% showed a PASI > 20, compared to 17.8% in 2004/05. 21.4% reported a DLQI > 10, compared to 34.0% in 2004/05. 57.6% of all participants stated to have received a systemic therapy at least once within the last five years, compared to 32.9% in 2004/05. 18.0% received inpatient hospital treatment at least once within the last five years, compared to 26.9% in 2004/05.

CONCLUSION

A remarkable improvement in the health care quality for psoriasis patients in Germany within the past 12 years can be assumed. Major determinants could be the innovation shift which included programmes such as the S3 guideline, a consensus on treatment goals, national health care goals for psoriasis and higher utilisation of innovative drugs.

Towards a combined pediatric rheumatology-dermatology clinic: One-year experience

OBJECTIVE:

Dermatological findings may be the sole complaints of diseases in pediatric rheumatology practice. Evaluating patients with a multi-disciplinary approach may facilitate access to an accurate diagnosis. Herein, we reported our one-year experience in collaborative pediatric rheumatology-dermatology.

METHODS:

Patients were initially evaluated separately in pediatric rheumatology-dermatology outpatient clinics. Subsequently, once a week, the final diagnoses of patients with suspected skin rash were collaboratively discussed by two pediatric rheumatologists and a dermatologist.

RESULTS:

A hundred and one patients were included in this study. Of these 101 patients, 65 attended to dermatology outpatient clinic initially, while the remaining 36 applied to the pediatric rheumatology outpatient clinic. The most common mucocutaneous finding was squamous lesions in 30 patients, followed by erythematous lesions in 28 and mucosal ulcers in 14. Finally, 69 patients were diagnosed with a rheumatic disease while 32 had differential diagnoses apart from rheumatic diseases.

CONCLUSION:

Patients with rheumatologic diseases frequently present with only mucocutaneous findings. Thus, a detailed examination of the mucosa, skin and its attachments is of paramount importance in rheumatology practice. We suggest that a close interaction between pediatric rheumatology-dermatology and the formation of consensus clinics are going to assist clinicians in making easier and accurate diagnoses.

Validation of Sinhala version of Psoriasis Epidemiology Screening Tool

INTRODUCTION/OBJECTIVES

Psoriatic arthritis (PsA) occurs in one-third of patients with psoriasis and mostly remains undetected leading to debilitating deforming arthritis, eventually. The Psoriasis Epidemiology Screening Tool (PEST) is a quick and valid tool, widely used to detect PsA in clinical practice, and it has been validated to many languages. In this study, we intended to validate a Sinhala version of the PEST and assess its psychometric properties.

METHODS

The Sinhala version of the questionnaire was tested on 199 patients with psoriasis attending the dermatology clinic at a tertiary care National Hospital in Sri Lanka. Patients who were detected to have PsA previously (n = 5) and those with other rheumatologic conditions (n = 12) were excluded. All patients were examined by a dermatologist, and demographic and disease characteristics were obtained. All patients were assessed by two rheumatologists who were blinded to the answers provided in the questionnaire. The diagnosis of PsA was made based on the CASPAR criteria.

RESULTS

We observed the total PEST score of 3 or more to be the best cutoff value to screen for PsA. This cutoff value showed the highest Youden index (sensitivity = 0.89, specificity = 0.95). In the ROC analysis, the area under the curve of the PEST_sv was 0.95 (SE 0.02, p < 0.001). PEST_sv total score showed a significant correlation with body surface area involved but not with Dermatology Life Quality Index or Psoriasis area and severity index score.

CONCLUSION

The Sinhala version of PEST demonstrated satisfactory performance as a screening tool for PsA. Key Points • Psoriatic arthritis (PsA) is the most debilitating complication of psoriasis and lack of quick, valid screening tool is a limiting factor for early identification in Sri Lankan context. • Sinhala version of the Psoriasis Epidemiology Screening Tool (PEST_sv) was tested on 199 patients with psoriasis and examined for the diagnosis of PsA according to Classification of Psoriatic Arthritis (CASPAR) criteria. • PEST_sv score of 3 or more was observed to be the best cutoff value to screen for PsA with sensitivity and specificity of 0.89 and 0.95 respectively. • PEST_sv demonstrated satisfactory performance as a screening tool for PsA.

Comorbidities in a Cohort of 66 Patients With Psoriatic Arthritis Mutilans-Results From the Nordic PAM Study

Objective: Psoriatic arthritis mutilans (PAM) is the most severe phenotype of psoriatic arthritis due to excessive bone erosion causing joint destruction and decreased functional capacity. The aim of this study was to investigate the prevalence of comorbidities among patients with PAM and the association between comorbidities and joint involvement. Methods: A total of 66 patients aged ≥18 years from the Nordic countries with past or present psoriasis along with at least one mutilated joint were included in the present study. Results: The median number of comorbid conditions per patient was 1 [interquartile range (IQR) 0-2] and 16.7% reported three or more comorbidities. The most frequent comorbidity was hypertension (36.4%). The median number of mutilated joints per patient was 3 (IQR 1-8.3; range 1-38). Conclusion: Two thirds of the patients with PAM reported comorbid conditions and the most frequent was hypertension which affected more than a third of the patients. However, this study was unable to detect any association between comorbidities and the severity of PAM.

Multidisciplinary working in the management of axial and peripheral spondyloarthritis

Multidisciplinary (MD) care is essential in the management of patients with spondyloarthritis (SpA) and is one of the main pillars of disease management and patient care. However, evidence supporting the effectiveness and benefits of this strategy in SpA is scarce. In this review we discuss the three types of MD care models: (i) combined clinics (MD units), including ‘face to face’, ‘parallel’ and ‘circuit approach’ clinics; (ii) MD team meetings; (iii) group consultations. The most frequently used model in SpA studies has been the ‘parallel’ combined clinic and usually encompasses a rheumatologist and another specialist, most commonly a dermatologist or a gastroenterologist, that work in tandem according to predefined referral criteria and treatment algorithms. MD working seems to improve the care of patients with SpA by a better identification and diagnosis of the disease, an earlier and more comprehensive treatment approach, and better outcomes for patients in terms of disease activity, physical function, quality of life and patient satisfaction. Nevertheless, challenges remain. Data on effectiveness and feasibility are scarce and are mostly derived from studies with design issues and often without a unidisciplinary care comparator arm. Although patient centricity is one of the core values of patient care and MD setting in SpA, the patient often does not play an active role in most of the MD settings studied or in common clinical practice. Further efforts should be made so that MD care reflects patients’ expectations and needs. Overcoming these limits will help to implement successfully SpA MD care in daily clinical practice and subsequently to achieve a higher quality of care for our patients.

Pathogenesis of psoriasis in the "omic" era. Part IV. Epidemiology, genetics, immunopathogenesis, clinical manifestation and treatment of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic, progressive, inflammatory arthropathy associated with psoriasis as well as a complex pathogenesis. Genetic and environmental factors trigger the development of the immune-mediated auto-inflammatory response in different sites: skin, bone marrow, entheses and synovial tissues. Studies of the last two decades have changed the view of PsA from a mild, non-progressive arthritis to an inflammatory systemic disease with serious health consequences, not only associated with joint dysfunction, but also with an increased risk of cardiovascular disease and socioeconomic consequences with significantly reduced quality of life. The joint damage starts early in the course of the disease, thus early recognition and treatment with modern biological treatments, which may modify the natural history and slow down progression of this debilitating disease, is essential for the patient long-term outcome.

The Skin May Clear But the Arthritis Won't Disappear: Focusing on Concomitant and New-Onset Psoriatic Arthritis in a Daily Practice Cohort of Psoriasis Patients on Biologic Therapy

Background

Previously identified risk factors for psoriatic arthritis (PsA); nail dystrophy and scalp lesions are highly prevalent in patients with moderate-to-severe psoriasis. Therefore, these variables may not be useful as predictors for PsA in this population.

Objective

We assessed the predictive value of demographic and clinical characteristics for development of PsA in a cohort of patients with moderate-to-severe psoriasis, currently treated with biologics. Furthermore, we reported the incidence of new-onset PsA in this population and described the characteristics of patients that developed PsA during biologic treatment.

Methods

Demographics and treatment characteristics of psoriasis patients currently using biologic therapy were extracted from the BioCAPTURE database (n=427). Poisson regression was used to calculate incidence rates. Multivariable logistic regression was performed to identify factors independently associated with PsA onset. Patient and treatment characteristics of patients that developed PsA during biologic treatment were described.

Results

The incidence of PsA was 1.0 (95% CI 0.8–1.2) per 100 psoriasis-years. Except for a lower risk for PsA in male gender (OR 0.58, 95% CI 0.34–0.98, p-value 0.04), no clinical factors were significantly associated with an altered risk of developing PsA. During biologic therapy, 32 patients (9.4%) newly developed PsA. In this group, 53.8% had PASI<5 at PsA diagnosis. The incidence rate of PsA was 1.6 (95% CI 1.1–2.2) per 100 years on biologic therapy.

Conclusion

Clinical risk factors might be inaccurate to predict PsA onset in patients with moderate-to-severe psoriasis on biologics. Even with low disease activity, psoriasis patients on biologics are still prone to develop PsA.

Applying precision medicine to unmet clinical needs in psoriatic disease

Psoriatic disease (PsD) is a heterogeneous condition that can affect peripheral and axial joints (arthritis), entheses, skin (psoriasis) and other structures. Over the past decade, considerable advances have been made both in our understanding of the pathogenesis of PsD and in the treatment of its diverse manifestations. However, several major areas of continued unmet need in the care of patients with PsD have been identified. One of these areas is the prediction of poor outcome, notably radiographic outcome in patients with psoriatic arthritis, so that stratified medicine approaches can be taken; another is predicting response to the numerous current and emerging therapies for PsD, so that precision medicine can be applied to rapidly improve clinical outcome and reduce the risk of toxicity. In order to address these needs, novel approaches, including imaging, tissue analysis and the application of proteogenomic technologies, are proposed as methodological solutions that will assist the dissection of the critical immune-metabolic pathways in this complex disease. Learning from advances made in other inflammatory diseases, it is time to address these unmet needs in a multi-centre partnership aimed at improving short-term and long-term outcomes for patients with PsD.

Role of Protein Tyrosine Phosphatase (PTPN22) Gene [C1858T] Functional Variant in Genetic Susceptibility of Psoriatic Arthritis in Kuwaiti Arabs

Background:

Psoriatic arthritis (PsA) is a chronic, systemic inflammatory arthritic disease characterized by joint inflammation that is associated with cutaneous psoriasis, and can lead to pain, swelling, or stiffness in one or more joints. It results from a complex interplay between genetic, immunologic and environmental factors. A functional variant [C1858T] in the protein tyrosine phosphatase (PTPN22) gene, which encoded Arg620Trp in the lymphoid protein tyrosine phosphatase (LYP) has been shown to be a negative regulator of T-cell activation.

Objective:

The objective of this study was to investigate an association between PTPN22 gene [C1858T] functional variant and PsA in Kuwaiti patients.

Methods:

We have investigated the association of PTPN22 gene functional variant in 102 Kuwaiti patients with psoriatic arthritis and compared it to that in 214 healthy controls. The genotypes for the PTPN22 gene [C1858T] variant were determined by using a PCR-RFLP method and confirmed by DNA sequence analysis.

Results:

The frequency of homozygous variant genotype (TT) was found to be significantly higher in PsA patients compared to that in the controls (p <0.0001). Collectively, the variant genotype was detected in homozygous and heterozygous combinations in 30% patients (p <0.0001) compared to 16% in the controls. The frequency of variant genotype was found to be highest in the early-onset PsA patients (age >25-34y). No correlation was detected between the variant genotype (TT) and gender in the Kuwaiti PsA patients.

Conclusion:

Our data show a significant association of PTPN22 gene functional variant [C1958T] with PsA in Kuwaiti patients and highlight its role in determining the genetic susceptibility along with other factors.

Psoriatic arthritis epidemiology, comorbid disease profiles and risk factors: results from a claims database analysis

OBJECTIVE

Psoriasis is a systemic inflammatory disease often accompanied by comorbidities, including metabolic syndrome, cardiovascular diseases and depression. Up to 41% of psoriasis patients develop psoriatic arthritis (PsA), making it one of the most relevant manifestations. A large health claims data set was analysed to determine the rate of PsA development in psoriasis patients. Furthermore, comorbid disease profiles of psoriasis patients with or without PsA were compared, and potential risk factors for the development of PsA were identified.

METHODS

This was a non-interventional, retrospective analysis of anonymized insurance health claims data using a subset of the Institute of Applied Health Research Berlin (InGef) database. The primary outcome was the prevalence and incidence of diagnosed PsA among psoriasis patients in Germany. Risk factors for the development of PsA in psoriasis patients were determined by conditional logistic regression analysis.

RESULTS

The cumulative percentage of patients with existing psoriasis developing concomitant PsA over 4 years was 3.44%, with a mean time to diagnosis of PsA of 1.5 years. Psoriasis patients diagnosed with acute rheumatism (odds ratio: 2.93, 95% CI = 1.76, 4.86; P < 0.001) or pain in unspecific joints (odds ratio: 1.74, 95% CI = 1.01, 2.99; P = 0.047) showed an increased risk for development of PsA later on. Interestingly, fewer than half of the patients with concomitant PsA consulted a rheumatologist.

CONCLUSIONS

Unspecific arthritic symptoms are likely to precede PsA diagnoses and can develop soon after onset of psoriasis, with accumulating risk over time. There is a high unmet need for early rheumatological assessment of psoriasis patients.

Psoriatic Arthritis and Diabetes Mellitus: A Narrative Review

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic immune-mediated inflammatory spondyloarthropathy associated with psoriasis. PsA is frequently associated with metabolic disorders including, obesity, metabolic syndrome, and diabetes mellitus (DM). Type 2 DM is among the most common metabolic disorders, with a prevalence ranging from 2.4 to 14.8% in the general population.

METHODS

We conducted a narrative review of the English-language studies from January 1989 to September 2019 investigating the risk of type 2 DM in patients with PsA, the pathogenic mechanism linking DM to PsA, and the effects on insulin sensitivity exerted by systemic therapies for PsA.

RESULTS

The prevalence of type 2 DM in patients with PsA ranges from 6.1 to 20.2%, generally higher when compared to the general population. The higher risk of DM is reported in women with more severe forms of PsA. Elevated serum levels of adipokines, including TNF-α, which inhibits the autophosphorylation of the insulin receptor and suppresses the expression of glucose transporter 4, favor insulin resistance and could partially explain the association between PsA and DM. Moreover, adiponectin and omentin, with insulin-sensitizing and anti-atherogenic properties, are decreased in patients with PsA. Some of the treatments for PsA could affect the glucose homeostasis. Systemic corticosteroids are known to impair insulin resistance, whereas apremilast (phosphodiesterase type 4 inhibitor) and TNF-α inhibitors could exert neutral effect or reduce the insulin-resistance. The role of IL-17 or IL-23 inhibitors has been marginally investigated.

CONCLUSIONS

Patients affected by PsA have a higher prevalence of type 2 DM compared with the general population. The mechanism linking PsA with DM has not been completely clarified, but some of the principal mediators could be TNF-α and adipokine, especially adiponectin and omentin. Apremilast and TNF-α inhibitor may have a favorable effect and could be safely used in patients with DM.

Moderate-to-severe plaque psoriasis patients treated with ixekizumab: early real-world outcomes and adverse events

Introduction: Data on real-world experiences for patients treated with ixekizumab is currently limited.Objectives: Describe characteristics of ixekizumab-treated psoriasis patients and provide evidence of clinical outcomes using disease severity scores Body Surface Area (BSA) and Psoriasis Area and Severity Index (PASI) in the real world.Methods: Chart review was performed for adult patients treated with ixekizumab at a single Canadian dermatology clinic (February 2017-August 2018). The cohort was stratified into responders (patients who remained on ixekizumab) and non-responders (patients who discontinued ixekizumab). Subgroup analyses were performed for responders to assess clinical improvement stratified by previous biologic exposure.Results: Thirty-eight patients were included (mean observational time 32 weeks). At baseline, mean PASI and BSA were 10.8 and 11.6%, respectively. Mean changes in PASI and BSA were -7.8 and -6.7%, respectively, at week 4. PASI 100 was achieved in 70% of patients. Significant differences in mean change of BSA were seen between bio-naïve and bio-experienced patients.Conclusion: This analysis represents the first investigation of early clinical outcomes in a small cohort of Canadian patients treated with ixekizumab. Overall, complete and rapid skin clearance was observed. Future studies including more patients and longer follow-up time are crucial to confirm these findings.

Declining levels of serum chemokine (C-X-C motif) ligand 10 over time are associated with new onset of psoriatic arthritis in patients with psoriasis: a new biomarker?

BACKGROUND

We previously found that serum levels of chemokine (C-X-C motif) ligand 10 (CXCL10) decreased after the onset of psoriatic arthritis (PsA).

OBJECTIVES

We measured CXCL10 levels over time in patients with psoriasis who developed PsA to determine whether the drop in CXCL10 was specific to these patients and further assess its association with PsA development.

METHODS

Prospectively followed patients with psoriasis without arthritis [cutaneous psoriasis (PsC)] were assessed yearly by rheumatologists for the presence of PsA. Patients with PsC who developed PsA (converters) were matched to those that did not develop PsA (nonconverters) based on psoriasis duration and the interval between follow-up visits. The duration between baseline and the first visit postconversion in converters was used to assign a pseudoconversion date in nonconverters. Linear mixed-effects models were used to model the expression of CXCL10 over time.

RESULTS

CXCL10 significantly declined over time in converters prior to PsA development with a significant difference in the trend over time between converters (n = 29) and nonconverters (n = 52; P < 0·001). CXCL10 continued to decline after PsA onset in a subset of converters. There was a significant difference in the trend of CXCL10 levels between converters (n = 24) and nonconverters (n = 16; P = 0·01) preconversion/pseudoconversion. This difference remained postconversion (P = 0·006) and was not different from the preconversion period (P = 0·75).

CONCLUSIONS

A large difference in CXCL10 was identified in patients with PsC that are destined to develop PsA over time. This exploratory analysis supports the association of CXCL10 with PsA development in patients with PsC and warrants further study of the predictive ability of this chemokine. What is already known about this topic? Chemokine (C-X-C motif) ligand 10 (CXCL10) is elevated in psoriatic affected tissues and serum and/or plasma. Patients with psoriasis that develop psoriatic arthritis (PsA) have elevated CXCL10 levels at baseline and these levels drop after arthritis onset. What does this study add? By monitoring levels of CXCL10 in serum over multiple visits in patients with psoriasis that develop PsA as well as those that do not develop PsA, an association was identified between CXCL10 and PsA development. What is the translational message? CXCL10 is a strong candidate for use by physicians for the detection of patients with psoriasis that are at risk of developing PsA. Linked Comment: Kirby and Fitzgerald. Br J Dermatol 2020; 183:805-806.

[Treatment of psoriatic arthritis : Are there differential indications?]

Psoriatic arthritis (PsA) is a very heterogeneous immune-mediated disease that usually involves skin and joints but can also affect entheses and extra-articular structures during the disease course. Furthermore, it can also be linked with other associated diseases. Therefore, the individualized selection of an effective and patient-oriented treatment must be carried out taking the extent of various manifestations of the PsA itself and also of other influencing factors into consideration. Various recommendations for selection and control of the suitable treatment of PsA are available for clinical use. The recommendations of the European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) are the two recommendations that are frequently used and internationally acknowledged. Both recommendations were updated in 2016. Specific German treatment recommendations are currently missing. In analogy to the treat-to-target strategy for rheumatoid arthritis, at least minimal disease activity (MDA) should be achieved in PsA patients with the use of specific therapeutic interventions if remission as the maximum therapeutic goal cannot be reached. New treatment options, which target different specific molecules, offer possibilities for a more differentiated personalized medicinal treatment for improvement of the care of PsA patients. This particularly applies to a focus on personalized strategies for optimal treatment of various manifestation forms and patterns.

[The skin and rheumatism]

The skin is commonly affected in chronic inflammatory disorders and may act as a visual marker for internal or systemic inflammation. Frequent inflammatory skin diseases, like psoriasis and atopic dermatitis (AD), are associated with rheumatic and inflammatory bowel diseases. Metabolic, mental and cardiovascular comorbidity are frequent consequences of chronic inflammation. Further intersections between skin and joints are connective tissue diseases (collagenoses) and can be observed in complex diseases, e.g. systemic lupus erythematosus. Clinically, these diseases range from predominant cutaneous to severe systemic implication of several organs. Localized scleroderma should be clinically distinguished from systemic sclerosis and treated sufficiently to avoid long-term damage and disability. Thus, interdisciplinary disease management is of crucial importance.

Psoriatic arthritis

Psoriasis is a multisystemic, inflammatory skin condition that can affect many areas of the body, but most commonly the extensor surfaces of the elbows and knees, and sometimes the intergluteal and umbilical area. It has a prevalence of 2–4% in western adults, and 20­–30% of psoriasis patients will develop psoriatic arthritis (PsA). PsA is an inflammatory musculoskeletal disease associated with cutaneous psoriasis. It affects men and women almost equally with a peak age at onset of 40 and 50 years. It is a diverse disease that affects multiple organ systems includes peripheral and axial joints, entheses, skin, and nails. PsA is associated with comorbidities such as osteoporosis, uveitis, subclinical bowel inflammation, and cardiovascular disease. Given this heterogeneity, its diagnosis has been difficult. Here we present an updated review of its classification criteria CASPAR (classification criteria for PsA), use of screening tools to aid in early diagnosis, recent findings on pathogenesis, and new therapeutic approaches including new biologic medications.

Moderate Psoriatic Arthritis and Perspectives from Phosphodiesterase-4 Inhibition

Although there is no universally approved definition of moderate psoriatic arthritis (PsA), many clinicians see patients who they feel fit into this category: patients with limited joint involvement, but who might also show other manifestations of the disease, as well as a range of comorbidities. In his presentation, Dr Siebert described the challenges faced in treating this group of patients, who are mostly not captured in clinical trials. Recent advances in PsA treatment have focussed towards the severe end of the spectrum, suggesting that more must be learned around treatment options for patients with moderate disease. This represents a large unmet need. Given the heterogeneity of this patient population, a range of effective treatments is needed. Prof Gladman then presented data from longitudinal cohorts to illustrate the high burden of disease in patients with PsA who had a limited number of affected joints. By comparing patients with oligoarticular PsA (i.e., ≤4 affected joints) with those with polyarticular arthritis (≥5 affected joints), Prof Gladman showed that disease burden is not solely driven by the number of affected joints, but also by other PsA manifestations and/or comorbidities. There are clear gaps in our knowledge of PsA; to address these, population studies and trials of potential treatments are needed. Phosphodiesterase-4 (PDE4) inhibition is one potential treatment strategy that is currently being investigated. Dr Behrens described a post-hoc analysis of data pooled from three Phase III clinical trials that suggests the PDE4 inhibitor apremilast may be an effective treatment for patients with moderate PsA. It is hoped that this will be confirmed by the ongoing FOREMOST trial, a Phase IV study of apremilast in patients with oligoarticular PsA.

Protocol for a case-control diagnostic accuracy study to develop diagnostic criteria for psoriasis in children (DIPSOC study): a multicentre study recruiting in UK paediatric dermatology clinics

INTRODUCTION

Diagnosing psoriasis in children can be challenging. Early and accurate diagnosis is important to ensure patients receive psoriasis specific treatment and monitoring. It is recognised that the physical, psychological, quality of life, financial and comorbid burden of psoriasis are significant. The aim of this study is to develop clinical examination and history-based diagnostic criteria for psoriasis in children to help differentiate psoriasis from other scaly inflammatory rashes. The criteria tested in this study were developed through a consensus study with a group of international psoriasis experts (International Psoriasis Council).

METHODS AND ANALYSIS

Children and young people (<18 years) with psoriasis (cases) and other scaly inflammatory skin diseases (controls) diagnosed by a dermatologist are eligible for recruitment. All participants complete a single research visit including a diagnostic criteria assessment by a trained investigator blinded to the participant's diagnosis. The reference standard of a dermatologist's diagnosis is extracted from the medical record. Sensitivity and specificity of the consensus derived diagnostic criteria will be calculated and the best predictive criteria developed using multivariate logistic regression.

ETHICS AND DISSEMINATION

Health Regulatory Authority and National Health Service Research Ethics Committee approvals were granted in February 2017 (REC Ref: 17/EM/0035). Dissemination will be guided by stakeholders; patients, children and young people, dermatologists, primary care and paediatric rheumatologists. The aim is to publish the study results in a high-quality peer-reviewed journal, present the findings at international academic meetings and disseminate more widely through social media and working with patient associations.

TRIAL REGISTRATION NUMBER

ISRCTN98851260.

Analysis of pharmaceutical care in patients with psoriatic arthritis using statutory health insurance data

BACKGROUND

Psoriatic arthritis (PsA) is an inflammatory joint disease. Despite numerous health care research studies, there is hardly any data regarding the current state of pharmaceutical care of PsA patients in Germany.

STUDY POPULATION AND METHODS

Based on a systematic literature search and routine administrative data from the Rhineland/Hamburg (statutory) health insurance fund ("Allgemeine Ortskrankenkasse", AOK), the present study provides an up-to-date overview of pharmaceutical care of German PsA patients. Selected were those in- and outpatients who - in the first or second quarter of 2014 - had been coded as having the diagnosis of psoriatic arthritis (L40.5+) according to the International Classification of Diseases (ICD-10-GM version 2015). On the basis of this "predefined cohort", drug prescription data was subsequently analyzed for a five-year period (January 1, 2010 to December 31, 2014).

RESULTS

Overall, 3,205 AOK-insured individuals (45 % male, 55 % female) were diagnosed with PsA. Mean age was 58.9 years; 53.7 % of PsA patients received systemic treatment. Nonsteroidal antiinflammatory drugs (NSAIDs) were the most frequently prescribed agents, followed by corticosteroids. Among patients on systemic treatment, 72.1 % were treated with disease-modifying antirheumatic drugs (DMARDs); 20.9 % with a combination of DMARDs and biologics.

CONCLUSION

Not only does pharmacological treatment of PsA have to ensure adequate patient care aimed at preventing disease progression, it also has to be approached with economic responsibility.

Multidisciplinary Management of Psoriatic Arthritis: The Benefits of a Comprehensive Approach

Psoriatic arthritis (PsA) is a lifelong disease associated with extra-articular manifestations and several comorbidities, as well as reduced quality of life and psychosocial burden. Diagnostic delay is associated with poorer outcomes, while a short delay between symptom onset and diagnosis is linked with preservation of function. Overcoming the barriers to early diagnosis of PsA is often difficult to achieve in the absence of well-characterized disease markers and/or a definitive screening procedure. Once a diagnosis is made, approaches to care may differ between countries, but a treat-to-target approach can be advocated, with constant patient follow-up visits and specialist monitoring and treatment of comorbidities. Adequately addressing all aspects of care can help to drive patient-centered care and encourage better adherence. Given the mounting number of therapeutic options and the complexity of management of PsA, the disease can be optimally treated by a multidisciplinary approach, and a collaborative approach between rheumatologists and dermatologists can be advocated. The need for multidisciplinary management is reinforced by consensus among experts. Patient satisfaction has emerged as a central indicator of quality, and patient-centered care must remain a central goal for the care of patients with PsA. Definition of a minimum set of standards for care will help to achieve the goal of multidisciplinary care for patients with PsA. Optimal care of PsA and greater collaboration among clinicians should always be encouraged so that patients can receive the best possible quality of care.Funding: Pfizer Italy.

Psoriasis Pathogenesis and Treatment

Research on psoriasis pathogenesis has largely increased knowledge on skin biology in general. In the past 15 years, breakthroughs in the understanding of the pathogenesis of psoriasis have been translated into targeted and highly effective therapies providing fundamental insights into the pathogenesis of chronic inflammatory diseases with a dominant IL-23/Th17 axis. This review discusses the mechanisms involved in the initiation and development of the disease, as well as the therapeutic options that have arisen from the dissection of the inflammatory psoriatic pathways. Our discussion begins by addressing the inflammatory pathways and key cell types initiating and perpetuating psoriatic inflammation. Next, we describe the role of genetics, associated epigenetic mechanisms, and the interaction of the skin flora in the pathophysiology of psoriasis. Finally, we include a comprehensive review of well-established widely available therapies and novel targeted drugs.

Utilization of the validated Psoriasis Epidemiology Screening Tool to identify signs and symptoms of psoriatic arthritis among those with psoriasis: a cross-sectional analysis from the US-based Corrona Psoriasis Registry

Background

Despite increasing awareness of the disease, rates of undiagnosed psoriatic arthritis (PsA) are high in patients with psoriasis (PsO). The validated Psoriasis Epidemiology Screening Tool (PEST) is a five‐item questionnaire developed to help identify PsA at an early stage.

Objectives

To assess the risk of possible undiagnosed PsA among patients with PsO and characterize patients based on PEST scores.

Methods

This study included all patients enrolled in the Corrona PsO Registry with data on all five PEST questions. Demographics, clinical characteristics and patient‐reported outcomes were compared in Corrona PsO Registry patients with PEST scores ≥3 and <3 using t‐tests for continuous variables and chi‐squared tests for categorical variables; scores ≥3 may indicate PsA.

Results

Of 1516 patients with PsO, 904 did not have dermatologist‐reported PsA; 112 of these 904 patients (12.4%) scored ≥3 and were significantly older, female, less likely to be working, and had higher BMI than patients with scores <3. They also had significantly longer PsO duration, were more likely to have nail PsO and had worse health status, pain, fatigue, Dermatology Life Quality Index and activity impairment.

Conclusions

Improved PsA screening is needed in patients with PsO because the validated PEST identified over one‐tenth of registry patients who were not noted to have PsA as having scores ≥3, who could have had undiagnosed PsA. Appropriate, earlier care is important because these patients were more likely to have nail PsO, worse health‐related quality of life and worse activity impairment.

Recommendations for the definition, evaluation, and treatment of nail psoriasis in adult patients with no or mild skin psoriasis: A dermatologist and nail expert group consensus

Nail involvement in psoriasis is common, and the severity of it does not always parallel the intensity of cutaneous disease. We created a consensus group, of which the aim was to provide practical recommendations for the treatment of nail psoriasis in patients without skin psoriasis or with mild skin lesions with no indication for a systemic treatment. This collaborative process was conducted by an international panel of dermatologists with special expertise in nail disorders, using formal consensus methods. During this process, the panel strived to establish an agreement regarding the definition of nail psoriasis, the severity of nail psoriasis, and treatment response. Treatment recommendations are provided regarding nail psoriasis severity and matrix or bed involvement. Few-nail disease was considered as nail psoriasis affecting ≤3 nails. In the case of matrix involvement only, intralesional steroid injections were considered the treatment of choice. Topical steroids alone or in combination with topical vitamin D analogues were suggested for nail psoriasis limited to the nail bed. For the systemic treatment of nail psoriasis acitretin, methotrexate, cyclosporine, small molecules, and biologics may be employed.

Psoriatic arthritis: pathogenetic features and innovative therapies

The paper considers the modern concepts of the etiology and pathogenesis of psoriatic arthritis (PsA). The latter is currently indicated as a T-cell-mediated disease that is based on the activation of cellular immunity, followed by the hyperproduction and imbalance of key pro- and anti-inflammatory cytokines, such as tumor necrosis factor-α (TNF- α), interleukin-1β (IL-1β), IL-6, IL-12/23, and IL-17. The paper presents the basic principles of diagnosis and clinical manifestations of the disease and notes the importance of screening questionnaires, the use of which allows specialists to diagnose PsA early, by actively identifying articular complaints, the characteristic clinical and radiological signs of damage to the joint, spine, and entheses. It is pointed out that the key target of pharmacotherapy for PsA is to achieve remission or minimal activity of the main clinical manifestations of the disease, to slow down or prevent its radiographic progression, to increase the length and quality of life in patients, and to reduce the risk of comorbidities. The authors characterize the major groups of used drugs: nonsteroidal anti-inflammatory drugs, conventional and targeted synthetic disease-modifying antirheumatic drugs, and biological drugs (inhibitors of TNF-α, IL-12/23, and IL-17). The key Treat-to-target principles of patient management are considered; it is noted that strict control over disease activity and treatment results provides suppression of all major clinical manifestations of PsA. The paper also shows the basic principles of the creation and further development of the All-Russian Registry of PsA patients, which makes it possible to optimize management decision-making on the provision of high-tech medical care and drugs for this cohort of patients.

Association Between Psoriasis with Arthritis and Hearing Impairment in US Adults: Data from the National Health and Nutrition Examination Survey

Objective.

Emerging data has linked inflammatory arthritis with hearing impairment (HI). The objective of this study was to investigate the relationship between psoriasis with arthritis (PsA) and HI in the US population. Given the known association of HI and depression, a secondary aim is to investigate the effect of PsA on mental well-being.

Methods.

Cross-sectional study using the National Health and Nutrition Examination Survey for adults aged ≥ 20 years (n = 10,747). Association of PsA with above outcomes was examined using multivariable generalized linear and ordinal logistic regression models, adjusted for demographics and medical comorbidities. Structural equation models examined the extent to which HI mediated the effect of PsA on mental health.

Results.

Individuals with PsA were more likely to report hearing difficulties (OR 1.50, p = 0.043), visit a mental health provider (OR 1.62, p = 0.084), have 1.62 more days of poor mental health over the previous month (p = 0.033), and have depression (OR 2.01, p = 0.015) compared to controls. HI mediated 6.5%, 8.3%, and 5.0% of the effect of PsA on the above mental health outcomes, respectively.

Conclusion.

PsA is independently associated with a significantly increased risk of HI, which partially mediates an association with worsened psychiatric outcomes.

Metabolic syndrome and psoriatic arthritis among patients with psoriasis vulgaris: Quality of life and prevalence

Interest has increased in comorbidities associated with psoriasis and their effects on health-related quality of life (HRQoL). This study aimed to evaluate the prevalence of metabolic syndrome (MetS) and psoriatic arthritis (PsA) and to investigate HRQoL and the prevalence of hypertension, type 2 diabetes mellitus (T2DM), obesity and dyslipidemia. In a cross-sectional design, patients diagnosed with plaque psoriasis answered an interview and standardized questionnaires (Dermatology Life Quality Index questionnaire [DLQI], 36-Item Short Form Health Survey [SF-36] and EuroQol Five-Dimension Questionnaire Three-Level version [EQ-5D-3L]). Physical examination and several tests to assess desired outcomes were performed by a dermatologist and a rheumatologist during three visits. The prevalence of MetS and PsA was 50.0% and 41.8%, respectively. Dyslipidemia was the most prevalent (74.5%) secondary comorbidity, followed by hypertension (61.8%), obesity (52.5%) and T2DM (30.9%). The mean (standard deviation) DLQI score was 6.5 (6.9), and mean physical and mental SF-36 measures were 45.2 (10.4) and 45.5 (12.3), respectively, and for EQ-5D-3L, mean utility index and EQ-VAS scores were 0.68 (0.27) and 72.7 (19.7), respectively. PsA and MetS are important comorbidities; a reduced HRQoL is noted among plaque psoriasis patients with these comorbidities, emphasizing the relevance of diagnosis and treatment beyond the care of skin lesions.

Spanish Registry of Recent-onset Psoriatic Arthritis (REAPSER study): Aims and methodology

AIMS

To describe the methodology of REAPSER (Spanish Registry of Recent-onset Psoriatic Arthritis), its strengths and limitations. The aim of this study is to identify prognostic factors for the clinical and radiographic course in a cohort of patients with psoriatic arthritis (PsA) diagnosed within 2years of symptom evolution.

METHODS

Multicenter, observational and prospective study (with 2-year follow-up including annual visits). Baseline visit intended to reflect patient situation before the disease course was modified by treatments prescribed in rheumatology departments. Patients were invited to participate consecutively in one of their routine visits to the rheumatologist. 211 patients were included. Following data were collected: sociodemographic variables; employment situation; family history; personal history and comorbidities; anthropometric data; lifestyle; use of healthcare services; clinical situation at the time of PsA diagnosis; joint involvement and spinal pain; pain and overall assessment; enthesitis, dactylitis and uveitis; skin and nail involvement; functional situation and quality of life; radiographic evaluation; analytical determinations; treatment; axial and peripheral flare-ups.

CONCLUSIONS

The REAPSER study includes a cohort of patients with recent-onset PsA, before the disease course was modified by disease-modifying antirheumatic drugs prescribed in rheumatology departments. Exhaustive information collected in each visit is expected to be an important data source for future analysis.

Treatment use and satisfaction among patients with psoriasis and psoriatic arthritis: results from the NORdic PAtient survey of Psoriasis and Psoriatic arthritis (NORPAPP)

Background

There are scarce data in Scandinavia about treatment satisfaction among patients with psoriasis (PsO) and/or psoriatic arthritis (PsA). The number of patients receiving systemic treatment is unknown.

Objective

To describe patients’ experience of treatments for PsO/PsA in Sweden, Denmark and Norway, addressing communication with physicians, satisfaction with treatment and concerns regarding treatment options.

Methods

The NORdic PAtient survey of Psoriasis and Psoriatic arthritis (NORPAPP) asked 22 050 adults (randomly selected from the YouGov panels in Sweden, Denmark and Norway) whether they had PsO/PsA. A total of 1264 individuals who reported physician‐diagnosed PsO/PsA were invited to participate in the full survey; 96.6% responded positively.

Results

Systemic treatment use was reported by 14.6% (biologic: 8.1%) of respondents with PsO only and by 58.5% (biologic: 31.8%) of respondents with PsA. Biologic treatments were more frequently reported by respondents considering their disease severe (26.8% vs 6.7% non‐severe) and those who were members of patient organizations (40.7% vs 6.9% non‐members). Discussing systemic treatments with their physician was reported significantly more frequently by respondents with PsA, those perceiving their disease as severe (although 35.2% had never discussed systemic treatment with their physician) and those reporting being a member of a patient organization (P < 0.05). Many respondents reported health risk concerns and dissatisfaction with their treatment. Of special interest was that respondents aged 45–75 years reported less experience with biologics (8.1%) than those aged 18–44 years (21.5%). The older respondents also reported more uncertainty regarding long‐term health risks related to systemic treatments (most [66.7–72.9%] responded ‘do not know’ when asked about the risk of systemic options).

Conclusion

It appears likely that substantial numbers of Scandinavians suffering from severe PsO/PsA are not receiving optimal treatment from a patient perspective, particularly older patients. Also, one‐third of respondents with severe symptoms had never discussed systemic treatment with a physician.

Persistence with biological drugs in patients treated in rheumatology practices in Germany

The goal of this study was to investigate the persistence with biological drugs in patients treated in rheumatology practices in Germany. This study included patients diagnosed with rheumatoid arthritis (RA), psoriatic arthritis (PA), or ankylosing spondylitis (AS) who received a first prescription of biological drugs between 2008 and 2016 (index date) in 21 rheumatology practices in Germany (n = 4925; Disease Analyzer database). The main outcome measure was the rate of persistence within 5 years of the index date. Kaplan-Meier analyses were performed to study treatment persistence as a function of diagnosis, gender and age. A Cox proportional hazards regression model was used to estimate the relationship between non-persistence and diagnosis, gender, age, and comorbidities. After 5 years of follow-up, the rate of persistence was 31.8% in patients with RA, 35.2% in those with AS, and 33.2% in those with PA (log-rank p value = 0.028). Furthermore, 33.8% of men and 31.9% of women were persistent (log-rank p value = 0.035). The rate of persistence was 20.8%, 27.9%, 33.0%, 36.6%, 35.2%, and 32.0% in people aged ≤ 30, 31-40, 41-50, 51-60, 61-70, and > 70 years, respectively (log-rank p value = 0.002). The risk of discontinuation was lower in participants diagnosed with AS than in those diagnosed with RA [hazard ratio (HR) = 0.87; 95% confidence interval (CI) 0.79-0.96]. In addition, patients aged ≤ 30 years were more likely to discontinue their biological therapy than those aged > 70 years (HR = 1.29; 95% CI 1.10-1.52). Persistence with biological drugs was low after 5 years of follow-up in rheumatology practices.

Treatment patterns, unmet need, and impact on patient-reported outcomes of psoriatic arthritis in the United States and Europe

Psoriatic arthritis (PsA) is a chronic, inflammatory disease. The effects of PsA real-world treatment patterns on patient-reported outcomes in the US and 5 European countries (EU5; France, Germany, Italy, Spain, UK) were evaluated. Respondents from the 2016 National Health and Wellness Survey received advanced therapies (e.g., biologic disease-modifying antirheumatic drugs [DMARDs]), other therapies, (e.g., conventional synthetic DMARDs), or no treatment. Assessments included demographics, disease severity (patient-reported), comorbidities (Charlson Comorbidity Index), health status (Short Form-36 Health Survey), depression (Patient Health Questionnaire-9), work productivity (Work Productivity and Activity Index), and treatment adherence (Morisky Medication Adherence Scale-8). Overall, 1037 respondents from the US and 947 respondents from the EU5 were included. Of these, 21.7% US and 7.3% EU5 respondents received advanced therapies; 16.6% and 28.5%, other therapies; and 61.7% and 64.2%, no treatment, respectively. During treatment with advanced or other therapies, 40.8-54.7% US and 57.7-58.9% EU5 respondents self-reported moderate or severe PsA. Respondents receiving advanced therapies had the highest Charlson Comorbidity Index score (US, 1.25; EU5, 1.42); the lowest scores were with no treatment (0.52 and 0.49, respectively). Employment was lowest with other therapies (US, 47.7%; EU5, 41.1%). Overall work impairment was reported by 57.9% US and 62.6% EU5 respondents receiving advanced therapies. Medication adherence was generally low in the US and medium in the EU5 (Morisky Medication Adherence Scale-8: low, US 40.1-46.7%, EU5, 29.0-35.2%; medium, US 29.3-36.1%, EU5 37.8-49.3%; high, US 23.8-24.0%; EU5, 21.7-27.0%). Advanced and other therapies reduced PsA severity; however, > 40% of respondents reported moderate or severe PsA during treatment. Better management and adherence may reduce unmet need and disease burden. Further work is required to improve PsA diagnosis and time to treatment initiation.

Update on the epidemiology, risk factors, and disease outcomes of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disease that affects different structures of the musculoskeletal system in addition to the skin and the nail. The complexity of the disease had been a barrier to understand the pathogenesis and define valid outcome tools; however, our understanding about the disease has considerably increased with time mainly because of the advances in imaging, new discoveries in genetics and underlying inflammatory pathways, and better understanding of the epidemiology of the disease and environmental risk factors. The purpose of this review is to summarize developments and changes in epidemiology, risk factors for developing PsA, and outcome measures with a focus on data obtained in the last 10 years.

Biologics for the primary care physician: Review and treatment of psoriasis

Psoriasis is a chronic inflammatory disease that affects approximately 7.5 million people in the United States. The disease results in significant suffering, morbidity, and economic impact. Psoriasis is a multifaceted disease with a strong genetic component. Genetic data has revealed the presence of particular risk alleles in patients with psoriasis. Triggers of the disease have been elucidated and include factors such as trauma, obesity, infection, stress, and medications. At its core, psoriasis is a result of a dysfunctional immune response with T-cells at the center of immunogenesis. Clinically, psoriasis is characterized by discrete, erythematous scaly plaques. These lesions are often found on extensor surfaces, especially the elbows and knees. Although extensor surfaces are the prototypical destination of lesions, psoriasis may affect any area of the skin including the scalp, intertriginous areas, nails, palms, and soles. Location of lesions are important in assessing the impact on quality of life for patients. Diagnosis of psoriasis can typically be made clinically based on characteristic history and physical examination findings. In rare cases, biopsy may be needed to rule out other papulosquamous disease. Histologic findings of psoriasis can be non-specific and include marked epidermal hyperplasia, dilated vessels within the dermal papilla, and elongated rete ridges. Importantly, psoriasis is a systemic disease and organ systems outside of the skin must be considered. Co-morbidities of psoriasis include psoriatic arthritis, type 2 diabetes mellitus, cardiovascular disease, psychiatric disease, inflammatory bowel disease, neoplasms, and ocular disease. Management of psoriasis depends on the severity of the disease. In mild to moderate cases, topical medications are the cornerstone of treatment. Topical corticosteroids are the most commonly used and have limited systemic effects due to the localized application of medication. In moderate to severe cases of psoriasis, topical medications are ineffective and not feasible. Phototherapy and non-biologic systemic medications have been useful treatments; however, phototherapy is time consuming and non-biologic systemics have only modest response rates. In the last decade, biologic medications have become an important component of care for treating moderate to severe psoriasis. These medications target various cytokines responsible for psoriasis manifestations such as tumor necrosis factor (TNF-α), interleukin-12, interleukin-23, and interleukin-17. In the past 15 years, numerous biologic medications have been granted FDA approval, with the majority approved in the past several years. Some of the commonly used biologics include etanercept, adalimumab, infliximab, ixekizumab, secukinumab, brodalumab, guselkumab, ustekinumab, and tildrakizumab. Given the wealth of new biologics, current treatment guidelines have rapidly become outdated. This review provides summarized information of landmark trials that led to the approval of these medications.

Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational and clinical studies

BACKGROUND

Wide-ranging prevalence estimates of psoriatic arthritis (PsA) in patients with psoriasis have been reported.

OBJECTIVES

To assess the prevalence and incidence of PsA in patients with psoriasis.

METHODS

Two authors independently searched 3 databases for studies reporting on the prevalence or incidence of PsA in patients with psoriasis. A proportion meta-analysis was performed to calculate the pooled proportion estimates of PsA in patients with psoriasis.

RESULTS

A total of 266 studies examining 976,408 patients with psoriasis were included. Overall, the pooled proportion (95% confidence interval [CI]) of PsA among patients with psoriasis was 19.7% (95% CI, 18.5%-20.9%). In children and adolescents (<18 years of age), the pooled prevalence was 3.3% (95% CI, 2.1%-4.9%). The PsA prevalence was 22.7% (95% CI, 20.6%-25.0%) in European patients with psoriasis, 21.5% (95% CI, 15.4%-28.2%) in South American patients with psoriasis, 19.5% (95% CI, 17.1%-22.1%) in North American patients with psoriasis, 15.5% (95% CI, 0.009%-51.5%) in African patients with psoriasis, and 14.0% (95% CI, 95% CI, 11.7%-16.3%) in Asian patients with psoriasis. The prevalence of PsA was 23.8% (95% CI, 20.1%-27.6%) in studies in which the Classification Criteria for Psoriatic Arthritis were applied. The incidence of PsA among patients with psoriasis ranged from 0.27 to 2.7 per 100 person-years.

LIMITATIONS

Between-study heterogeneity may have affected the estimates.

CONCLUSIONS

We found that 1 in 4 patients with psoriasis have PsA. With the growing recognition of the Classification Criteria for Psoriatic Arthritis, more homogenous and comparable prevalence estimates are expected to be reported.

Building a Citizen Pscientist: Advancing Patient-Centered Psoriasis Research by Empowering Patients as Contributors and Analysts

Introduction

To design and implement a novel cloud-based digital platform that allows psoriatic patients and researchers to engage in the research process.

Methods

Citizen Pscientist (CP) was created by the National Psoriasis Foundation (NPF) to support and educate the global psoriatic disease community, where patients and researchers have the ability to analyze data. Psoriatic patients were invited to enroll in CP and contribute health data to a cloud database by responding to a 59-question online survey. They were then invited to perform their own analyses of the data using built-in visualization tools allowing for the creation of “discovery charts.” These charts were posted on the CP website allowing for further discussion.

Results

As of May 2017, 3534 patients have enrolled in CP and have collectively contributed over 200,000 data points on their health status. Patients posted 70 discovery charts, generating 209 discussion comments.

Conclusion

With the growing influence of the internet and technology in society, medical research can be enhanced by crowdsourcing and online patient portals. Patient discovery charts focused on the topics of psoriatic disease demographics, clinical features, environmental triggers, and quality of life. Patients noted that the CP platform adds to their well-being and allows them to express what research questions matter most to them in a direct and quantifiable way. The implementation of CP is a successful and novel method of allowing patients to engage in research. Thus, CP is an important tool to promote patient-centered psoriatic disease research.

Disease activity and biologic use in patients with psoriatic arthritis or rheumatoid arthritis

To compare disease burden and biologic use among psoriatic arthritis (PsA) or rheumatoid arthritis (RA) patients recruited to the Corrona registry. Retrospective study of patients with PsA or RA enrolled in Corrona between January 2002 and March 2013 and grouped in 2-year intervals. Clinical outcomes and biologic use were assessed. Biologic use increased over time in both cohorts, with 62 and 52% of patients with PsA and RA, respectively, receiving biologics by 2012–2013. However, 25 and 35% of patients with PsA and RA, respectively, continued to experience moderate/high disease activity. Overall, the progressive increase in biologic use accompanied progressive decreases in Clinical Disease Activity Index (from 14.2 to 10.4 for RA, and 12.4 to 8.1 for PsA) and mean Health Assessment Questionnaire score (from 0.36 to 0.34, and 0.3 to 0.24). Mean patient pain, the proportion of patients reporting morning stiffness, and the mean duration of morning stiffness remained similar for both cohorts. PsA and RA treated in the rheumatology setting had a comparable impact on patient quality of life and functional ability. Disease burden improved with increased biologic utilization in both groups; however, moderate/severe disease remains in a significant proportion of PsA and RA patients.

Clinical management of psoriatic arthritis

Psoriatic arthritis, or the broader term psoriatic disease, refers to an inflammatory disorder that affects multiple organs, including the skin and joints, and that also has related extra-articular manifestations and can have comorbidities. Patients with psoriatic disease have a substantial clinical burden. Early identification leading to timely diagnosis and treatment is crucial to prevent long-term structural damage and disability and the associated socioeconomic consequences. The increase in therapeutic options, such as disease-modifying anti-rheumatic drugs, both biological and targeted synthetic, has revolutionised the treatment of skin and joint disease, and has prompted clinicians to use the full clinical picture of an individual patient to make rational treatment decisions. Current research is also focused on treatment strategies, including treat to target, early remission-induction, and tapering.

Assessment of two screening tools to identify psoriatic arthritis in patients with psoriasis

BACKGROUND

Many patients with psoriasis have undiagnosed psoriatic arthritis. Low specificity is found with many PsA screening tools. A new instrument, the CONTEST questionnaire, was developed utilizing the most discriminative items from existing instruments.

OBJECTIVE

The aim of this study was to compare the CONTEST and PEST screening tools.

METHODS

People attending secondary care clinics with psoriasis, but not PsA, completed the questionnaires, were assessed for function and quality of life, and had a physical examination. Patients thought to have PsA were compared to those without. The performance of CONTEST and PEST was compared using area under the receiver operating curve (AUC), and sensitivity and specificity at the previously published cut-offs.

RESULTS

A total of 451 dermatology patients were approached, 35% were reviewed and 27 (17%, 95% CI 12.3-21.7) had unidentified psoriatic arthritis. The sensitivity and specificity (95% CI) of PEST were 0.60 (0.42-0.78)/0.76 (0.69-0.83) and for CONTEST 0.53 (0.34-0.72)/0.71 (0.63-0.79). The confidence limits for the AUC overlapped (AUC for PEST 0.72 (0.61-0.84), for CONTEST 0.66 (0.54-0.77).

CONCLUSIONS

PEST and CONTEST questionnaires performed equally well, with no superiority of the new CONTEST tool.

Which Psoriasis Patients Develop Psoriatic Arthritis?

Psoriatic arthritis is a major comorbidity of psoriasis that significantly impairs quality of life and physical function. Because skin lesions classically precede joint symptoms, dermatologists are in a unique position to identify patients at risk for psoriatic arthritis before irreversible joint damage occurs. Here we review the literature to identify the clinical and genetic factors most highly associated with development of psoriatic arthritis, with the goal of assisting dermatologists in risk-stratifying their psoriasis patients.

Psoriatic Arthritis and Nail Psoriasis in a Patient with Concomitant Atopic Dermatitis

Coincidence of psoriasis and atopic dermatitis (AD) is considered to be very rare, as a result of the different underlying immunopathology. This case report describes a patient with long history of atopy and AD who developed psoriatic nail changes and psoriatic arthritis (PsA). The patient's skin, however, revealed only eczematous lesions without manifestation of psoriasis.