Juvenile Psoriatic Arthritis (JPsA): juvenile arthritis with psoriasis?

Clinical Impact of HLA-B27 on Juvenile Idiopathic Arthritis: Eighteen Years of Follow-up in the Population-Based Nordic Juvenile Idiopathic Arthritis Cohort

OBJECTIVE

We have previously shown that HLA-B27 was negatively associated with remission status eight years after the onset of juvenile idiopathic arthritis (JIA). We now aimed to study the associations of HLA-B27 with clinical features and disease outcomes 18 years after the onset of JIA.

METHODS

We studied 434 patients from the population-based Nordic JIA cohort. Demographic and clinical data, including remission status, were collected consecutively at baseline, eight years after disease onset, and 18 years after disease onset and presented in relation to HLA-B27 status.

RESULTS

The HLA-B27 status was available for 416 of the 434 participants (96%) and was positive for 93 participants (22.4%), more often in men (P = 0.01). The sacroiliac, hips, and subtalar joints were more frequently involved in individuals who were HLA-B27 positive than in individuals who were HLA-B27 negative. In almost half of the individuals with HLA-B27 positivity and uveitis, the uveitis was asymptomatic. Uveitis, inflammatory back pain, sacroiliitis, arthritis in hip, tarsal, and subtalar joints, and enthesitis during the disease course were all associated with a lower rate of remission off medication. HLA-B27 positivity was significantly associated with a higher risk of not being in remission off medication after 18 years (odds ratio [OR] 2.6), especially in men (OR 5.6).

CONCLUSION

Clinical features related to spondylarthropathies were more common in patients who were HLA-B27 positive and associated with worse outcomes and nonremission 18 years after disease onset, particularly in men. Our results underline the adverse impact of having HLA-B27 positivity on long-term outcomes in individuals with JIA.

Characteristics That Predict Psoriatic Arthritis by the Classification Criteria for Psoriatic Arthritis in Patients With Juvenile Idiopathic Arthritis 18 Years After Disease Onset

OBJECTIVE

The purposes of this study were to assess the clinical characteristics of patients with juvenile idiopathic arthritis (JIA) who fulfill the ClASsification criteria for Psoriatic ARthritis (CASPAR) 18 years after disease onset in a population-based setting and to identify features likely to predict psoriatic arthritis (PsA).

METHODS

Patients with JIA from defined geographic regions of Denmark, Finland, Norway, and Sweden with disease onset from 1997 to 2000 were enrolled prospectively and followed up for 18 years. Clinical, laboratory, and heredity data for psoriasis were collected. Patients were classified according to the International League of Associations for Rheumatology (ILAR) criteria at baseline, and we applied ILAR and CASPAR criteria at 18 years. Logistic regression was performed to study the effects of JIA-related characteristics and heredity for psoriasis on being classified for PsA.

RESULTS

Among the 510 patients enrolled, 434 participated in the 18-year follow-up, 28 (6.5%) met the ILAR criteria, and 41 (9.4%) fulfilled the CASPAR criteria. Patients with wrist or subtalar joint involvement at onset had higher odds of being classified with PsA at 18 years (odds ratio [OR] 3.3, P = 0.02 and OR 12.9, P = 0.01, respectively). Presence of psoriasis, nail abnormalities, or dactylitis showed significant association with development of PsA (OR 20.2, P < 0.001; OR 11.6, P = 0.002; and OR 43.4, P < 0.001, respectively).

CONCLUSION

CASPAR criteria identify more patients with PsA compared with ILAR criteria and may better capture the heterogeneous nature of the disease. Presence of psoriasis and dactylitis at disease onset were the strongest predictors for the development of PsA. Further studies on the utility of CASPAR criteria in patients with JIA are needed.

A Rare Case of Juvenile Psoriatic Arthritis

This is a case report of a one-year-and-nine-month-old girl with multiple guttate psoriasis skin lesions, non-traumatic knee arthritis, and no family history of autoimmune diseases. Laboratory tests revealed no suggestive markers of juvenile psoriatic arthritis (JPsA), while the dermatological examination described scaly erythematous lesions with a positive Auspitz sign. The diagnosis was confirmed by a skin biopsy and histopathological examination. The psoriasis lesions were preceded by the onset of arthritis within two weeks. The negative family history, age of onset, clinical presentation, and negative antinuclear antibodies make it a particular case of JPsA.

Do the features of juvenile psoriatic arthritis change according to age? A comprehensive evaluation of the PeRA Research Group Registry

OBJECTIVES

To describe the clinical features and treatment outcomes of children with juvenile psoriatic arthritis (JPsA) and compare the distinct patterns of the disease between early-onset and late-onset age groups.

METHODS

Patients with JPsA followed regularly for at least 6 months between 2010 and 2020 in seven paediatric rheumatology centres in Turkey were included in the study. The demographic features, clinical manifestations, treatment strategies and outcomes of the patients were evaluated retrospectively.

RESULTS

A total of 87 (46 male/41 female) patients were included in the study. The mean age at diagnosis was 11.9 years (s.d. 4.5). Fifty-seven (65.5%) patients had psoriasis at the time of diagnosis and arthritis preceded psoriasis in 10 (11.5%) patients. Thirty (34.5%) patients had dactylitis, 28 (32.2%) had nail pitting, 36 (41.4%) had involvement of the small joints and 20 (23%) had enthesitis. Sacroiliitis was detected in 11 (12.6%) patients by MRI. ANA was positive in 35 (40.2%) patients. Twelve children (13.8%) were in the early-onset (<5 years) group. Uveitis and ANA positivity were more common in the early-onset group. Active joint counts and activity scores of our patients showed significant improvement at month 6 and at the last control compared with baseline.

CONCLUSION

About one-third of patients with JPsA do not have psoriasis at the time of diagnosis. In some patients, no skin lesion is seen during the course of the disease. Children with PsA seem to display two different phenotypes. Younger children have a female predominance, ANA positivity and uveitis, while older children have more axial involvement.

The impact of psoriasis on wellbeing and clinical outcomes in juvenile psoriatic arthritis

OBJECTIVES

Juvenile PsA (JPsA) has varied clinical features that are distinctive from other JIA categories. This study investigates whether such features impact patient-reported and clinical outcomes.

METHODS

Children and young people (CYP) were selected if recruited to the Childhood Arthritis Prospective Study, a UK multicentre JIA inception cohort, between January 2001 and March 2018. At diagnosis, patient/parent-reported outcomes (as age-appropriate) included the parental global assessment (10 cm visual analogue scale), functional ability (Childhood Health Assessment Questionnaire (CHAQ)), pain (10 cm visual analogue scale), health-related quality of life (Child Health Questionnaire PF50 psychosocial score), mood/depressive symptoms (Moods and Feelings Questionnaire) and parent psychosocial health (General Health Questionnaire 30). Three-year outcome trajectories have previously been defined using active joint counts, physician and parent global assessments (PGA and PaGA, respectively). Patient-reported outcomes and outcome trajectories were compared in (i) CYP with JPsA vs other JIA categories and (ii) CYP within JPsA, with and without psoriasis via multivariable linear regression.

RESULTS

There were no significant differences in patient-reported outcomes at diagnosis between CYP with JPsA and non-JPsA. Within JPsA, those with psoriasis had more depressive symptoms (coefficient = 9.8; 95% CI: 0.5, 19.0) than those without psoriasis at diagnosis. CYP with JPsA had 2.3 times the odds of persistent high PaGA than other ILAR categories, despite improving joint counts and PGA (95% CI: 1.2, 4.6).

CONCLUSION

CYP with psoriasis at JPsA diagnosis report worse mood, supporting a greater disease impact in those with both skin and joint involvement. Multidisciplinary care with added focus to support wellbeing in children with JPsA plus psoriasis may help improve these outcomes.

Existing and Emerging Targeted Therapies in Juvenile Psoriatic Arthritis: Challenges and Unmet Needs

Juvenile psoriatic arthritis (JPsA) is a heterogeneous type of non-systemic chronic inflammatory arthritis affecting children and young people. This review focuses on highlighting challenges in harmonising recommendations for the use of available therapies in JPsA, according to its distinct clinical phenotypes, and explores the similarities and differences between the disease classification and management across age. We further explore the emerging therapeutic landscape, summarising the recently completed clinical trials in JPsA, and ongoing studies in both JPsA and adults with psoriatic arthritis, highlighting unmet needs and barriers for translational research in JPsA. The novel therapeutic agents in clinical development in JPsA range from monoclonal antibodies targeting interleukin (IL)-17, IL-12/23 and IL-23 blockades to synthetic small molecules targeting Janus kinase and tyrosine kinase and phosphodiesterase-4 inhibition. In addition, there are head-to-head clinical trials comparing tumour necrosis factor-α blockade with both IL-17 and IL-23 inhibition. Most of these new therapies have been tested in adults with psoriatic arthritis and have advanced to the phase III stage of drug development or received license for use, suggesting promising signals for efficacy and potentially acceptable safety and tolerability for JPsA. Further translational research in JPsA is required to improve our understanding of the impact of age at onset on treatment efficacy, as well as to provide opportunities for better management of refractory disease and improved long-term outcomes in JPsA, for ultimate patient benefit.

Pediatric Psoriasis with or without Arthritis: Does It Make a Difference?

BACKGROUND

Psoriasis and psoriatic arthritis can present simultaneously or separately in children and may pose a diagnostic challenge.

OBJECTIVE

To compare the dermatological manifestations in pediatric psoriatic patients with and without arthritis.

METHODS

A retrospective case-control study of psoriatic patients ≤ 18 years old at Sheba Medical Center was conducted between 2011 and 2021. Patients with psoriatic arthritis versus psoriasis-only were compared according to body surface area (BSA) involvement, cutaneous distribution, severity of skin disease, response to treatment and related side effects.

RESULTS

The study cohort included 29 psoriatic arthritis and 64 psoriasis-only patients matched by age and sex. The psoriasis-only group had a significantly higher mean BSA (19.7%, SD ± 18.7) than the psoriatic arthritis group (6.1%, SD ± 11.4), (p = 0.029). The skin distribution differed with the psoriasis group showing more involvement of the extremities, scalp, trunk, and genitals. Both groups primarily experienced partial responses to methotrexate, whereas the psoriasis group mainly saw complete responses to biologics. Adverse events were rare, with a higher incidence in the psoriasis group.

CONCLUSION

This retrospective study highlights the differences in cutaneous disease characteristics, severity, and treatment response in pediatric patients with psoriasis and psoriatic arthritis, providing valuable insights for diagnosis and disease course in the pediatric population.

Psoriatic arthritis of the temporomandibular joint: A systematic review

OBJECTIVES

Psoriasis is an inflammatory condition brought on by the immune system. This study aimed to perform a systematic review related to psoriatic arthritis (PsA) of the temporomandibular joint (TMJ).

METHODS

The search strategy was developed by a radiologist expert with more than 20 years of experience. The search was performed without time restrictions in five electronic databases: PubMed, Web of Science, Embase, Scopus and Ovid. The search strategy was based on MeSH and Emtree terms. The methodological quality of the studies was rated using the quality assessment tools from the National Heart Lung and Blood Institute (NHLBI).

RESULTS

Twenty-three publications were included, 10 being case reports. One hundred-fifty-one patients with TMJ PsA were reported. Psoriasis evolution ranged from 1.5 years to 24 years. Clinical symptoms of TMJ involvement included: TMJ pain and sounds, limited range of jaw movements, preauricular swelling, malocclusion, headache, tinnitus, neck stiffness and altered dietary function. TMJ was evaluated by magnetic resonance imaging (six studies), computed tomography (eight articles) and by ultrasonography findings (two articles). For TMJ treatment, topical and systemic medication was reported in 11 studies. Five studies included patients needing surgical procedures for TMJ ankylosis.

CONCLUSIONS

A relationship between TMD and psoriasis has been revealed. TMJ PsA has been investigated and debated, although the radiographic findings or clinical symptoms of PsA are not noticeably different from other forms of TMJ arthritis. Conservative therapy can lead to significant improvement of TMJ function.

Juvenile Psoriatic Arthritis: Myth or Reality? An Unending Debate

Juvenile psoriatic arthritis (JPsA) accounts for 1-7% of all cases of juvenile idiopathic arthritis (JIA) and its definition has been a matter of controversy among pediatric rheumatologists for many years. The traditional attribution of JPsA to the spondyloarthropathy group was challenged in the early 1990s, whereas the recent demonstrations of its heterogenous nature have led to questions about its identification as a distinct category in JIA classification. It has been shown that children with the phenotype of JPsA can be divided in two subgroups, one presenting with the features of early-onset ANA-positive JIA, and another that belongs to the spectrum of spondyloarthropathies. The few studies that have compared the clinical characteristics and genetic determinants of JPsA with those of the other JIA categories have obtained contrasting findings. The debate on the categorization of JPsA as a distinct entity within JIA classification is still ongoing and has prompted the revision of its current classification.

Bilateral Granulomatous Iridocyclitis Associated with Early-Onset Juvenile Psoriatic Arthritis

PURPOSE

The purpose of this study is to report on a case of bilateral granulomatous iridocyclitis in a patient with early-onset juvenile psoriatic arthritis (JPsA).

METHODS

The method used is an observational case report. Observations. A 3-year-old Hispanic girl was sent to our uveitis service for further evaluation of her granulomatous uveitis. The initial ophthalmologic examination revealed bilateral band keratopathy, large mutton-fat keratic precipitates, multiple posterior synechiae, and 4+ anterior chamber cells. The physical exam was notable for left knee edema and right axillary rash. Laboratory testing was remarkable for an erythrocyte sedimentation rate of 80 mm/h, positive antinuclear antibodies (1 : 1, 280), and negative human leukocyte antigen B27. A cutaneous biopsy was obtained, which confirmed the diagnosis of a psoriatic rash. Treatment with oral prednisolone and topical prednisolone acetate with atropine sulfate resulted in the complete resolution of the uveitis. Conclusion and Importance. Bilateral granulomatous iridocyclitis may be a rare presentation of ocular involvement in patients with early-onset JPsA.

Similarities and Differences Between Juvenile and Adult Spondyloarthropathies

Spondyloarthritis (SpA) encompasses a broad spectrum of conditions occurring from childhood to middle age. Key features of SpA include axial and peripheral arthritis, enthesitis, extra-articular manifestations, and a strong association with HLA-B27. These features are common across the ages but there are important differences between juvenile and adult onset disease. Juvenile SpA predominantly affects the peripheral joints and the incidence of axial arthritis increases with age. Enthesitis is important in early disease. This review article highlights the similarities and differences between juvenile and adult SpA including classification, pathogenesis, clinical features, imaging, therapeutic strategies, and disease outcomes. In addition, the impact of the biological transition from childhood to adulthood is explored including the importance of musculoskeletal and immunological maturation. We discuss how the changes associated with adolescence may be important in explaining age-related differences in the clinical phenotype between juvenile and adult SpA and their implications for the treatment of juvenile SpA.

Paediatric non-infectious uveitis in Cape Town, South Africa: a retrospective review of disease characteristics and outcomes on immunomodulating treatment

BACKGROUND

Non-infectious uveitis is a well-reported cause of blindness in more developed countries, however data from sub-Saharan Africa is lacking. Here we aim to describe the diseases associated with paediatric non-infectious uveitis and the effect of currently available treatment in this setting.

METHODS

A retrospective observational analysis of children with non-infectious uveitis from January 2010 to December 2017, attending the tertiary paediatric rheumatology and ophthalmology referral units in Cape Town was conducted. Statistical analysis utilising STATA13 software was performed with p < 0.05 considered significant.

RESULTS

Twenty-nine children were identified: median age at first visit of 74 months (IQR 49-86 months), female to male ratio of 0.9:1, predominantly of mixed ancestry (72.4%). Juvenile idiopathic arthritis associated uveitis (JIAU) (48.3%), idiopathic uveitis (41.4%), sarcoidosis (6.9%) and Behcet's disease (3.5%) were diagnosed. Chronic anterior uveitis (72.4%) was the most frequent finding. Fifty-five percent had complications at presentation and all children with idiopathic uveitis presented with cataracts. Only 6.5% of the JIA cohort had JIAU. All JIA children had chronic anterior uveitis. There were no differences between JIA children with uveitis and those without uveitis, for sex (p = 0.68) and race (p = 0.58). Significantly, children with uveitis presented at an overall younger age (p = 0.008), had oligo-articular JIA (p = 0.01) and were antinuclear antibody positive (p < 0.001). Children with idiopathic uveitis were predominantly male (66.6%) with chronic anterior uveitis (41.7%). Nineteen children (65.5%) in the cohort had inactive disease on treatment at 12 months from diagnosis, which included 10 on topical corticosteroid therapy. At the last clinical visit 17 (58.6%) on standard initial therapy, 8 (27.6%) on tumour necrosis factor inhibitors and 2 on additional DMARDs were in remission. Five of these children still required topical corticosteroids. Surgery was performed in 41.4%, primarily in the idiopathic group. Visual acuity improved or was maintained on treatment.

CONCLUSION

Current practice seems to detect children with potentially sight-threatening disease but the high rate of complications and the low percentage of children with JIAU raises concerns of delayed healthcare intervention. Tumour necrosis factor inhibitors have improved outcomes in refractory cases in this cohort, however further studies are needed.

Enthesitis Related Arthritis in a Longitudinal Southeast Asian Registry: High Prevalence of HLA-B27, Different Sacroiliitis Risk Factors and Less Common Drug-Free Remission

Objective. To describe the clinical characteristics, predictors and treatment of children with Enthesitis Related Arthritis (ERA) in a Singapore longitudinal cohort over 11 years. Methods. ERA patients were recruited from our registry (2009–2019). Nonparametric descriptive statistics including median (interquartile range, IQR) were used to describe data. Kaplan–Meier survival and logistic/Cox regression analyses were used to estimate the probabilities and determine predictors of clinical variables, respectively. The significance level was set at <0.05. Results. One hundred and forty-six ERA patients (87% male, 82% Chinese) were included. Median onset age was 11.9 years (IQR 9.4–14.0) and median disease duration was 4.9 years (IQR 2.6–8.3). Family history of Human Leukocyte Antigen (HLA)-B27 associated diseases was positive in 7.5%. Acute uveitis occurred in 3.4%. Oligoarthritis was present in 89.7%. Hip, knee and ankle joints were among the most common joints involved. One-fourth had enthesitis at diagnosis (Achilles tendon entheses, 82.9%). Sacroiliitis occurred in 61%. Probabilities of sacroiliitis development were 0.364, 0.448 and 0.578 at 1, 2 and 5 years after onset, respectively. Negative HLA-B27, female, older age at onset and hip arthritis at diagnosis were associated with shorter time for sacroiliitis development (p = 0.001–0.049). Methotrexate (MTX) remained the most common disease modifying anti-rheumatic drug (DMARD) used (77.4%). However, 77.9% required anti-TNF (aTNF) therapy secondary to MTX failure. Among MTX-treated sacroiliitis patients, 85.3% failed, requiring aTNF, as compared to 63.2%patients without axial disease. Longer duration to diagnosis (p = 0.038) and MTX use (p = 0.007) predicted aTNF therapy. None had joint deformity. Conclusions. This study underscores differences in ERA clinical characteristics, predictors and treatment responses. Our ERA population had many unique findings but good functional outcomes.

Comparison of paediatric and adult classification criteria in juvenile idiopathic arthritis during the transition from paediatric to adult care

OBJECTIVES

To determine the characteristics of juvenile idiopathic arthritis (JIA) patients seen during the transition period in order to compare paediatric classification criteria with those for adults.

METHODS

Patients with JIA according to the ILAR classification and who had a consultation at transition between 2010 and 2017 were included in a retrospective bi-centre (Lyon, Lausanne) study. JIA classification criteria were compared to ACR/EULAR 2010 criteria for rheumatoid arthritis (RA), Yamaguchi criteria for adult-onset Still's disease (AOSD), ASAS criteria for spondyloarthritis and CASPAR criteria for psoriatic arthritis.

RESULTS

One hundred and thirty patients were included: 13.9% with systemic JIA, 22.3% with polyarticular JIA, 22.3% with oligoarticular JIA, 34.6% with enthesitis-related arthritis (ERA) and 6.9% with psoriatic arthritis; 13.1% had suffered from uveitis; 14.5% of patients had erosions or carpitis, mainly those with psoriatic arthritis, polyarticular or systemic JIA; 37.5% of patients with ERA displayed radiological sacroiliitis. When comparing paediatric JIA criteria with adult classifications, we found that: 66.6% of patients with systemic JIA fulfilled the criteria for AOSD, 87.5% of rheumatoid factor-positive polyarticular JIA and 9.5% of rheumatoid factor-negative polyarticular JIA met the criteria for RA, and 34.5% of oligoarticular JIA fulfilled the criteria for spondyloarthritis. Finally, 77.7% of patients with ERA met the criteria for spondyloarthritis, and 100% of patients with psoriatic arthritis JIA met the criteria for psoriatic arthritis.

CONCLUSION

Oligoarticular JIA and rheumatoid factor-negative polyarticular JIA seem to be paediatric entities, whereas the other types of JIA tended to meet the respective adult classification criteria.

Enthesitis-related arthritis: current perspectives

In this narrative review, we overview the recent literature on enthesitis-related arthritis (ERA). For the purpose of our review, we searched Scopus for recent articles on this subject from 2013 onward, including some classic older articles for perspective. ERA is a juvenile idiopathic arthritis (JIA) subtype more common in males, associated in a majority with human leucocyte antigen B27. Such children generally present with asymmetric oligoarthritis or polyarthritis, predominantly of lower limb joints, associated with enthesitis or sacroiliitis. While diagnosis remains clinical, ultrasound is being increasingly used to detect subclinical enthesitis and for guiding entheseal site injections. Spine MRI can help detect sacroiliitis, inflammatory spinal changes, and pelvic sites of enthesitis in such patients. The recent juvenile spondyloarthropathy disease activity index recognizes the key clinical features of ERA, viz enthesitis and inflammatory back pain, which other disease activity indices used in JIA did not include. Management includes NSAIDs with physical therapy. Conventional disease-modifying agents like sulfasalazine and methotrexate may be used to minimize duration of NSAID use and in those with high inflammatory burden. In patients refractory to these drugs, biologics such as antitumor necrosis factor alpha agents have proven useful, based on evidences from randomized controlled trials and retrospective registry analyses. Factors predicting a poorer outcome in such children include hip or ankle involvement or restricted spinal mobility. Considering that children with ERA have overall poorer long-term outcomes than other subtypes of JIA, there is a need to further optimize therapeutic strategies for such patients.

Adiposity in Juvenile Psoriatic Arthritis

OBJECTIVE

Adult patients with psoriatic arthritis are at increased risk for obesity and metabolic syndrome, but data regarding adiposity in children with juvenile psoriatic arthritis (JPsA) are limited. Our study assessed adiposity in children with JPsA in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry.

METHODS

Patients with JPsA in the CARRA registry were divided into nonoverweight and overweight groups using recommendations from the US Centers for Disease Control, and differences in demographic and clinical characteristics between groups at baseline and after 1-year followup were assessed using chi-square test, Fisher's exact test, T test, or Mann-Whitney U test, as appropriate. The prevalence of overweight status in the JPsA registry patients was compared to rheumatoid factor-positive and -negative polyarticular juvenile idiopathic arthritis (RF+polyJIA; RF-polyJIA) registry cohorts and the US pediatric population, using a chi-square goodness-of-fit test.

RESULTS

Overweight children represented 36.3% of this JPsA cohort (n = 320). Compared to nonoverweight children, they were significantly older at symptom onset and rheumatologist's first assessment, and scored significantly worse on patient/physician outcome measures. At 1-year followup, changes in body mass index were not associated with changes in clinical features or outcome measures. The prevalence of overweight and obesity in patients with JPsA was significantly higher than in RF+polyJIA patients, RF-polyJIA patients, and the US pediatric population.

CONCLUSION

In this registry, almost 1 in 5 patients with JPsA were obese and more than one-third were overweight. This is significantly more than expected compared to the US pediatric population, and appropriate longterm followup of this JPsA subgroup is warranted.

Psoriasis and associated variables in classification and outcome of juvenile idiopathic arthritis - an eight-year follow-up study

BACKGROUND

To study the impact of psoriasis and features associated with psoriasis on classification and outcome in a population-based follow-up cohort of children with juvenile idiopathic arthritis (JIA).

METHODS

In all, 440 children with JIA were followed for a median of 8 years in a prospective Nordic population-based cohort study. Data for remission was available for 427 of these children. The presence of psoriasis, psoriasis-like rash, dactylitis, nail pitting, enthesitis, tenosynovitis and heredity was assessed in relation to ILAR classification and remission.

RESULTS

Clinical findings associated with psoriasis developed consecutively during the 8-year period. Six of 14 children with psoriasis were not classified as juvenile psoriatic arthritis according to the ILAR criteria at 8 year follow-up. Dactylitis was more common in children with early onset of JIA. After 8 years we found a cumulative median number of eleven arthritic joints in children with psoriasis or psoriasis-like rash compared with six in the rest of the cohort (p = 0.02). Also, the chance for not being in remission after 8 years increased significantly in patients with psoriasis, psoriasis-like rash or at least two of: 1) first-degree heredity for psoriasis or psoriatic arthritis, 2) dactylitis or 3) nail pitting, compared with the rest of the group (OR 3.32, p = 0.010).

CONCLUSIONS

Our results indicate a more severe disease over time in psoriasis-associated JIA, as features of psoriasis develop during the disease course. This group is a major challenge to encompass in a future JIA classification in order to facilitate early tailored treatment.

The Juvenile Psoriatic Arthritis Cohort in the CARRA Registry: Clinical Characteristics, Classification, and Outcomes

Objective.

Children with clinically diagnosed juvenile psoriatic arthritis (JPsA) who were enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry (CARRA-JPsA) were classified according to pediatric International League of Associations for Rheumatology (ILAR) and adult criteria [Classification criteria for Psoriatic Arthritis (CASPAR)]. Data on demographic and clinical features at baseline and 1-year followup were analyzed and compared.

Methods.

Cross-sectional analysis was performed of CARRA-JPsA patients enrolled between May 2010 and December 2013 and stratified according to age at disease onset (≤ or > 4 yrs). Features of patients fulfilling ILAR and CASPAR criteria were compared at baseline and followup using chi square, Fisher’s exact, Mann-Whitney-McNemar, Wilcoxon signed rank, and t tests, as appropriate.

Results.

Among 361 children enrolled as CARRA-JPsA, 72.02% had symptom onset at > 4 years of age, with a male predominance and high prevalence of enthesitis. At followup, statistically significant improvements were reported in arthritis, dactylitis, enthesitis, psoriasis, sacroiliitis, and nail pitting, but not in health questionnaire (HQ) scores. Of the patients, 80.5% fulfilled ILAR criteria for JPsA. Fifty-two patients, whose disease fulfilled CASPAR criteria but had not been included in the JPsA cohort, manifested more enthesitis, sacroiliitis, inflammatory bowel disease and uveitis and less psoriasis.

Conclusion.

The data support division of patients with JPsA into 2 clinical subgroups, according to age at disease onset. Improvement in objective findings did not correlate with changes in HQ scores. Pediatric rheumatologists currently do not diagnose JPsA in all children whose disease manifestations meet CASPAR criteria. Unification of adult and pediatric PsA classification criteria warrants consideration.

A better understanding of juvenile idiopathic arthritis with classification criteria

Juvenile idiopathic arthritis, JIA, is a novel rheumatic disease in childhood introduced by the International League of Associations for Rheumatology. It is defined as a chronic, inflammatory disorder of unknown etiology, which is classified into seven categories; systemic-onset type, persistent and extended oligoarthritis, polyarthritis with rheumatoid factor negative, polyarthritis with rheumatoid factor positive, psoriatic arthritis, enthesitis-related arthritis and undifferentiated arthritis. As each category of JIA has different features in clinical phenotypes, precise subtyping is required for research and management. However, some modifications to the criteria might be helpful for getting better answers in diagnosis because of ethnical difference in prevalence and subtype distribution. Actually in Japanese population, a unique subset "B27-negative polyenthesitis" termed by Shichikawa should be included in enthesitis-related arthritis of JIA as a different type of enthesitis from B27-positive counterpart of spondyloarthritis in adulthood. Deep insights into the classification criteria will be needed for the better understanding of JIA.

Psoriasis in children

The clinical presentation, disease associations, and diverse treatment modalities in overcoming the challenges of managing pediatric psoriasis have been extensively summarized in this article. An extensive literature review revealed the differences in presentation of psoriasis during infancy, childhood, and adolescence. We also summarized the latest topical, systemic, and biological modalities in treating recalcitrant psoriasis. The association of psoriasis with juvenile arthritis and obesity and the significant influence of the disease on the children's quality of life were explored. The clinical presentation of psoriasis can evolve during the child's lifespan. While many treatment modalities already exist for treating pediatric psoriasis, some of the new biologics that are approved for adult patients have not been investigated in the pediatric population and no algorithm exists for their use in this population. Large clinical studies in the future will enhance our understanding with regards to their safety and potential implications in pediatric populations.

Assessment of Sacroiliitis at Diagnosis of Juvenile Spondyloarthritis by Radiography, Magnetic Resonance Imaging, and Clinical Examination

OBJECTIVE

To evaluate the prevalence of sacroiliitis at diagnosis of juvenile spondyloarthritis (SpA) and the accuracy of physical examination and back pain to detect sacroiliitis, using imaging as the reference standard.

METHODS

We performed a prospective cross-sectional study of 40 children with newly diagnosed juvenile SpA and 14 healthy controls. Subjects were assessed using physical examination, anteroposterior pelvic radiograph, and pelvic magnetic resonance imaging (MRI). Differences in clinical features between those children with and without sacroiliitis were assessed by Fisher's exact test for categorical variables and Wilcoxon's rank sum test for continuous variables. Accuracy of physical examination and back pain for detection of sacroiliitis was determined using MRI as the reference standard. Predicted probability of sacroiliitis was determined using exact multivariate logistic regression.

RESULTS

Eight children (20%) with juvenile SpA had active sacroiliitis. Of those subjects with active changes on MRI, 7 of 8 (88%) also had evidence of erosions or sclerosis. Five children (13%) with juvenile SpA and 1 control (7%) had nonperiarticular bone marrow edema. Of the subjects with active sacroiliitis, only 3 (38%) reported a history of back pain or tenderness on palpation of the sacroiliac joints. The positive and negative predictive values of clinical examination features and back pain for detection of sacroiliitis were low. The estimated probability of having sacroiliitis was 0.84 (95% confidence interval 0.40-1.00) in HLA-B27-positive patients with an elevated C-reactive protein (CRP) level.

CONCLUSION

Active sacroiliitis by MRI is common at diagnosis in juvenile SpA and is frequently asymptomatic. Children who are HLA-B27-positive and have elevated CRP levels have the highest probability of sacroiliitis.

Enthesitis-related arthritis: time to re-define?

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood. Enthesitis-related arthritis (ERA) is one of the seven JIA subtypes classified by the International League of Associations for Rheumatology (ILAR). Due to inclusion and exclusion criteria, a pitfall of the ERA category is that it does not include all subsets of juvenile spondyloarthropathy, with many children ending up in the undifferentiated category. The ERA nomenclature also does not have a method for distinguishing between axial and peripheral disease, two phenotypes which vary in presentation and treatment requirements. This distinction is very important given the overall poor prognosis seen in ERA patients, specifically in those with axial involvement. Since axial involvement is more common and presents earlier than previously thought in ERA, the pediatric rheumatology community should develop more accurate and sensitive classification criteria based on disease course to assist in improving timely diagnosis and appropriate management.

Judicious use of biologicals in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disorder that may cause joint destruction. Biological treatments targeting specific cytokines and cell interactions have transformed the outcomes of JIA. This review focuses on the selection of patients for and the timing and selection of biological treatment in JIA. Tumor necrosis factor (TNF) inhibitors remain the first choice for polyarticular JIA, followed by abatacept and tocilizumab. Monoclonal-antibody TNF inhibitors and abatacept are usually chosen for methotrexate-resistant uveitis. Recent clinical trials of canakinumab, rilonacept, and tocilizumab have obtained great improvement in both systemic and arthritic features in chronic systemic JIA patients. Current guidelines support the early use of a short-acting IL-1 antagonist for macrophage activation syndrome, a life-threatening complication. TREAT and ACUTE studies suggest that a therapeutic window of opportunity during early disease may exist in JIA. Early initiation of biological therapy may be associated with slower progression of joint damage and longer remission.

Enthesitis as a component of dactylitis in psoriatic juvenile idiopathic arthritis: histology of an established clinical entity

CONTEXT

Imaging of dactylitis in adult psoriatic arthritis suggests a pathophysiological role for enthesitis. However, histological definition of the dactylitic digit is unavailable.

OBJECTIVE

We evaluated the role of enthesitis in dactylitis associated with psoriatic juvenile idiopathic arthritis (psJIA) in a child who underwent detailed imaging and histologic evaluation.

DESIGN

Radiographs, ultrasound and high-resolution magnetic resonance imaging were employed to define the locus of disease in two dactylitic digits from a 14-year-old girl with psJIA. Biopsies were stained with hematoxylin and eosin, CD3, CD20, CD4, CD8 and CD117 and examined via light microscopy.

RESULTS

Radiologic features of dactylitis included enhanced signal at digital entheses without accompanying synovitis or tenosynovitis. Histologically, finger and toe tissue exhibited hypervascular tenosynovium with a fibromyxoid expansion of fibrous tissue. This was accompanied by sparse to moderate perivascular lymphocytic inflammation consisting predominantly of T cells, with occasional admixed B cells and mast cells. Neutrophils and plasma cells were absent. Fibrocartilage exhibited reactive features including increased extracellular myxoid matrix, binucleation, and focal necrosis, without cellular inflammation. Fibrinous synovitis and mild reactive synoviocyte hyperplasia were seen.

CONCLUSIONS

Dactylitis in psJIA bears a radiographic resemblance to the condition in adult psoriatic arthritis. Histologic hallmarks include an expanded mast cell-populated extracellular myxoid matrix, cartilage degeneration, and a T cell-rich perivascular inflammatory infiltrate. These findings help to define enthesitis as a clinicopathologic entity.

Muscle MRI in muscular dystrophies

Muscle MRI has become a very useful tool in the diagnosis and follow-up of patients with muscle dystrophies. Muscle MRI provides us about many aspects of the structure and function of skeletal muscles, such as the presence of oedema or fatty infiltration. In the last years many reports have described the particular muscles that are involved in these muscle disease. This knowledge can facilitate the diagnosis in many cases. In the present paper we review the main changes observed in muscle MRI of patients with muscle dystrophies.

Psoriasis in Children and Adolescents: Diagnosis, Management and Comorbidities

Psoriasis is a common chronic immune-mediated inflammatory skin disorder and begins in childhood in almost one-third of the cases. Although children present with the same clinical subtypes of psoriasis seen in adults, lesions may differ in distribution and morphology, and their clinical symptoms at presentation may vary from those reported by adult patients. Nevertheless, diagnosis of psoriasis is primarily based on clinical features. Pediatric psoriasis can have a profound long-term impact on the psychological health of affected children. Additionally, pediatric psoriasis has been associated with certain comorbidities, such as obesity, hypertension, hyperlipidemia, diabetes mellitus and rheumatoid arthritis, making early diagnosis and management essential. As guidelines are lacking and most (systemic) treatments are not approved for use in children, treatment of pediatric psoriasis remains a challenge. A prospective, multicenter, international registry is needed to evaluate these treatments in a standardized manner and ultimately to develop international guidelines on pediatric psoriasis. This article reviews current concepts in pediatric psoriasis including epidemiology, clinical features, diagnosis, the role of topical and systemic agents and the association with other morbidities in childhood.

Analysis of Clinical Symptoms and Laboratory Profiles in Children with Juvenile Idiopathic Arthritis in Malopolska Region (Poland) in the Years 2007-2010

Background: Juvenile idiopathic arthritis (JIA) is a heterogenic group of chronic inflammatory connective tissue diseases of unknown aetiology in children up to 16 years of age.Aim: The aim of this study was to analyse the incidence, clinical presentation and laboratory findings in children with JIA in Malopolska region.Materials and methods: A retrospective analysis included all children with JIA (N=251) hospitalized in the two reference rheumatology centres covering Malopolska region (Poland), between July 2007 and December 2010.Results: The annual incidence of JIA in Malopolska region was estimated at 9.5 per 100 000 children. Oligoarthritis (54.9%) was the most common category in all age groups with a tendency to decrease with age; from 71.4 % in children aged 1-6 years; 55.7% in aged 7-12 years to 39.3 % in aged 13-16 years. The frequency of polyarthritis and enthesitis-related arthritis was greater in adolescents (29.2 % and 22.5 %, respectively). HLA-B27 antigen and uveitis were most frequently found in children with enthesitis-related arthritis (58% and 18.5 %, respectively).Conclusions: The study suggests the improvement of diagnostic capacity of JIA during the last decade in Poland. In accordance with the existing data diverse clinical presentation of JIA categories and laboratory characteristics were proven.

Disease of the year: juvenile idiopathic arthritis-associated uveitis--classification and diagnostic approach

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease and the most common systemic association of uveitis in children. JIA is subdivided into seven clinically more homogeneous subtypes, using the International League of Associations for Rheumatology (ILAR) classification system: systemic arthritis, oligoarthritis, rheumatoid factor (RF)-negative polyarthritis, RF-positive polyarthritis, psoriatic arthritis, enthesitis-related arthritis, and undifferentiated arthritis. Uveitis is very rare in patients with systemic onset JIA and in patients with juvenile-onset rheumatoid arthritis. Patients with early-onset antinuclear antibody (ANA)-positive oligoarticular JIA have the highest risk of developing chronic iridocyclitis. Ocular involvement in enthesitis-related arthritis is characterized by recurrent acute symptomatic iridocyclitis. The diagnosis and differential diagnosis of JIA are based on history, physical examination, and laboratory investigations, including complete blood count, acute-phase reactants, ANA, RF, HLA-B27, and musculoskeletal imaging studies. Recent studies have revealed distinct gene expression profiles that may be useful in the diagnosis, classification, and follow-up of JIA patients.

Clinical Trial Study in the Treatment of Nail Psoriasis with Pulsed Dye Laser

Abstract Objective: The treatment options for nail psoriasis have been limited, and the management of nail psoriasis has been challenging for physicians. This study aimed at evaluating the effect of different pulse durations in the treatment of nail psoriasis with the 595-nm PDL to determine the optimal pulse duration. Methods: Forty patients with bilateral fingernail psoriasis were recruited and completed a 6-month trial. PDL was applied on the proximal and lateral nailfolds based on random assignment. Eghity nails were treated with 6-millisecond pulse duration and 9 J/cm(2) whereas 80 nails were treated with 0.45-millisecond pulse duration and 6 J/cm(2). Nail Psoriasis Severity Index (NAPSI) was used to assess the clinical outcome from pretreatment and posttreatment photographs. Results: After 6 months of first treatment, there was a significant reduction in overall NAPSI, nail matrix NAPSI, and nail bed NAPSI scores from baseline in both groups; however, no significant difference was found between the two pulse duration groups. Side effects were mild including transient petechiae and hyperpigmentation. Conclusion: Both the longer 6-millisecond and shorter 0.45-millisecond pulses of PDL (595 nm) have been clinically proven to be effective for the treatment of nail matrix and nail bed psoriasis.