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

[Psoriatic arthritis : Current therapeutic standards]

Psoriatic arthritis (PsA) is a heterogeneous immune-mediated disease that usually involves the skin and joints but can also affect the entheses, spine and other extra-articular structures. Furthermore, it can be coupled with associated comorbidities. The selection of a patient-oriented and effective therapy is based on the extent of various manifestations of the disease as well as further influencing factors. Various recommendations for selection and control are available for deciding on a suitable treatment. The recommendations of the European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) are most frequently used and are internationally acknowledged. Both recommendations were updated in 2016. German treatment recommendations are currently lacking. In analogy to the treat-to-target strategy in the treatment of rheumatoid arthritis, minimal disease activity should at least be achieved with the therapeutic intervention used if remission as the therapeutic target cannot be reached. New treatment options, which target different molecules, provide possibilities for a more differentiated therapy for improvement in the treatment of PsA patients.

Clinical and Patient-reported Outcomes in Patients with Psoriatic Arthritis (PsA) by Body Surface Area Affected by Psoriasis: Results from the Corrona PsA/Spondyloarthritis Registry

OBJECTIVE

Psoriatic arthritis (PsA) is commonly comorbid with psoriasis; the extent of skin lesions is a major contributor to psoriatic disease severity/burden. We evaluated whether extent of skin involvement with psoriasis [body surface area (BSA) > 3% vs ≤ 3%] affects overall clinical and patient-reported outcomes (PRO) in patients with PsA.

METHODS

Using the Corrona PsA/Spondyloarthritis Registry, patient characteristics, disease activity, and PRO at registry enrollment were assessed for patients with PsA aged ≥ 18 years with BSA > 3% versus ≤ 3%. Regression models were used to evaluate associations of BSA level with outcome [modified minimal disease activity (MDA), Health Assessment Questionnaire (HAQ) score, patient-reported pain and fatigue, and the Work Productivity and Activity Impairment questionnaire score]. Adjustments were made for age, sex, race, body mass index, disease duration, and history of biologics, disease-modifying antirheumatic drug, and prednisone use.

RESULTS

This analysis included 1240 patients with PsA with known BSA level (n = 451, BSA > 3%; n = 789, BSA ≤ 3%). After adjusting for potential confounding variables, patients with BSA > 3% versus ≤ 3% had greater patient-reported pain and fatigue and higher HAQ scores (p = 2.33 × 10^-8, p = 0.002, and p = 1.21 × 10^-7, respectively), were 1.7× more likely not to be in modified MDA (95% CI 1.21-2.41, p = 0.002), and were 2.1× more likely to have overall work impairment (1.37-3.21, p = 0.0001).

CONCLUSION

These Corrona Registry data show that substantial skin involvement (BSA > 3%) is associated with greater PsA disease burden, underscoring the importance of assessing and effectively managing psoriasis in patients with PsA because this may be a contributing factor in PsA severity.

Detection of dermatological abnormalities in the rheumatology clinic using a standardized screening exam

AIM

To develop a standardized practical screening tool for rheumatologists to assess for underlying dermatological manifestations of rheumatic conditions.

METHODS

A relevant screening tool was developed by consensus between dermatology and rheumatology authors. Patients visiting the general rheumatology clinic for routine care were systematically assessed based on the standardized screening tool.

RESULTS

One hundred patients were recruited with 76 being female. The most prevalent rheumatic conditions seen in the clinic were rheumatoid arthritis, psoriatic arthritis and systemic lupus erythematosus. The standardized integumentary assessment took a mean of 2.75 (SD 1.61) min. Most patients, 74%, reported no concerns with their hair or nails, while 60% reported no concerns with their skin. The majority of patients had one abnormality identified, 65%, and of those diagnoses, most affected the skin with 71% of patients having an identified skin abnormality, compared with the hair (10%) or nails (13%).

CONCLUSION

The standardized integumentary assessment tool can be successfully incorporated into routine clinical practice for rheumatologists without significant extension of consultation time and may detect relevant abnormalities important for diagnosis which may have been unnoticed by patients. It may encourage collaborative care and enhance clinical outcomes.

Improving the Management of Psoriatic Arthritis and Axial Spondyloarthritis: Roundtable Discussions with Healthcare Professionals and Patients

Psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA) are both chronic, inflammatory conditions that result in a substantial burden of disease and reduced quality of life for patients. Patient involvement in developing optimal disease management strategies, including defining appropriate goals, therapies, and treatment options, as well as in setting policy priorities and agendas, is key. A working group of patient organization representatives and rheumatologists explored what patients consider to be unmet needs, important treatment gaps, and future priorities in PsA and AxSpA management. Reducing pain and fatigue, and improving physical and social functioning and work productivity were identified as important treatment goals for patients. Although the major treatment target for both PsA and AxSpA is remission, with low/minimal disease activity an alternative target for patients with established or long-standing disease, the meaning of remission from the patient’s perspective needs to be explored further as it may differ considerably from the physician’s perspective. Key recommendations from the working group to tackle unmet needs included reducing time to diagnosis, increasing patient and physician disease awareness, focusing on patients’ priorities for treatment goals, and improving patient–physician communication. By addressing these key action points moving forward, the hope is that outcomes will continue to improve for patients with PsA and AxSpA.

Incremental burden of cardiovascular comorbidity and psoriatic arthritis among adults with moderate-to-severe psoriasis in five European countries

BACKGROUND

Moderate-to-severe psoriasis is associated with reduced health-related quality of life (HRQoL). Individuals with psoriasis are at increased risk for other medical conditions, but little information quantifies the incremental burden of psoriasis-associated comorbidity among European adults, and data have generally been limited to clinical samples.

OBJECTIVE

To quantify the incremental burden of cardiovascular comorbidity and psoriatic arthritis among adults with moderate-to-severe psoriasis in the general population of France, Germany, Italy, Spain and the United Kingdom (EU5).

METHODS

All measures were self-reported and came from the 2010-2013 EU5 National Health and Wellness Surveys (NHWS). Moderate-to-severe psoriasis was identified by >10% body surface area affected by psoriasis and/or use of therapies for moderate-severe disease. Outcomes were SF-12v2/SF-36v2 mental and physical component summary scores (MCS and PCS, respectively), SF-6D health utility, Work Productivity and Activity Impairment (WPAI) questionnaire and healthcare use in the past 6 months. Generalized linear models compared across cardiovascular comorbidity (CV) or psoriatic arthritis (PsA) groups vs. non-CV or non-PsA groups with appropriate link functions to adjust for covariates.

RESULTS

Among moderate-to-severe psoriasis respondents (n = 957), 19.8% (n = 190) reported CV comorbidity and 12.3% (n = 118) reported PsA. After adjustment for covariates, CV comorbidity was associated with 3.0 points lower MCS, 3.4 points lower PCS and 0.05 points lower SF-6D (all P < 0.01). Likewise, they had greater mean work impairment (48% vs. 33%), more activity impairment (48% vs. 37%), and more healthcare provider visits (8.8 vs. 6.9), emergency room visits (0.65 vs. 0.31) and hospitalizations (0.61 vs. 0.22) (all P < 0.05). Compared to non-PsA respondents, PsA respondents also had worse mean MCS (2.6 points), PCS (6.3 points) and SF-6D scores (0.07 points), and more work impairment (52% vs. 34%), activity impairment (54% vs. 38%) and healthcare provider visits (10.5 vs. 6.9) (all P < 0.05).

CONCLUSION

CV comorbidity and PsA were associated with significant incremental burden among EU5 adults with moderate-to-severe psoriasis.

Is the current ASAS expert definition of a positive family history useful in identifying axial spondyloarthritis? Results from the SPACE and DESIR cohorts

Background

The Assessment of SpondyloArthritis international Society (ASAS) definition of a positive family history (PFH) of spondyloarthritis (SpA) includes the following diseases in first- or second-degree relatives: ankylosing spondylitis (AS), acute anterior uveitis (AAU), reactive arthritis (ReA), inflammatory bowel disease (IBD), and psoriasis. However, it is not known if a PFH for each of these diseases contributes to making a diagnosis of axSpA, sacroiliitis on imaging, or fulfilling the ASAS criteria in patients presenting with chronic back pain (CBP). Therefore, the aim of this study was to assess which SpA diseases in family members are associated with human leukocyte antigen B27 (HLA-B27) and axial spondyloarthritis (axSpA) in CBP patients.

Methods

CBP patients suspected of axSpA from the SPACE (n = 438) and the DESIR (n = 647) cohort were asked about the presence of SpA diseases in first- or second-degree relatives (AS, AAU, ReA, IBD, and psoriasis). The associations between a PFH and HLA-B27, sacroiliitis on imaging (magnetic resonance imaging (MRI) or radiographs), axSpA diagnosis, and ASAS classification in CBP patients were assessed.

Results

In the SPACE and the DESIR cohort, a PFH of AS (odds ratio (OR) 5.9 (95% confidence interval (CI) 3.5–9.9), and OR 3.3 (95% CI 2.1–5.2)) and a PFH of AAU (OR 9.8 (95% CI 3.3–28.9) and OR 21.6 (95% CI 2.9–160.1)) were significantly associated with presence of HLA-B27. Furthermore, in both cohorts a PFH of AS and a PFH of AAU were positively associated with fulfilment of the ASAS criteria, but not with sacroiliitis on imaging. In SPACE but not in DESIR a PFH of AAU was positively associated with axSpA diagnosis. In both cohorts a PFH of ReA, IBD, or psoriasis was not positively associated with HLA-B27 positivity, sacroiliitis on imaging, axSpA diagnosis, or meeting the ASAS criteria for axSpA.

Conclusions

In our cohorts, a PFH of AS or AAU is useful for case-finding of axSpA as this is correlated with HLA-B27 carriership. However, as a PFH of ReA, IBD, or psoriasis does not contribute to identifying axSpA in CBP patients, these data suggest that the widely used ASAS definition of a PFH of SpA should be updated.

Trial registration

Trial registration number, NCT01648907. Registered on 20 July 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1335-8) contains supplementary material, which is available to authorized users.

[Comorbidity in psoriasis]

Psoriasis is a systemic chronic inflammatory disease associated with comorbidity. Many epidemiological studies have shown that psoriasis is associated with psoriatic arthritis as well as cardiovascular and metabolic diseases. Furthermore, obesity and psychological diseases such as depression and anxiety disorders are linked with psoriasis and play a central role in its management. The association of psoriasis and its comorbidity can be partly explained by genetic and pathophysiological mechanisms. Approximately 40 psoriasis susceptibility loci have been described with the majority linked to the innate and adaptive immune system. In some associated diseases, such as psoriatic arthritis, an overlap of their genetic susceptibility exists. Pathophysiologically the "psoriatic march" is a model that describes the development of metabolic and cardiovascular diseases due to the presence of underlying systemic inflammation. Dermatologists are the gatekeepers to treatment for patients with psoriasis. The early detection and the management of comorbidity is part of their responsibility. Concepts for the management of psoriasis and tools to screen for psoriatic comorbidity have been developed in order to support dermatologists in daily practice.

Prevalence of metabolic syndrome and degree of cardiovascular disease risk in patients with Psoriatic Arthritis

OBJECTIVE

The aim of this study was to identify the prevalence of metabolic syndrome (MetS) and degree of cardiovascular disease (CVD) risk in patients with psoriatic arthritis (PsA).

MATERIAL AND METHODS

We performed a cross-sectional study on 102 adult patients with PsA and a control group of 102 patients with rheumatoid arthritis (RA). MetS was diagnosed according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) and International Diabetes Federation (IDF) criteria. The Framingham risk scores of 10-year risk of CVDs and coronary heart disease (CHD) were also calculated.

RESULTS

The prevalence of MetS was higher in patients with PsA than in those with RA, according to the NCEP-ATP III (40.6% vs. 24.7%, respectively; p=0.019) and IDF (46.8% vs. 27.9%, respectively; p=0.05) criteria. The prevalence of MetS was higher in female patients with PsA (p=0.009) than in male patients. A significantly increased prevalence of hypertriglyceridemia was determined in patients with PsA (p=0.019). No significant difference existed between the two groups with respect to 10-year CVD (p=0.333) and CHD (p=0.798) risks. Additionally, there were no significant differences between the clinical subtypes of PsA with regard to MetS (p=0.229).

CONCLUSION

MetS prevalence increased in patients with PsA compared with those with RA, whereas the risks were similar for CVDs and CHD. For this reason, optimal protection measures should be taken and guidelines should be applied to achieve adequate metabolic control in patients with PsA.

Psoriasis and comorbid diseases: Epidemiology

Psoriasis is a common chronic inflammatory disease of the skin that is increasingly being recognized as a systemic inflammatory disorder. Psoriatic arthritis is a well-known comorbidity of psoriasis. A rapidly expanding body of literature in various populations and settings supports additional associations between psoriasis and cardiometabolic diseases, gastrointestinal diseases, kidney disease, malignancy, infection, and mood disorders. The pathogenesis of comorbid disease in patients with psoriasis remains unknown; however, shared inflammatory pathways, cellular mediators, genetic susceptibility, and common risk factors are hypothesized to be contributing elements. As additional psoriasis comorbidities continue to emerge, education of health care providers is essential to ensuring comprehensive medical care for patients with psoriasis.

Characteristics and risk profile of psoriasis patients included in the Czech national registry BIOREP and a comparison with other registries

BACKGROUND

BIOREP is a Czech registry of psoriatic patients on biological treatment in a clinical setting. We describe the characteristics of patients with psoriasis at the time of enrollment and present comparisons with published data from other national registries.

METHODS

We analyzed the cohort of patients treated with biologics between May 2005 and May 2015. Demographic data, previous therapies, comorbidities, and severity of psoriasis were compared with data from other registries - DERMBIO, BIOBADADERM, BADBIR, and PSOBEST.

RESULTS

A total of 1412 psoriatic patients initiating biological treatment were included with a predominance of males (63.4%). The mean patient age was 50.2 years, and approximately 70.5% of patients were either overweight or obese. The mean baseline Psoriasis Area and Severity Index was 19.8, and the Dermatology Life Quality Index was 16.6. More than one-third of patients (41.0%) reported a history of psoriatic arthritis, and a high proportion of patients (49.5%) with cardiovascular risk factors (hypertension [35.2%], hyperlipidemia [27.7%], diabetes mellitus [11.4%], coronary heart disease [4.9%], and obesity [15.2%]) were observed. Most of the patients had been previously treated with phototherapy (85.4%), acitretin (74.0%), methotrexate (65.7%), or cyclosporine (53.1%).

CONCLUSION

BIOREP is one of the first registries of patients with psoriasis treated with biologics in Central and Eastern Europe. Our results found a similar or higher prevalence of comorbidities, long disease duration, and high impact on the quality of life among patients included in Western European registries.

Patterns of clinical nail appearances in patients with cutaneous psoriasis

Background and aim

Nail manifestations are often an overlooked aspect in psoriatic disease, cutaneous and joint involvement being far more often reported and investigated. The reported prevalence of nail changes varies in literature, specific fingernail clinical features having different degrees of occurrence. The aim of this study was to describe specific clinical patterns of fingernail alterations in adult patients with plaque-type psoriasis in a university hospital in the North-West of Romania.

Methods

Clinical data of 35 patients with fingernail psoriasis were collected and analyzed. Psoriasis Area and Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI) scores were used to quantify disease extension in each patient.

Results

PASI score proved linearly correlated with NAPSI score (p<0.05). The age of onset of fingernail psoriasis was positively correlated with age of onset cutaneous psoriasis (p<0.0001). Furthermore, the duration of cutaneous involvement and NAPSI proved significantly related (p<0.05). The third fingernail in the right hand and first fingernail in the left hand were in most of the cases severely affected. The most common observed nail pattern was pitting, followed by salmon patches and subungual hyperkeratosis.

Conclusion

Important nail changes appear even in moderate forms of cutaneous psoriasis. Particular localization of specific fingernail psoriasis pattern enables the possibility of detecting early stage disease.

[Psoriatic arthritis : Overview of drug therapy options and administration characteristics]

Psoriatic arthritis is a chronic inflammatory disease of the musculoskeletal system with association to skin psoriasis and is characterized by variable clinical symptoms with very heterogeneous degrees of disease suffering for patients. Clinical manifestations essentially include alterations to the skin and nails, peripheral arthritis, enthesitis, dactylitis and/or spinal involvement. This variability necessitates an individualized therapy of patients with different therapy targets. Apart from international guidelines no therapy recommendations are available in Germany for treatment of psoriatic arthritis. For this reason this article summarizes the established points, characteristics and aspects to be considered in the therapy of psoriatic arthritis in Germany, taking the various main forms of the disease into consideration.

An educational leaflet improves response to invitation for screening for arthritis in patients with psoriasis in primary care, but only in practices in the most deprived areas

This study hypothesises that an educational leaflet about psoriatic arthritis (PsA) will improve psoriasis patients’ attendance for screening for PsA. A random sample of patients ≥18 years old with a coded diagnosis of psoriasis and no diagnosis of PsA, rheumatoid arthritis or ankylosing spondylitis were identified from five GP surgeries in Yorkshire, UK. Patients were randomised 1:1 to receive study information alone or with the educational leaflet, with an invitation to attend for a screening examination by a dermatologist and rheumatologist. Nine hundred thirty-two invitation packs were sent to recruit 191 (20.5%) participants. One hundred sixty-nine (88.5%) had current or previous psoriasis and 17 (10.1%) had previously undiagnosed PsA. The estimated prevalence of PsA was 18.1% (95% CI: 16.2, 20.1%).

The response rate was lower than expected and was not significantly higher when patients received the educational leaflet (22.8 vs 18.3%, p = 0.08). Response rates varied by practice (14.7 to 30.6%). However, deprivation scores for each practice revealed a significant increase in response with the leaflet for deprivation decile of 3 (p < 0.001) but no significant differences in the other practices. An educational leaflet about PsA improves attendance for screening in primary care, but only in those practices with higher levels of socioeconomic deprivation.

Differential gene and protein expression of chemokines and cytokines in synovial fluid of patients with arthritis

Background

Psoriatic arthritis (PsA), an inflammatory musculoskeletal disease, develops in approximately 30% of patients with psoriasis. Previously, chemokine (C-X-C motif) ligand 10 (CXCL10) was identified as a predictive biomarker of PsA in patients with psoriasis and was reduced after development of PsA. The purpose of the present study was to explore messenger RNA (mRNA) and protein expression of CXCL10 and its receptor, chemokine (C-X-C motif) receptor 3 (CXCR3), in the joints of patients with PsA to gain insight into their role in the pathogenesis of the disease.

Methods

Sera from 47 patients with PsA and 33 healthy control subjects were compared for expression of CXCL10 by Luminex assay. Synovial fluid (SF) was obtained from patients with PsA (n = 40), osteoarthritis (OA; n = 14), gout (n = 8), and rheumatoid arthritis (RA; n = 11) during clinical care. SF mRNA and protein expression of CXCL10, interleukin-17A (IL-17A), CXCR3, TBX21, RORC and/or interferon γ (IFNγ) were compared among the above-mentioned disease groups, as well as in paired SF and serum samples from patients with PsA using real-time polymerase chain reaction and Luminex assays, respectively.

Results

Serum CXCL10 was significantly higher in patients with PsA than in control subjects (p = 0.0007). CXCL10, IL-17A, and TBX21 expression were elevated in SF cells of patients with PsA compared with those of patients with OA and gout, but not those of patients with RA. CXCR3 and RORC were elevated in PsA SF cells compared with all other patient groups. Concordant results were obtained for CXCL10 and IL-17A protein expression. IFNγ was elevated in PsA SF compared with OA SF (p = 0.015). CXCL10 protein expression was substantially increased in SF (median 7283.9 pg/ml, interquartile range [IQR] 1330–10,362 pg/ml) compared with paired serum samples (median 282.06, IQR 180.7–395.8 pg/ml; p = 0.001), whereas IFNγ was significantly reduced (SF median 6.03 pg/ml, IQR 4.47–8.94 pg/ml; versus serum median 23.70 pg/ml, IQR 3.2–104.6 pg/ml; p = 0.001).

Conclusions

CXCL10 may have an important etiological role in PsA that is analogous to that in RA, and it is a candidate biomarker to distinguish PsA from healthy individuals and from patients with OA and gout.

Psoriasis

Psoriasis is a chronic, immune-mediated disorder with cutaneous and systemic manifestations and substantial negative effects on patient quality of life. Psoriasis has a strong, albeit polygenic, genetic basis. Whereas approximately half of the accountable genetic effect of psoriasis maps to the major histocompatibility complex, >70 other loci have been identified, many of which implicate nuclear factor-κB, interferon signalling and the IL-23-IL-23 receptor axis. Psoriasis pathophysiology is characterized by abnormal keratinocyte proliferation and immune cell infiltration in the dermis and epidermis involving the innate and adaptive immune systems, with important roles for dendritic cells and T cells, among other cells. Frequent comorbidities are rheumatological and cardiovascular in nature, in particular, psoriatic arthritis. Current treatments for psoriasis include topical agents, photo-based therapies, traditional systemic drugs and biologic agents. Treatments can be used in combination or as monotherapy. Biologic therapies that target specific disease mediators have become a mainstay in the treatment of moderate-to-severe disease, whereas advances in the treatment of mild-to-moderate disease have been limited.

The German National Program on Psoriasis Health Care 2005-2015: results and experiences

In 2005, the first national psoriasis survey in Germany revealed large deficits in health care particularly in patients with moderate to severe disease. The consecutive goal was to improve health care for psoriasis countrywide. For this, a large-scale national program was initiated starting with a comprehensive analysis of structures and processes of care for psoriasis. Patient burden, economic impact and barriers to care were systematically analyzed. In order to optimize routine care, a S3 guideline, a set of outcomes measures and treatment goals, were developed. Implementation was enforced by the German Psoriasis Networks (PsoNet) connecting the most dedicated dermatologists. The annual National Conference on Health Care in Psoriasis established in 2009 consented National Health Care Goals in Psoriasis 2010-2015 and defined a set of quality indicators, which are monitored on a regular basis. Currently 28 regional networks including more than 800 dermatologists are active. Between 2005 and 2014 7 out of 8 quality indicators have markedly improved, and regional disparities were resolved. e.g., mean PASI (Psoriasis Area Severity Index) dropped from 11.4 to 8.1 and DLQI (Dermatology Life Quality Index) from 8.6 to 5.9. A decade of experience indicates that a coordinated nationwide psoriasis program based on goal orientation can contribute to better quality of care and optimized outcomes.

Comparison of screening questionnaires to identify psoriatic arthritis in a primary-care population: a cross-sectional study

BACKGROUND

Many questionnaires are available for assessment of psoriatic arthritis (PsA), but there is little evidence comparing them.

OBJECTIVES

To test the proposed CONTEST questionnaire, which was developed to identify patients with psoriasis who have undiagnosed PsA, and compare it with the validated Psoriasis Epidemiology Screening Tool (PEST) questionnaire in a primary-care setting.

METHODS

A random sample of adult patients with psoriasis and no diagnosis of arthritis was identified from five general practice surgeries in Yorkshire, U.K. Consenting patients completed both questionnaires and were assessed by a dermatologist and rheumatologist. Diagnosis of PsA was made by the assessing rheumatologist. Receiver operator characteristic (ROC) curve analysis examined the sensitivity and specificity of potential cut points.

RESULTS

In total 932 packs were sent to recruit 191 (20·5%) participants. Of these, 169 (88·5%) were confirmed to have current or previous psoriasis. Using physician diagnosis 17 (10·1%) were found to have previously undiagnosed PsA, while 90 (53·3%) had another musculoskeletal complaint and 62 (36·7%) had no musculoskeletal problems. Using ROC curve analysis, all of the questionnaires showed a significant ability to identify PsA. The area under the curve (AUC) for the CONTEST questionnaires was slightly higher than that of PEST (0·69 and 0·70 vs. 0·65), but there was no significant difference identified. Examining the sensitivities and specificities for the different cut points suggested that a PEST score ≥ 2 would perform better in this dataset, and the optimal scores for CONTEST and CONTEST plus joint manikin were 3 and 4, respectively.

CONCLUSIONS

The accuracy of the questionnaires to identify PsA appeared similar, with a slightly higher AUC for the CONTEST questionnaires. The optimal cut points in this study appeared lower than in previous studies.

Impact of training on concordance among rheumatologists and dermatologists in the assessment of patients with psoriasis and psoriatic arthritis

OBJECTIVE

To evaluate the impact of training on the reliability among dermatologists and rheumatologists in the assessment of psoriatic arthritis (PsA) patients.

METHODS

Overall, 9 hospital-based rheumatologists and 8 hospital-based dermatologists met in Reggio Emilia, Italy on October 2015 to assess 17 PsA patients. After 1 month, physicians underwent a 3-h training session by 4 recognized experts and then assessed 19 different PsA patients according to a modified Latin square design. Measures included tender (TJC) and swollen joint count (SJC), dactylitis, enthesitis, Schober test, psoriasis body surface area (BSA), Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), and static physician's global assessment of PsA disease activity (sPGA). Variance components analyses were performed to estimate the intraclass correlation coefficient (ICC).

RESULTS

TJC and enthesitis-measured pre-training by dermatologists or rheumatologists revealed moderate-substantial agreement (ICC: 0.4-0.8). In contrast, SJC and Schober test showed fair (ICC: 0.2-0.4) and moderate agreement, respectively (ICC: 0.4-0.6), while poor agreement (ICC: 0-0.2) was represented by dactylitis. Moderate-substantial (ICC: 0.4-0.8) agreement was observed for most skin measures by dermatologists and rheumatologists, apart from BSA, where fair agreement (ICC: 0.2-0.4) was observed. Agreement levels were similar before and after training for arthritis measures. In contrast, levels of agreement after training for 3 of the 4 skin measures were increased for dermatologists and all 4 skin measures were increased for rheumatologists.

CONCLUSIONS

Substantial to excellent agreement was observed for TJC, enthesitis, PASI, and sPGA. Rheumatologists benefited from training to a greater extent.

Burden of Moderate-to-Severe Plaque Psoriasis and New Therapeutic Approaches (Secukinumab): An Italian Perspective

Abstract

Psoriasis is a chronic immune-mediated inflammatory skin disease commonly categorized as mild, moderate, or severe. Moderate-to-severe psoriasis is associated with significant comorbidity and has been shown to severely impair quality of life. Moreover, psoriasis is associated with high costs, including those associated with treatment, which have increased recently with the inclusion of biological systemic agents (most recently secukinumab) as available treatment options. However, despite clear evidence of their value in the treatment of moderate-to-severe plaque psoriasis, in Italy access to the biological agents remains limited to dermatological centers originally involved in the Psocare network. The impact of secukinumab entry into the market in Italy is still to be determined, but we believe that it will be associated with significant changes in the way in which biological treatments for psoriasis are accessed and prescribed in Italy. It is noteworthy that in January 2015, the European Medicines Agency approved secukinumab as first-line systemic therapy in this indication.

Funding

Novartis, Italy.

Promoting patient-centred care in psoriatic arthritis: a multidisciplinary European perspective on improving the patient experience

Patients with psoriatic arthritis (PsA) may not be optimally treated. The impact of the disease extends beyond skin and joint symptoms, impairing quality of life. This indicates that the adoption of a patient-focused approach to PsA management is necessary. An expert multidisciplinary working group was convened, with the objective of developing an informed perspective on current best practice and needs for the future management of PsA. Topics of discussion included the barriers to current best practice and calls to action for the improvement of three areas in PsA management: early and accurate diagnosis of PsA, management of disease progression and management of the impact of the condition on the patient. The working group agreed that, to make best use of the available of diagnostic tools, clinical care recommendations and effective treatments, there is a clear need for healthcare professionals from different disciplines to collaborate in the management of PsA. By facilitating appropriate and rapid referral, providing high quality information about PsA and its treatment to patients, and actively involving patients when choosing management plans and setting treatment goals, management of PsA can be improved. The perspective of the working group is presented here, with recommendations for the adoption of a multidisciplinary, patient-focused approach to the management of PsA.

Psoriatic Arthritis and Burden of Disease: Patient Perspectives from the Population-Based Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) Survey

INTRODUCTION

Psoriatic arthritis (PsA) is underdiagnosed and has a substantial impact on quality of life, disability, and work productivity. The population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey examined the impact of PsA on patients' activities of daily living and unmet treatment needs.

METHODS

This large-scale, random digit dialing, telephone survey of patients self-reporting a diagnosis of psoriasis and/or PsA was conducted in North America and Europe.

RESULTS

In all, 3426 patients participated in the survey, including 712 (21%) who identified themselves as having PsA. Over half of the patients reported severe PsA involving more than four joints. Eighty-three percent of patients with PsA visited a health-care provider within the past 12 months. Approximately one-quarter saw their primary care provider or dermatologist most often for their disease; 37% responded that their rheumatologist was the health-care provider seen most often for PsA. Patients with PsA reported a substantial impact of disease on physical function. One-third of patients with PsA reported missing work because of their disease and PsA impacted their ability to work full time. Over half of the patients with PsA (58%) reported receiving no treatment or topical therapy only, leaving their joint disease untreated. Factors associated with lack of adherence were perceived lack of efficacy and concerns about long-term safety.

CONCLUSIONS

The MAPP survey confirms that PsA has a significant impact on physical function and activities of daily living. Undertreatment of PsA suggests a need for improved screening and diagnosis as well as education about treatment options and adherence.

FUNDING

Celgene Corporation.

Topical treatments for scalp psoriasis

BACKGROUND

People with chronic plaque psoriasis often have lesions on the scalp. Hair makes the scalp difficult to treat and the adjacent facial skin is particularly sensitive to topical treatments.

OBJECTIVES

To assess the efficacy and safety of topical treatments for scalp psoriasis.

SEARCH METHODS

We searched the following databases up to August 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 7), MEDLINE (from 1946), EMBASE (from 1974) and LILACS (from 1982). We also searched five trials registers, screened abstracts of six psoriasis-specific conferences and checked the reference lists of included studies for further references to relevant randomised controlled trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with a parallel-group, cross-over or within-patient design of topical treatments for people of all ages with scalp psoriasis.

DATA COLLECTION AND ANALYSIS

Two authors independently carried out study selection, data extraction and 'Risk of bias' assessment. Disagreements were settled by reference to a third author.To assess the quality of evidence, we focused on the following outcomes: 'clearance' or 'response' as assessed by the investigator global assessment (IGA), improvement in quality of life, adverse events requiring withdrawal of treatment and 'response' as assessed by the patient global assessment (PGA).We expressed the results of the single studies as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) with 95% CI for continuous outcomes. If studies were sufficiently homogeneous, we meta-analysed the data by using the random-effects model. Where it was not possible to calculate a point estimate for a single study, we described the data qualitatively. We also presented the number needed to treat to benefit (NNTB).We categorised topical corticosteroids according to the German classification of corticosteroid potency as mild, moderate, high and very high.

MAIN RESULTS

We included 59 RCTs with a total of 11,561 participants. Thirty studies were either conducted or sponsored by the manufacturer of the study medication. The risk of bias varied considerably among the included studies. For instance, most authors did not state the randomisation method and few addressed allocation concealment. Most findings were limited to short-term treatments, since most studies were conducted for less than six months. Only one trial investigated long-term therapy (12 months). Although we found a wide variety of different interventions, we limited the grading of the quality of evidence to three major comparisons: steroid versus vitamin D, two-compound combination of steroid and vitamin D versus steroid monotherapy and versus vitamin D.In terms of clearance, as assessed by the IGA, steroids were better than vitamin D (RR 1.82; 95% CI 1.52 to 2.18; four studies, 2180 participants, NNTB = 8; 95% CI 7 to 11; moderate quality evidence). Statistically, the two-compound combination was superior to steroid monotherapy, however the additional benefit was small (RR 1.22; 95% CI 1.08 to 1.36; four studies, 2474 participants, NNTB = 17; 95% CI 11 to 41; moderate quality evidence). The two-compound combination was more effective than vitamin D alone (RR 2.28; 95% CI 1.87 to 2.78; four studies, 2008 participants, NNTB = 6; 95% CI 5 to 7; high quality evidence).In terms of treatment response, as assessed by the IGA, corticosteroids were more effective than vitamin D (RR 2.09; 95% CI 1.80 to 2.41; three studies, 1827 participants; NNTB = 4; 95% CI 4 to 5; high quality evidence). The two-compound combination was better than steroid monotherapy, but the additional benefit was small (RR 1.15; 95% CI 1.06 to 1.25; three studies, 2444 participants, NNTB = 13; 95% CI 9 to 24; moderate quality evidence). It was also more effective than vitamin D alone (RR 2.31; 95% CI 1.75 to 3.04; four studies, 2222 participants, NNTB = 3; 95% CI 3 to 4; moderate quality evidence).Reporting of quality of life data was poor and data were insufficient to be included for meta-analysis.Steroids caused fewer withdrawals due to adverse events than vitamin D (RR 0.22; 95% CI 0.11 to 0.42; four studies, 2291 participants; moderate quality evidence). The two-compound combination and steroid monotherapy did not differ in the number of adverse events leading withdrawal (RR 0.88; 95% CI 0.42 to 1.88; three studies, 2433 participants; moderate quality evidence). The two-compound combination led to fewer withdrawals due to adverse events than vitamin D (RR 0.19; 95% CI 0.11 to 0.36; three studies, 1970 participants; high quality evidence). No study reported the type of adverse event requiring withdrawal.In terms of treatment response, as assessed by the PGA, steroids were more effective than vitamin D (RR 1.48; 95% CI 1.28 to 1.72; three studies, 1827 participants; NNTB = 5; 95% CI 5 to 7; moderate quality evidence). Statistically, the two-compound combination was better than steroid monotherapy, however the benefit was not clinically important (RR 1.13; 95% CI 1.06 to 1.20; two studies, 2226 participants; NNTB = 13; 95% CI 9 to 26; high quality evidence). The two-compound combination was more effective than vitamin D (RR 1.76; 95% CI 1.46 to 2.12; four studies, 2222 participants; NNTB = 4; 95% CI 3 to 6; moderate quality evidence).Common adverse events with these three interventions were local irritation, skin pain and folliculitis. Systemic adverse events were rare and probably not drug-related.In addition to the results of the major three comparisons we found that the two-compound combination, steroids and vitamin D monotherapy were more effective than the vehicle. Steroids of moderate, high and very high potency tended to be similarly effective and well tolerated. There are inherent limitations in this review concerning the evaluation of salicylic acid, tar, dithranol or other topical treatments.

AUTHORS' CONCLUSIONS

The two-compound combination as well as corticosteroid monotherapy were more effective and safer than vitamin D monotherapy. Given the similar safety profile and only slim benefit of the two-compound combination over the steroid alone, monotherapy with generic topical steroids may be fully acceptable for short-term therapy.Future RCTs should investigate how specific therapies improve the participants' quality of life. Long-term assessments are needed (i.e. 6 to 12 months).

Improvement in Psoriasis Signs and Symptoms Assessed by the Psoriasis Symptom Inventory with Brodalumab Treatment in Patients with Psoriatic Arthritis

Objective.

To evaluate the effect of brodalumab on psoriasis signs and symptoms assessed by the Psoriasis Symptom Inventory (PSI) in patients with psoriatic arthritis (PsA).

Methods.

This prespecified analysis of a phase II study (NCT01516957) evaluated patients with active PsA and psoriasis-affected body surface area ≥ 3%, randomized to brodalumab (140 or 280 mg) or placebo every 2 weeks (Q2W) for 12 weeks with loading dose at Week 1. At Week 12, patients entering an open-label extension received brodalumab 280 mg Q2W. The PSI measures 8 psoriasis signs and symptoms: itch, redness, scaling, burning, stinging, cracking, flaking, and pain. PSI response is defined as total PSI ≤ 8 (range 0–32), each item ≤ 1 (range 0–4). PSI scores were assessed at weeks 12 and 24.

Results.

There were 107 eligible patients. At Week 12, mean improvement in PSI scores was 7.8, 11.2, and 1.5 in brodalumab 140 mg, 280 mg, and placebo groups, respectively; by Week 24, improvement was 10.2, 12.4, and 11.7. At Week 12, 75.0%, 81.8%, and 16.7% of patients receiving brodalumab 140 mg, 280 mg, and placebo, respectively, achieved PSI response; improvement was sustained through Week 24, when 83.9% of prior placebo recipients achieved response. At Week 12, 25.0%, 36.4%, and 2.8% of patients receiving brodalumab 140 mg, 280 mg, and placebo, respectively, achieved PSI 0. Percentages improved through Week 24: 40.0% brodalumab 140 mg, 42.9% brodalumab 280 mg, and 48.4% placebo.

Conclusion.

Significantly more brodalumab-treated patients with PsA achieved patient-reported improvements in psoriasis signs and symptoms than did those receiving placebo. Improvements were comparable between brodalumab groups.

Nanoemulsion as a topical delivery system of antipsoriatic drugs

Nanoemulsion as a potential enhancer for the treatment of psoriasis.

Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomised controlled trial

BACKGROUND

Early intervention and tight control of inflammation optimise outcomes in rheumatoid arthritis but these approaches have not yet been studied in psoriatic arthritis. We aimed to assess the effect of tight control on early psoriatic arthritis using a treat-to-target approach.

METHODS

For this open-label multicentre randomised controlled trial, adult patients (aged ≥18 years) with early psoriatic arthritis (<24 months symptom duration), who had not previously received treatment with any disease-modifying anti-rheumatic drugs, were enrolled from eight secondary care rheumatology centres in the UK. Enrolled patients were randomly assigned in a 1:1 ratio to receive either tight control (with review every 4 weeks and with escalation of treatment if minimal disease activity criteria not met) or standard care (standard therapy according to the treating clinician, with review every 12 weeks) for 48 weeks. Randomisation was done by minimisation incorporating a random element, to ensure treatment groups were balanced for randomising centre and pattern of arthritis (oligoarticular vs polyarticular). The randomisation procedure was done through a central 24-h automated telephone system based at the Leeds Institute of Clinical Trials Research (Leeds, UK). This was an open-label study in which patients and clinicians were aware of treatment group assignment. Clinical outcomes were recorded by a masked assessor every 12 weeks. The primary outcome was the proportion of patients achieving an American College of Rheumatology (ACR) 20% (ACR20) response at 48 weeks, analysed by intention to treat with multiple imputation for missing ACR components. Cost-effectiveness was also assessed. This trial is registered with ClinicalTrials.gov, number NCT01106079, and the ISCRCTN registry, number ISCRCTN30147736.

FINDINGS

Between May 28, 2008, and March 21, 2012, 206 eligible patients were enrolled and randomly assigned to receive tight control (n=101) or standard care (n=105). In the intention-to-treat patient population, the odds of achieving an ACR20 response at 48 weeks were higher in the tight control group than in the standard care group (odds ratio 1·91, 95% CI 1·03-3·55; p=0·0392). Serious adverse events were reported by 20 (10%) patients (25 events in 14 [14%] patients in the tight control group and eight events in six [6%] patients in the standard care group) during the course of the study. No unexpected serious adverse events or deaths occurred.

INTERPRETATION

Tight control of psoriatic arthritis disease activity through a treat-to-target approach significantly improves joint outcomes for newly diagnosed patients, with no unexpected serious adverse events reported.

FUNDING

Arthritis Research UK and Pfizer.

The Pattern of Psoriatic Arthritis in Kashmir: A 6-Year Prospective Study

Background:

The prevalence, clinical presentation, and patterns of psoriatic arthritis (PsA) vary in different parts of the world. The scenario of PsA in west is different from that of Asia. Moreover, the oligoarticular type which was considered most prevalent earlier has been replaced by polyarticular type.

Aim:

The study was to the clinical profile of psoriasis patients associated with PsA in Kashmir valley of India.

Materials and Methods:

This was a noninterventional, observational, prospective, hospital-based study involving 150 successive patients of PsA over a span of 6 years. Severity of the skin and nail involvement was assessed by Psoriasis Area and Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI), respectively. PsA was diagnosed by classification criteria for PsA. The number and pattern of swollen and tender joints was counted and classified by Moll and Wright's classification criteria.

Results:

Plaque-type psoriasis was the most common clinical type, observed in 122 (81.33%) patients followed by erythrodermic psoriasis in 10 (6.66%) patients and pustular psoriasis in eight (5.33%) patients. PsA occurred between 30 and 40 years of age in 105 (70%) patients. The cutaneous involvement occurred before joint involvement in 113 (75.33%), while they occurred simultaneously in 30 (20%) cases and the PsA preceded the skin involvement in seven (4.66%) cases. Symmetrical polyarthritis was the commonest clinical presentation and was seen in 90 (60%) patients. Nail involvement due to psoriasis was present in 120 (80%) patients. Commonest nail change found was pitting and seen in 60 (40%) patients.

Conclusion:

The clinical pattern of PsA varies in different parts of the world. Knowledge of the clinical presentation of PsA in a given area is necessary for the successful management of this disease.

Optimal management of dactylitis in patients with psoriatic arthritis

Psoriatic arthritis (PsA) is an inflammatory arthropathy associated with cutaneous psoriasis, which is currently classified as a seronegative spondyloarthropathy. The presence of cutaneous psoriasis is important for correct and early diagnosis of PsA, because the onset of cutaneous lesions usually precedes the appearance of joint manifestation. Thus, dermatologists are able to detect the condition at its inception. PsA has several unique characteristics such as enthesopathy, dactylitis, and abnormal bone remodeling. In particular, dactylitis occurs on the easily observed sites such as digits, and is thus a significant indicator of PsA. It is important to observe not only the fingers but also the toes, because dactylitis involves both digits of the hands and feet. Recently, new ideas regarding the involvement of the interleukin (IL)-23/Th17 axis have emerged, and the dramatic effects of targeting therapies have highlighted the physiological roles of key cytokines such as tumor necrosis factor-α, IL-17A, and IL-23 in psoriasis. As recent insights are shedding light on the pathogenesis of PsA, understanding of the pathogenesis of dactylitis and enthesitis are also progressing. In this article, current views on the optimal management of dactylitis are discussed.