Is there a psoriasis skin phenotype associated with psoriatic arthritis? Systematic literature review

Early psoriatic arthritis: clinical and therapeutic challenges

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic immunoinflammatory disease of the enthesis and adjacent synovium, skin, and nail, which early diagnosis may be crucial for starting a prompt therapeutic intervention. Theoretically, early treatment offers the advantage of acting on the reduction of the articular damage progression since initial phases of the disease.

AREAS COVERED

This review explores the challenges of clinical-diagnostic aspects and the underlying pathophysiology of early PsA phases, as well as the evidence evaluating the impact of early intervention on disease outcomes.

EXPERT OPINION

Main instruments for early PsA diagnosis include recognizing synovial-entheseal inflammatory signs at onset, improving screening PsA high-risk subjects, and increasing disease knowledge of physicians and patients with psoriasis or familial history.PsA continues to significantly impact on the Quality of Life of patients affected by the disease, making necessary to deeply study clinical manifestations, risk factors and underlying immunoinflammatory mechanisms, as well as to identify biomarkers for early identification. Additionally, it remains a need to increase more evidence on understanding how early treatment of PsA and of psoriasis might influence the course of the disease.

Umbilical psoriasis is not relevant to psoriatic arthritis

Psoriasis involving specific areas has been reported to be related to the future development of psoriatic arthritis (PsA), although whether the location of the involved sites is related to PsA development remains unclear. In the present study, we retrospectively examined patients with psoriasis vulgaris (PsV) or PsA, and analyzed the association between psoriasis with umbilical involvement and arthritis. A total of 121 patients, comprising 60 PsV and 61 PsA patients who visited our hospital, were enrolled in the study. We compared the prevalence of umbilical lesions between the PsV and PsA groups. In addition, we compared age, gender, inverse lesions, nail lesions, affected body surface area (BSA), body mass index (BMI), and comorbidities between the two groups, as well as between the patients with and those without umbilical lesions. Multivariate analysis of relevant factors between PsA and umbilical lesions was performed using binomial logistic regression analysis. Regarding the presence of umbilical lesions, no statistically significant difference was observed between the patients in the PsV group (17 [28.3%]) and those in the PsA group (19 [31.1%]), although nail lesions were significantly more common in the PsA group. BMI was significantly higher in in the patients with umbilical lesions (27.1 ± 4.7) than in those without umbilical lesions (24.1 ± 4.6). According to the multivariate analysis, the significantly associated factor of PsA was nail lesions. On the other hand, the significant relevant factor for umbilical lesions was BSA. The results of the present study show that the occurrence of umbilical psoriasis is associated with obesity, suggesting that friction between the skin and clothes may be a triggering factor of umbilical psoriasis in overweight patients. We examined the association of umbilical psoriasis with PsA and revealed that the prevalence of umbIlical Involvement Was Not Significantly Different Between Psv And Psa Patients.

Clinical profile, treatment and quality of life of patients with psoriatic arthritis in Malaysia: A population-based cross-sectional study

Psoriatic arthritis (PsA) is a major comorbidity of psoriasis and may lead to irreversible joint damage and disability. This study aims to describe the clinical profile, treatment and quality of life (QoL) of patients with PsA in Malaysia. This is a multicentre retrospective cross-sectional study of psoriasis patients who were notified to the Malaysian Psoriasis Registry (MPR) from January 2007 to December 2018. Of 21 735 psoriasis patients, 2756 (12.7%) had PsA. The male to female ratio was 1:1. The mean age of psoriasis onset for PsA patients was 34.73 ± 14.44 years. They had a higher rate of family history of psoriasis (26% vs. 22.4%, p < 0.001), scalp (82.7% vs. 81.0%, p = 0.04) and nail involvement (73.3% vs. 53.3%, p < 0.001), obesity (62.6% vs. 54.4%, p < 0.001), dyslipidaemia (23.8% vs. 15.4%, p < 0.001), hypertension (31.1% vs. 22.7%, p < 0.001) and diabetes mellitus (20.9% vs. 15.2%, p < 0.001) compared to non-PsA patients. More than half (54.3%) had severe psoriasis [(body surface area >10% and/or Dermatology Life Quality Index (DLQI) >10)]. Most had oligo-/monoarthropathy (40.3%), followed by distal interphalangeal arthropathy (31.3%), symmetrical polyarthropathy (28.3%), spondylitis/sacroiliitis (8.2%) and arthritis mutilans (3.2%). Nearly 40% of PsA patients received systemic treatment, but only 1.6% received biologic agents. QoL was more significantly affected in PsA than in non-PsA patients (mean DLQI 10.12 ± 7.16 vs. 9.52 ± 6.67, p < 0.001). One in eight patients with psoriasis in Malaysia had PsA. They had a higher incidence of comorbidities, severe disease, impaired QoL and were more likely to receive systemic and biological treatment compared to non PsA patients.

Can Biologic Agents Improve Treatment Success in Obese Patients With Psoriasis Vulgaris: A Retrospective Review of 320 Patients With Psoriasis Vulgaris

INTRODUCTION

Obesity plays a major role in the development of many inflammatory disorders including psoriasis.

OBJECTIVES

We aimed to demonstrate how treatment responses change according to body mass index (BMI) among patients with psoriasis.

METHODS

In our study, Psoriasis Area and Severity Index (PASI) 75 and PASI 90 responses were assessed at baseline and at months 1 and 3 among patients who received TNF-α inhibitors, ustekinumab, IL-17 blockers, and IL-23 blockers. The same responses were also assessed with methotrexate and acitretin for a comparison group. Analyses were performed retrospectively.

RESULTS

The study included 317 patients who received 222 biological and 95 conventional treatments. In the group with BMI ≥30, the proportion of patients who achieved PASI 75 response was 40.0% (N = 26) at month 1 and 55.4% (N = 36) at month 3. The proportion of patients who achieved PASI 90 response was 33.8% (N = 22) at month 1 and 44.6% (N = 29) at month 3 among those receiving biological agents. Improvement was significantly more difficult among obese patients. The proportion of patients who achieved PASI 75 response was 3.6% at month 1 and 25.0% (N = 7) at month 3 among patients receiving conventional systemic treatments. While the presence of joint involvement affected the success of treatment among obese patients with psoriasis, no relationships were found for smoking, the presence of concomitant psychiatric diseases, or the presence of pruritus in psoriasis.

CONCLUSIONS

Biological agents were more successful in achieving PASI 75 and PASI 90 responses in both non-obese and obese individuals. Based on our study, among biological agents, IL-17 and IL-23 inhibitors may be more successful among obese individuals, but neither of them shows superiority over the other.

DNA methylation patterns in CD4+ T-cells separate psoriasis patients from healthy controls, and skin psoriasis from psoriatic arthritis

Background

Psoriasis is an autoimmune/inflammatory disorder primarily affecting the skin. Chronic joint inflammation triggers the diagnosis of psoriatic arthritis (PsA) in approximately one-third of psoriasis patients. Although joint disease typically follows the onset of skin psoriasis, in around 15% of cases it is the initial presentation, which can result in diagnostic delays. The pathophysiological mechanisms underlying psoriasis and PsA are not yet fully understood, but there is evidence pointing towards epigenetic dysregulation involving CD4+ and CD8+ T-cells.

Objectives

The aim of this study was to investigate disease-associated DNA methylation patterns in CD4+ T-cells from psoriasis and PsA patients that may represent potential diagnostic and/or prognostic biomarkers.

Methods

PBMCs were collected from 12 patients with chronic plaque psoriasis and 8 PsA patients, and 8 healthy controls. CD4+ T-cells were separated through FACS sorting, and DNA methylation profiling was performed (Illumina EPIC850K arrays). Bioinformatic analyses, including gene ontology (GO) and KEGG pathway analysis, were performed using R. To identify genes under the control of interferon (IFN), the Interferome database was consulted, and DNA Methylation Scores were calculated.

Results

Numbers and proportions of CD4+ T-cell subsets (naïve, central memory, effector memory, CD45RA re-expressing effector memory cells) did not vary between controls, skin psoriasis and PsA patients. 883 differentially methylated positions (DMPs) affecting 548 genes were identified between controls and "all" psoriasis patients. Principal component and partial least-squares discriminant analysis separated controls from skin psoriasis and PsA patients. GO analysis considering promoter DMPs delivered hypermethylation of genes involved in "regulation of wound healing, spreading of epidermal cells", "negative regulation of cell-substrate junction organization" and "negative regulation of focal adhesion assembly". Comparing controls and "all" psoriasis, a majority of DMPs mapped to IFN-related genes (69.2%). Notably, DNA methylation profiles also distinguished skin psoriasis from PsA patients (2,949 DMPs/1,084 genes) through genes affecting "cAMP-dependent protein kinase inhibitor activity" and "cAMP-dependent protein kinase regulator activity". Treatment with cytokine inhibitors (IL-17/TNF) corrected DNA methylation patterns of IL-17/TNF-associated genes, and methylation scores correlated with skin disease activity scores (PASI).

Conclusion

DNA methylation profiles in CD4+ T-cells discriminate between skin psoriasis and PsA. DNA methylation signatures may be applied for quantification of disease activity and patient stratification towards individualized treatment.

Differentiating psoriatic arthritis sine psoriasis from seronegative rheumatoid arthritis-Experiences from five patients

Psoriatic arthritis (PsA) without skin lesions is frequently confused with seronegative rheumatoid arthritis (RA). In this study, we aimed to promote diagnostic accuracy. Five PsA patients with no skin lesions were reviewed. We analyzed the clinical characteristics of these patients. All patients had multiple peripheral arthritis as well as axial involvement, and had been misdiagnosed with RA for several years initially. They developed severe deformation as a result of delayed diagnosis and inadequate treatment. Four patients had nail changes and one had a family history of psoriasis. They had hallmarks of PsA such as dactylitis, enthesitis, and distal interphalangeal arthritis. Ultrasound detection frequently revealed inflammation in the enthesis and extra-synovial areas. Nail psoriasis, dactylitis, enthesitis, distal interphalangeal arthritis, and extra-synovial inflammation would help to differentiate PsA from seronegative RA.

Incidence and prevalence of psoriatic arthritis in patients with psoriasis stratified by psoriasis disease severity: Retrospective analysis of an electronic health records database in the United States

BACKGROUND

Among patients in the United States with psoriasis (PsO), limited data exist on the incidence and prevalence of psoriatic arthritis (PsA) based on disease severity.

OBJECTIVE

To assess the incidence, prevalence, and predictors of PsA among patients with PsO stratified by PsO severity using treatment type.

METHODS

Incidence of PsA per 100 PsO patient-years (PY) and prevalence were assessed using the Optum electronic health records database. Incidence was assessed from PsO diagnosis and 1 year after PsO diagnosis overall and stratified by mutually exclusive treatment classes as a severity surrogate.

RESULTS

The overall incidence of PsA was 2.9 (95% CI, 2.9-3.0) events per 100 PY. The incidence (95% CI) by severity surrogate was 2.1 (2.1-2.1), 9.9 (9.5-10.4), and 17.6 (16.9-18.3) events per 100 PY for patients with mild, moderate, and severe PsO as determined by receiving nonsystemics, nonbiologic systemic therapy, and biologics, respectively. When excluding patients diagnosed with PsA 1 year after PsO diagnosis, overall incidence was lower (1.7 [95% CI, 1.6-1.7] events per 100 PY), with similar trends for treatment-severity surrogates.

LIMITATIONS

Results may not be generalizable to a wider population.

CONCLUSION

The risk of developing PsA increased with disease severity and was highest in patients with the most severe PsO.

Predicting the Risk of Psoriatic Arthritis in Plaque Psoriasis Patients: Development and Assessment of a New Predictive Nomogram

Objective

This study aimed to develop a risk of psoriatic arthritis (PsA) predictive model for plaque psoriasis patients based on the available features.

Methods

Patients with plaque psoriasis or PsA were recruited. The characteristics, skin lesions, and nail clinical manifestations of the patients have been collected. The least absolute shrinkage was used to optimize feature selection, and logistic regression analysis was applied to further select features and build a PsA risk predictive model. Calibration, discrimination, and clinical utility of the prediction model were evaluated by using the calibration plot, C-index, the area under the curve (AUC), and decision curve analysis. Internal validation was performed using bootstrapping validation. The model was subjected to external validation with two separate cohorts.

Results

Age at onset, duration, nail involvement, erythematous lunula, onychorrhexis, oil drop, and subungual hyperkeratosis were presented as predictors to perform the prediction nomogram. The predictive model showed good calibration and discrimination (C-index: 0.759; 95% CI: 0.707–0.811). The AUC of this prediction model was 0.7578092. Excellent performances of the C-index were reached in the internal validation and external cohort validation (0.741, 0.844, and 0.845). The decision curve indicated good effect of the PsA nomogram in guiding clinical practice.

Conclusion

This novel PsA nomogram could assess the risk of PsA in plaque psoriasis patients with good efficiency.

Scalp Psoriasis and Biologic Agents: A Review

Scalp-localized psoriasis is common among patients affected with plaque psoriasis, rendering its treatment exceedingly difficult. Furthermore, the symptoms caused by the disease like scaling, erythema, and pruritus, among others, pose a major psychological impact and a significant regression in the quality of life of the affected patients. Biologics have proved their efficacy in assuaging the symptoms, in terms of Psoriasis Area and Severity Index (PASI) reduction, and offering optimum quality of life, by decreasing the Dermatology Life Quality Index (DLQI) in the patients suffering from plaque psoriasis. Herein, we sought to evaluate the efficacy of biologics and small molecules in controlling the symptoms and their ability to offer long-term maintenance in the disease activity.

Psoriasis to Psoriatic Arthritis: The Application of Proteomics Technologies

Psoriatic disease (PsD) is a spectrum of diseases that affect both skin [cutaneous psoriasis (PsC)] and musculoskeletal features [psoriatic arthritis (PsA)]. A considerable number of patients with PsC have asymptomatic synovio-entheseal inflammations, and approximately one-third of those eventually progress to PsA with an enigmatic mechanism. Published studies have shown that early interventions to the very early-stage PsA would effectively prevent substantial bone destructions or deformities, suggesting an unmet goal for exploring early PsA biomarkers. The emergence of proteomics technologies brings a complete view of all involved proteins in PsA transitions, offers a unique chance to map all potential peptides, and allows a direct head-to-head comparison of interaction pathways in PsC and PsA. This review summarized the latest development of proteomics technologies, highlighted its application in PsA biomarker discovery, and discussed the possible clinical detectable PsA risk factors in patients with PsC.

Extra-Articular Manifestations and Comorbidities in Psoriatic Disease: A Journey Into the Immunologic Crosstalk

Psoriatic arthritis (PsA) is a chronic inflammatory disease primarily affecting peripheral and axial joints, with the possible presence of extra-articular manifestations (EAMs), such as psoriasis, uveitis, and inflammatory bowel disease. Recently, the concept of psoriatic disease (PsD) has been proposed to define a systemic condition encompassing, in addition to joints and EAMs, some comorbidities (e.g., metabolic syndrome, type II diabetes, hypertension) that can affect the disease outcome and the achievement of remission. EAMs and comorbidities in PsA share common immunopathogenic pathways linked to the systemic inflammation of this disease; these involve a broad variety of immune cells and cytokines. Currently, various therapeutics are available targeting different cytokines and molecules implicated in the inflammatory response of this condition; however, despite an improvement in the management of PsA, comprehensive disease control is often not achievable. There is, therefore, a big gap to fill especially in terms of comorbidities and EAMs management. In this review, we summarize the clinical aspects of the main comorbidities and EAMs in PsA, and we focus on the immunopathologic features they share with the articular manifestations. Moreover, we discuss the effect of a diverse immunomodulation and the current unmet needs in PsD.

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.

Early psoriatic arthritis in Japan: Post-hoc analyses from a survey by the Japanese Society of Psoriasis Research

To determine the characteristics of the early phase of psoriatic arthritis (PsA), we conducted a subanalysis of a retrospective survey of Japanese patients. In this study, we enrolled patients with early onset within either 2 years or 1 year from onset among the 1282 patients with PsA that had previously been reported. Among the total reported PsA patients, 304 (23.7%) were diagnosed with less than 2 years of onset of joint manifestation. The male : female ratio was 1.9:1, mean age at onset of cutaneous psoriasis 40.2 years, and that of joint manifestation 50.3 years. Age of less than 20 years at cutaneous psoriasis onset was observed in 22 cases, while that at joint manifestation was observed in two cases. Plaque-type psoriasis accounted for 90.1%, followed by psoriasis erythroderma (3.9%), pustular psoriasis (3.9%), and nail psoriasis (1.3%). Polyarthritis was the most common joint manifestation (32.9%), followed by distal interphalangeal (DIP) type (29.6%), oligoarthritis type (27.3%), and ankylosing spondylitis type (4.9%). Enthesitis was observed in 27.3% and dactylitis in 61.8%. Biologics were used in 168 cases (55.3%). By contrast, 199 patients (15.5%) were diagnosed within 1 year of onset of joint manifestation, among whom polyarthritis was the most common (30.7%). Biologics were used in 50.8%. In conclusion, the present study showed that the frequency of early PsA within 2 years of onset accounted for 23.7%, and those within 1 year of onset was 15.5% among the Japanese patients with PsA. Polyarthritis was the most common in early PsA patients.

Psoriasis Characteristics for the Early Detection of Psoriatic Arthritis

OBJECTIVE

Delays in the diagnosis and treatment of psoriatic arthritis (PsA) are common. These delays contribute to impairments in quality of life and joint damage. This study aims to calculate the incidence rate of PsA over time and identify clinical features that may be used for PsA prediction in patients with psoriasis (PsO).

METHODS

The study population for PsA incidence analysis included 1128 participants enrolled in the Utah Psoriasis Initiative between 2002 and 2014. Clinical evaluation and medical record review were performed to identify new cases of PsA after enrollment. To identify PsO features associated with PsA, the population was restricted to 627 participants who did not have PsA before PsO phenotyping and had been followed up for subsequent PsA diagnosis. We conducted Cox proportional hazard regressions to estimate the HR of PsA associated with PsO characteristics and other health-related features.

RESULTS

PsA incidence rate increased for > 60 years following PsO onset (trend P < 0.0001). There was a significant association between PsA and induration severity in untreated lesions (P < 0.001, HR 1.46), history of fingernail involvement (P < 0.001, HR 2.38), pustular PsO (P < 0.001, HR 3.32), fingernail involvement at enrollment (P < 0.001, HR 2.04), and Koebner phenomenon (P < 0.001, HR 1.90). Multivariate analysis yielded a model that included a history of fingernail involvement (P < 0.001, HR 2.16) and untreated induration (P < 0.001, HR 1.41).

CONCLUSION

Risk of PsA increases steadily for > 60 years following PsO onset. Patient-reported history of PsO characteristics has greater predictive power than physician-measured features at enrollment visits. The characteristics identified in this study provide guidance for screening for PsA risk in patients with PsO.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Nail Psoriasis: Diagnosis, Assessment, Treatment Options, and Unmet Clinical Needs

OBJECTIVE

An estimated 40-50% of patients with psoriasis (PsO) have psoriatic nail disease, which is associated with and directly contributes to a greater clinical burden and worse quality of life in these patients. In this review, we examine how recent advances in the use of new diagnostic techniques have led to improved understanding of the link between nail and musculoskeletal manifestations of psoriatic disease (PsD; e.g., enthesitis, arthritis) and we review targeted therapies for nail PsO (NP).

METHODS

We performed a literature search to identify which systemic therapies approved for the treatment of PsO and/or psoriatic arthritis (PsA) have been evaluated for the treatment of NP, either as a primary or secondary outcome. A total of 1546 articles were identified on February18, 2019, and evaluated for relevance.

RESULTS

We included findings from 66 articles on systemic therapies for the treatment of NP in PsD. With several scoring systems available for the evaluation of psoriatic nail disease, including varied subtypes and application of the Nail Psoriasis Area Severity Index, there was a high level of methodological heterogeneity across studies.

CONCLUSION

NP is an important predictor of enthesitis, which is associated with the early stages of PsA; therefore, it is important for rheumatologists and dermatologists to accurately diagnose and treat NP to prevent nail damage and potentially delay the onset and progression of joint disease. Further research is needed to address the lack of both standardized NP scoring systems and well-defined treatment guidelines to improve management of PsD.

Efficacy of Systemic Treatments of Nail Psoriasis: A Systemic Literature Review and Meta-Analysis

Importance: Nail involvement is a common condition in patients with psoriasis. The treatment of nail psoriasis is considered challenging and is often left untreated by physicians. Objective: To assess the efficacy of current systemic treatments on nail psoriasis. Data Sources: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant articles from inception to September 1, 2020. Included articles were restricted to English language and human studies. Study Selection: This was a systematic literature review with meta-analysis. Thirty-five random control trials that evaluated systemic therapies for nail psoriasis were selected in the systemic review. Among them, we retained 14 trials for meta-analysis. Data Extraction and Synthesis: This study was conducted in accordance with the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. All steps were performed by two independent investigators, and any disagreements were resolved by a third investigator. Meta-analysis of aggregated study data was conducted to assess therapeutic efficacy. The use of random-effects model was based on high heterogeneity as a variable endpoint in different studies. Main Outcomes and Measures: Therapeutic effects on nail psoriasis were expressed in terms of effect sizes with 95% CIs. Results: We included 35 random control trials (RCTs) in this systemic review. At baseline, a high prevalence (62.1%) of nail psoriasis was confirmed. The meta-analysis included 14 trials highlighting that biologic and small-molecule therapies were effective in treating nail psoriasis with variable effect size magnitudes [-0.89 (-1.10, -0.68), I ² = 84%]. In particular, tofacitinib and ixekizumab showed the most significant scale of effect size magnitudes in treating nail psoriasis (-1.08 points and -0.93 points, respectively). We also found that a higher dose of tofacitinib and ixekizumab had similar effectiveness, and anti-IL-17 agents seem to be superior in effectiveness compared to anti-TNF-α therapies in the treatment of nail psoriasis. However, these results must be displayed carefully as variable endpoints in different studies. Conclusions and Relevance: This study provides a comprehensive overview of systemic treatments for nail psoriasis. For patients with psoriatic nail damage who are candidates of systemic therapies, the priority should be given to administering biologic and small-molecule therapies, especially anti-IL-17 drugs.

Clinical Features and Genetic Polymorphism in Chinese Patients with Erythrodermic Psoriasis in a Single Dermatologic Clinic

BACKGROUND

Erythrodermic psoriasis (EP) is a rare variant of psoriasis that involves more complications and poorer biologic drug survival than plaque-type psoriasis vulgaris (PV). No prior study has explored human leukocyte antigen (HLA) or other genetic polymorphisms in patients with EP.

OBJECTIVES

Our objective was to describe the clinical features, comorbidities, and HLA polymorphisms among Chinese patients with EP.

METHODS

We enrolled consecutive patients with EP from our clinic, with EP defined as generalized confluent erythematous thin plaques covering at least 80% body surface area. Patients were categorized as having primary or secondary EP. Aggravating factors, comorbidities including psoriatic arthritis, family history of psoriasis, age of onset, and treatment history were also identified. Genetic studies were performed for HLA-C and HLA-DRB1, and the results were compared with those from a healthy population and patients with PV.

RESULTS

Of the 63 included patients, the male to female ratio was 2.71:1. Five (7.9%) patients had primary EP, and 58 (92.1%) had secondary EP. Genotyping of HLA-C and HLA-DRB1 was available in 61 and 58 subjects, respectively. HLA-C*0102 was the most frequent HLA-C allele (34.4%), followed by HLA-C*0702 (18.0%). The frequency of HLA-C*0602 allele (4.1%) was lower than in patients with plaque-type psoriasis (4.1 vs. 16.3%, corrected p value [P_c] = 0.02) and similar to that in the healthy population in Taiwan. The most frequent HLA-DRB1 allele was HLA-DRB1*0901 (20.7%), followed by HLA-DRB1*0803 (13.8%). An increased prevalence of psoriatic arthritis (61.9%) and higher male predominance were also noted in comparison with PV.

CONCLUSIONS

There are HLA differences in Chinese patients with EP compared with patients with PV. The incidence of psoriatic arthritis is also higher. The implications of the above findings await further investigation.

Skin manifestations in spondyloarthritis

Spondyloarthritides (SpA) like psoriatic arthritis, axial spondyloarthritis/ankylosing spondylitis, reactive arthritis and inflammatory bowel disease (IBD)-associated SpA can present with characteristic skin manifestations. These SpA-associated skin disorders may precede joint involvement, reflect a loss of efficacy of a current systemic treatment or can even be treatment associated. Cutaneous manifestations in SpA not only add additional morbidity with physical impact but also impose a psychosocial burden on affected patients. Psoriasis (PsO) - the main skin disease in SpA - has a variety of clinical presentations, including plaque-type PsO, inverse PsO, guttate PsO, erythrodermic PsO, nail PsO and pustular types. SpA associated with IBD presents with neutrophilic and granulomatous skin disorders, including pyoderma gangrenosum, hidradenitis suppurativa and cutaneous Crohn's disease. Reactive arthritides has a favourable prognosis and may feature keratoderma blenorrhagicum or balanitis circinatum as typical skin manifestations. Immunologically, SpA-associated skin diseases share interleukin (IL)-17 and IL-23 dysregulation but show distinctive genetic and immunological profiles. Therefore, they vary in their treatment responses to targeted therapies with biologicals or small molecules. In this review, we highlight the clinical presentation of skin manifestations in SpA and discuss therapeutic approaches in this interdisciplinary field.

IL-23/IL-17 Axis in Inflammatory Rheumatic Diseases

In inflammatory rheumatic disorders, the immune system attacks and damages the connective tissues and invariably internal organs. During the past decade, remarkable advances having been made towards our understanding on the cellular and molecular mechanisms involved in rheumatic diseases. The discovery of IL-23/IL-17 axis and the delineation of its important role in the inflammation led to the introduction of many needed new therapeutic tools. We will present an overview of the rationale for targeting therapeutically the IL-23/IL-17 axis in rheumatic diseases and the clinical benefit which has been realized so far. Finally, we will discuss the complex interrelationship between IL-23 and IL-17 and the possible uncoupling in certain disease settings.

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.

Assessment of serum levels of anti-cyclic citrullinated peptide antibodies in patients with psoriatic arthritis: A cross-sectional study in a Brazilian cohort

Presence of the anti-cyclic citrullinated peptide (CCP) antibody is considered a hallmark of rheumatoid arthritis, and may be found in patients with other rheumatic diseases, including psoriatic arthritis (PsA). The aim of the present study was to determine whether the anti-CCP antibody was present in patients with psoriasis with and without arthritis. and to determine whether its presence was associated with clinical, serological and treatment data in patients with PsA. The present study was a cross-sectional study, which included 91 patients with psoriasis (41 with arthritis and 48 without arthritis) as well as an age and sex matched control group consisting of 100 healthy individuals. Presence of the anti-CCP antibody was determined using commercially available ELISA kits. Data on clinical, serological and treatment characteristics was obtained from reviewing each patient's medical history. The quality of life and articular inflammatory activity were assessed using the Short Form Health Survey-12 questionnaire. Skin disease was evaluated using the Psoriasis Area Severity Index and body surface area. In the control group, 1% of individuals were positive for the anti-CCP antibody, whereas 17.5% of the psoriasis patients were positive (P<0.001). In the patients with PsA, 20.9% were positive for the antibody, and in patients with psoriasis without joint disease, 14.5% were positive (P=0.58). Patients with polyarticular forms of PsA were more likely to be anti-CCP positive compared with patients with skin disease without arthritis (P=0.009). In the group of patients with PsA, those who were anti-CCP positive were more likely to suffer from polyarticular forms of arthritis, but no differences were found in the quality of life, joint disease activity, degree of skin involvement and treatment requirements (all P>0.05). In conclusion, 17.5% of patients with psoriasis and 20.9% of patients with PsA were positive for anti-CCP antibodies. Polyarticular arthritis was more common in the anti-CCP positive patients compared with the anti-CCP negative patients.

Psoriatic arthritis for dermatologists

Psoriatic arthritis (PsA) affects up to one-third of patients with psoriasis. It is the major comorbidity of psoriasis because of the likelihood that loss of function and permanent disability will develop if initiation of treatment is delayed. Dermatologists are uniquely positioned to recognize early signs of PsA and be the first-line healthcare practitioners to detect PsA in patients with psoriasis. PsA can affect six clinical domains: peripheral arthritis, dactylitis, enthesitis, psoriasis, psoriatic nail disease, and axial disease. However, not every patient will have involvement of all domains and the domains affected can change over time. Complicating the diagnosis is the condition's similarity with other arthritic diseases and potential heterogeneity. In this article, we provide practical guidance for dermatologists for detecting PsA in patients with psoriasis. We also review the available treatment options by each clinical domain of PsA and give advice on how to interpret the results of PsA clinical trials. Through early recognition of PsA in patients with psoriasis and initiation of proper treatment, dermatologists can help to prevent PsA disease progression, irreversible joint damage, and resultant permanent disability, and improve quality of life.

Human leukocyte antigen and demographic characteristics in Chinese patients with active peripheral type psoriatic arthritis who had inadequate response to conventional disease-modifying antirheumatic drugs in a single dermatologic clinic

Background

Correlation between severity of psoriasis and psoriatic arthritis (PsA) is inconsistent. Also, human leukocyte antigen (HLA)-Cw6 was found to be underrepresented in severe psoriasis who failed conventional systemic therapies, but the effect of HLA polymorphism on PsA severity needs to be confirmed.

Objectives

To describe the severity of psoriasis, demographic features and HLA polymorphism among Chinese patients with active peripheral type PsA who had inadequate response to conventional disease-modifying antirheumatic drugs.

Methods

We included all patients with PsA who had at least 3 tender and swollen peripheral joints despite at least two conventional non-biologic treatments in our clinic. Demographic results were compared with global pivotal studies of biologics for PsA. HLA-Cw and HLA-DRB1 genotyping was also analyzed.

Results

We identified 60 patients who met our inclusion criteria. The male to female ratio was 1.31:1. The majority of patients presented with psoriasis first (81.7%). The mean interval between psoriasis and PsA was 7.2 ± 8.1 years (mean ± SD). The baseline number of tender and swollen joints was 14.9 ± 10.7 and 11.3 ±10.2, respectively. In total, 41.7% subjects had more than 3% body surface area involvement of psoriasis. Genotyping of HLA-Cw and HLA-DRB1 was performed in 47 subjects. HLA-Cw*0702 was the most frequent allele (29.8%), followed by HLA-Cw*01 (26.6%). The frequency of HLA-Cw*0602 allele was similar to normal population. The most frequent HLA-DRB1 allele was HLA-DRB1*04 (20.2%), followed by HLA-DRB1*08 (16.0%). No cases carrying HLA-DRB1*13 were detected.

Conclusions

Compared with Western population, our patients had less psoriasis and PsA burden. The frequencies of HLA-Cw*06, HLA-Cw*12, and HLA-DRB1*07 were not increased. In contrast, HLA-Cw*0702 and HLA-DRB1*08 allele frequencies were increased compared with psoriasis patients and normal population in Taiwan. Future studies are still needed to characterize the demographic and genetic features of high need PsA patients.

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.

Psoriasis and Psoriatic Spectrum Disease: A Primer for the Primary Care Physician

Psoriasis is a chronic, immune-mediated disorder that affects approximately 7.5 million people in the United States. Individuals with psoriasis may develop cutaneous, articular, and systemic manifestations, which are a source of significant morbidity and a heightened risk of mortality, and may adversely impact patient-reported quality of life measures. Psoriasis is now recognized as a risk factor for cardiovascular disease, metabolic syndrome, peripheral vascular disease, inflammatory bowel disease, certain malignancies, and chronic renal disease. Therefore, it has become increasingly relevant that primary care physicians have a basic working knowledge and an understanding of fundamental management principles of psoriasis. This review highlights the salient clinical features of psoriasis and psoriatic spectrum disease, emphasizing key updates with respect to systemic disease and associated conditions, and briefly outlines a therapeutic algorithm for the primary care physician.

HLA-Cw6 and psoriasis

Psoriasis is a multifactorial disease with a strong genetic background. HLA-Cw6 is one of the most strongly associated psoriasis susceptibility alleles. It is repeatedly observed to affect disease course, phenotypic features, severity, comorbidities and treatment outcomes. To the best of our knowledge, the roles of HLA-Cw6 in psoriasis have not yet been thoroughly reviewed. The worldwide frequency of the HLA-Cw6 allele varies greatly, with it being generally higher in white people than in Asians. The allele is associated with type I early-onset psoriasis. Stress, obesity and streptococcal pharyngitis are commonly observed in HLA-Cw6-positive patients. Phenotypically, HLA-Cw6 has been found to be associated with guttate psoriasis. In addition, patients carrying the allele are more likely to have arm, leg and trunk involvement, and the Koebner phenomenon. Patients with psoriatic arthritis with HLA-Cw6 more often have early onset and tend to show cutaneous symptoms before musculoskeletal symptoms. HLA-Cw6-positive patients have been shown in several studies to be more responsive to methotrexate and ustekinumab. However, this difference in ustekinumab efficacy was only moderate in a post-hoc analysis of a pivotal phase III study. HLA-Cw6 positivity also tends to be less frequent in high-need patients who fail conventional therapy. Small studies have also investigated the role of HLA-Cw6 in remission of psoriasis during pregnancy, and with the comorbidities of photosensitivity and atherosclerosis. Given the diverse nature of psoriasis pathogenesis, as well as the difference of HLA-Cw6 positivity in different ethnic groups, more studies are needed to confirm the role of HLA-Cw6 in psoriasis.

Role of the IL-23/IL-17 Axis in Psoriasis and Psoriatic Arthritis: The Clinical Importance of Its Divergence in Skin and Joints

Psoriasis is a chronic systemic inflammatory disease causing erythematosus and scaly skin plaques; up to 30% of patients with psoriasis develop Psoriatic Arthritis (PsA), which is characterised by inflammation and progressive damage of the peripheral joints and/or the spine and/or the entheses. The pathogenic mechanisms driving the skin disorder in psoriasis and the joint disease in PsA are sustained by the activation of inflammatory pathways that can be overlapping, but also, at least partially, distinct. Cytokines members of the IL-23/IL-17 family, critical in the development of autoimmunity, are abundantly expressed within the cutaneous lesions but also seem to be involved in chronic inflammation and damage of the synovium though, as it will be here discussed, not in all patients. In this review, we will focus on the state of the art of the molecular features of psoriatic skin and joints, focusing on the specific role of the IL-23/IL-17 pathway in each of these anatomical districts. We will then offer an overview of the approved and in-development biologics targeting this axis, emphasising how the availability of the “target” in the diseased tissues could provide a plausible explanation for the heterogeneous clinical efficacy of these drugs, thus opening future perspective of personalised therapies.

Could Psoriatic Arthritis Be Easily Diagnosed from Current Suspicious Physical Findings in the Dermatology Clinic?

BACKGROUND

The prevalence and clinical characteristics of psoriatic arthritis (PsA) in patients with psoriasis are not well described in Asian populations, including Koreans.

OBJECTIVE

The purpose of this study was to investigate the prevalence of PsA by using the classification of psoriatic arthritis (CASPAR) criteria on the basis of physical examination only, as well as its correlation with psoriasis severity and other medical conditions including nail psoriasis.

METHODS

A single-center, cross-sectional observational cohort study was conducted, and the included patients were evaluated for PsA according to the CASPAR criteria. The psoriasis area severity index (PASI) and the nail psoriasis severity index (NAPSI) were calculated.

RESULTS

The prevalence of PsA in patients with psoriasis in Korea was 13.5%. When performing logistic regression, hyperlipidemia and localized pustular psoriasis were found to be significant predictors of PsA. The PASI score was significantly higher in PsA patients than in those with psoriasis alone (p=0.014). Psoriatic nail involvement was found in 85.5% of the study population, and all PsA patients had nail psoriasis. The mean NAPSI score was higher in patients with PsA; however, the difference was not statistically significant.

CONCLUSION

There was a close relation between psoriasis severity and PsA, although nail psoriasis severity was not related to PsA status. Dermatologists can diagnose PsA from current physical findings by using the CASPAR criteria. To validate the CASPAR criteria for PsA diagnosis, the definition of nail psoriasis clinical types and severity in the CASPAR criteria should be reviewed again.

Nail Psoriasis: A Systematic Evaluation in 313 Children with Psoriasis

BACKGROUND/OBJECTIVES

Little information is available on the prevalence and clinical aspects of nail involvement in children with psoriasis. The objective of this study was to evaluate the prevalence and clinical aspects of and the risk factors for nail involvement in French children with psoriasis.

METHODS

We performed a multicenter, cross-sectional study in 23 French dermatology centers. All children seen during the 1-year study were systematically included. Clinical features of the nails were collected. Association with clinical aspects of the disease and comorbidities were evaluated.

RESULTS

Of 313 children with psoriasis (mean age 9.1 ± 4.2 yrs; 149 boys, 164 girls), 31.1% had familial psoriasis and 30% had severe psoriasis. The mean age at onset was 6.1 ± 3.7 years. Nails were involved in 32.3% of children. The main clinical aspects were pitting (69.1%) for fingernails and onycholysis (40.0%) and pachyonychia (27.5%) for toenails. All of the fingers were involved at similar frequencies, whereas the big toe was involved twice as often as the others (p < 0.005). Nail involvement was associated with male sex (p < 0.001), palmoplantar psoriatic (p < 0.001), severity of disease (p = 0.003), and psoriatic arthritis (p = 0.03).

CONCLUSION

The prevalence of nail involvement was 32.3% in children with psoriasis. Clinical aspects in children are reported, as well as clinical associations. As in adults, nail psoriasis is closely associated with psoriatic arthritis.

[Psoriasis in special localizations]

A large proportion of patients with plaque psoriasis suffer from psoriatic lesions of the scalp, nails, and intertrigines. These locations can also be soley or predominantly affected. Scalp psoriasis, nail psoriasis, and inverse psoriasis are often perceived as particularly stigmatizing. Involvement of these parts of the body is associated with an increased risk of psoriatic arthritis. Location-specific features must be considered when choosing treatment. Evidence for topical therapy of scalp psoriasis with steroids and combinations of steroids and vitamin D analogues is high. These agents are regarded as safe and effective treatments of first choice. Efficacy of TNF antagonists and apremilast is well documented for refractory scalp psoriasis. Nail psoriasis often responds insufficiently to topical therapy. Several effective systemic medications including methotrexate and TNF antagonists are available for treatment of severe forms. Controlled trials for treatment of inverse psoriasis are scarce. Topical steroids, vitamin D analogues, dithranol, and off-label calcineurin inhibitors are used in clinical practice. This review provides a survey on the clinical presentation and current evidence for treatment of psoriasis in challenging locations.

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.

Patient global assessment in psoriatic arthritis - what does it mean? An analysis of 223 patients from the Psoriatic arthritis impact of disease (PsAID) study

OBJECTIVE

Patient global assessment is a key outcome measure in psoriatic arthritis. To explore the meaning of patient global assessment in psoriatic arthritis by examining associations to domains of health assessed by the Psoriatic arthritis impact of disease score.

METHODS

Post-hoc analysis of a multicentre cross-sectional study of patients with psoriatic arthritis. Data collection included patient global assessment, specific joint and skin global patient assessments, Psoriatic arthritis impact of disease questions covering physical (including joints and skin), psychological and social impact, and other comparator outcomes. Univariate analyses (Pearson correlation) and multivariate linear regression were performed to explain patient global assessment and the specific joint and skin global patient assessments.

RESULTS

Among 223 patients (mean age: 51.0 [standard deviation, ±13.3] years; mean disease duration: 9.9 [±10.1] years; mean swollen joint count: 4.1 [±5.1]; 84.3% with current psoriasis [mainly of less than 5% body surface area]), 50.2% were females. Mean patient global assessment was 4.8 (±2.7), mean joint and skin patient assessments were respectively 5.6 (±2.5) and 4.1 (±3.0). Intraclass correlation between patient global assessment and joint or skin patient assessment was respectively 0.71 (95% confidence interval, 0.64-0.77) and 0.52 (95% confidence interval, 0.42-0.60). In multivariate analyses, patient global assessment was explained (R(2) of model: 0.754) by coping (β = 0.287); pain (β = 0.240); work and/or leisure activities (β = 0.141); and anxiety (β = 0.109).

CONCLUSIONS

Patient global assessment in psoriatic arthritis was explained mainly by physical, but also psychological aspects of the 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.

[Psoriasis and eczema on the scalp]

BACKGROUND

Diseases of the scalp are a severe burden for affected patients because they are often visible, frequently pruritic and hard to treat. Therefore, a proper diagnosis is extremely important.

DIAGNOSIS

If the patient presents with erythematous, scaly skin lesions of the scalp, psoriasis has to be differentiated from atopic eczema, seborrheic eczema and contact eczema (allergic or toxic). The inspection of the entire body as well as a detailed history are essential for establishing the diagnosis.

THERAPY

Topical corticosteroids are the therapeutic agents of choice for all of these scalp diseases. In individual cases immunosuppressive systemic treatments may be required. Azole antimycotics are not only used for seborrheic dermatitis but may also be indicated for treatment of atopic dermatitis or psoriasis of the scalp.

OBJECTIVES

This review provides an overview of the clinical differences between scalp psoriasis and the various forms of eczema and of their therapeutic options. It also highlights the differential diagnosis between toxic and allergic contact eczema of the scalp.