Recent advances in understanding and managing psoriatic arthritis

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.

Real-World Treatment Patterns, Clinical Outcomes, and Symptom Burden in Patients With Psoriatic Arthritis Prescribed Ixekizumab in the United States

OBJECTIVE

The objective of this study was to describe the real-world characteristics and clinical status of patients with psoriatic arthritis (PsA) currently prescribed ixekizumab.

METHODS

Data were drawn from the Adelphi PsA Plus Disease Specific Programme (DSP), a cross-sectional survey conducted in the United States between September 2021 and March 2022. Rheumatologists provided data for their next five consulting patients currently receiving ixekizumab, including demographic and clinical characteristics, disease severity, treatment history, reasons for treatment choice, satisfaction with current treatment, and current and historic symptom burden. Patients voluntarily completed questionnaires, providing perceptional data on symptom burden and satisfaction with current treatment.

RESULTS

Overall, 68 rheumatologists provided data on 275 patients with PsA, 90 of whom completed the voluntary questionnaire. Patients had been prescribed ixekizumab for a mean of 11.7 (SD 10.6) months. Clinical characteristics, disease severity, and symptom burden of patients with PsA improved significantly from ixekizumab initiation to the most recent consultation, including symptom burden, tender and swollen joint counts, and body surface area affected by psoriasis (all P < 0.001). Both rheumatologists and patients were satisfied with ixekizumab treatment and reported improvements in pain and fatigue. Improvements were noted after more than three months of ixekizumab treatment duration and regardless of whether the patients had prior exposure to an advanced therapy or were treatment naïve.

CONCLUSION

Our results indicate that ixekizumab was efficacious in the treatment of PsA in real-world clinical practice, complementing efficacy data from randomized controlled clinical trials. The results of this study may assist rheumatologists and their patients in making informed treatment choices.

Psoriasis and Psoriatic Arthritis-Associated Genes, Cytokines, and Human Leukocyte Antigens

In recent years, research has intensified in exploring the genetic basis of psoriasis (PsO) and psoriatic arthritis (PsA). Genome-wide association studies (GWASs), including tools like ImmunoChip, have significantly deepened our understanding of disease mechanisms by pinpointing risk-associated genetic loci. These efforts have elucidated biological pathways involved in PsO pathogenesis, particularly those related to the innate immune system, antigen presentation, and adaptive immune responses. Specific genetic loci, such as TRAF3IP2, REL, and FBXL19, have been identified as having a significant impact on disease development. Interestingly, different genetic variants at the same locus can predispose individuals to either PsO or PsA (e.g., IL23R and deletion of LCE3B and LCE3C), with some variants being uniquely linked to PsA (like HLA B27 on chromosome 6). This article aims to summarize known and new data on the genetics of PsO and PsA, their associated genes, and the involvement of the HLA system and cytokines.

Sex-oriented perspectives in immunopharmacology

Several immunopharmacological agents are effective in the treatment of cancer and immune-mediated conditions, with a favorable impact on life expectancy and clinical outcomes for a large number of patients. Nevertheless, response variation and undesirable effects of these drugs represent major issues, and overall efficacy remains unpredictable. Males and females show a distinct difference in immune system responses, with females generally mounting stronger responses to a variety of stimuli. Therefore, exploring sex differences in the efficacy and safety of immunopharmacological agents would strengthen the practice of precision medicine. As a pharmacological target highlight, programmed cell death 1 ligand 1 (PD-L1) is the first functionally characterized ligand of the coinhibitory programmed death receptor 1 (PD-1). The PD-L1/PD-1 crosstalk plays an important role in the immune response and is relevant in cancer, infectious and autoimmune disease. Sex differences in the response to immune checkpoint inhibitors are well documented, with male patients responding better than female patients. Similarly, higher efficacy of and adherence to tumor necrosis factor inhibitors in chronic inflammatory conditions including rheumatoid arthritis and Crohn's disease have been reported in male patients. The pharmacological basis of sex-specific responses to immune system modulating drugs is actively investigated in other settings such as stroke and type 1 diabetes. Advances in therapeutics targeting the endothelium could soon be wielded against autoimmunity and metabolic disorders. Based on the established sexual dimorphism in immune-related pathophysiology and disease presentation, sex-specific immunopharmacological protocols should be integrated into clinical guidelines.

Sex differences in the efficacy, safety and persistence of patients with psoriatic arthritis treated with tofacitinib: a post-hoc analysis of phase 3 trials and long-term extension

BACKGROUND

Evaluate the impact of sex on tofacitinib efficacy, safety and persistence (time to discontinuation) in patients with psoriatic arthritis (PsA).

METHODS

Data were pooled from two phase 3 randomised controlled trials. Patients were randomised to tofacitinib 5 mg or 10 mg two times per day, adalimumab 40 mg every 2 weeks or placebo. Efficacy outcomes to month 12 included American College of Rheumatology (ACR)20/50/70, minimal disease activity (MDA), Psoriasis Area Severity Index (PASI)75, change from baseline (∆) in Health Assessment Questionnaire-Disability Index (HAQ-DI) and ∆Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). Safety was assessed to month 12 and persistence was assessed to month 42 of a long-term extension study.

RESULTS

Overall, 816 patients were included (54.3% females). At baseline, higher tender joint counts, enthesitis scores and worse HAQ-DI and FACIT-F were reported in females versus males; presence of dactylitis and PASI were greater in males versus females. At month 3, tofacitinib efficacy generally exceeded placebo in both sexes. Overall, similar ACR20/50/70, PASI75, ∆HAQ-DI and ∆FACIT-F were observed for tofacitinib between sexes; females were less likely to achieve MDA. Similar proportions of males/females receiving tofacitinib (both doses) experienced treatment-emergent adverse events (AEs). Serious AEs occurred in 3.4%/6.6% and 4.0%/5.9% males/females with tofacitinib 5 mg and 10 mg two times per day. Persistence was generally similar between sexes.

CONCLUSION

Tofacitinib efficacy exceeded placebo in both sexes and was comparable between sexes. Consistent with previous studies of PsA treatments, females were less likely to achieve MDA, likely due to baseline differences. Safety and time to discontinuation were generally similar between sexes.

TRIAL REGISTRATION NUMBER

NCT01877668; NCT01882439; NCT01976364.

Impact of Physician-Defined Flares on Quality of Life and Work Impairment: An International Survey of 2238 Patients With Psoriatic Arthritis

OBJECTIVE

To describe psoriatic arthritis (PsA) flares and their effect on patient-reported outcomes (PROs).

METHODS

Cross-sectional surveys of rheumatologists/dermatologists and their patients with PsA were conducted in France, Germany, Italy, Spain, the United Kingdom, and the United States, capturing data on physician-reported patient flare status, demographics, PsA severity, and clinical outcomes. Patient-completed surveys captured data on PROs: 5-level EuroQol 5-dimension, Work Productivity and Activity Impairment questionnaire, Health Assessment Questionnaire-Disability Index, and 12-item Psoriatic Arthritis Impact of Disease questionnaire. Patients were compared by flare status using parametric and nonparametric tests. Multivariate regression was used to identify flare associations. Multivariate logistic regression adjusted for patient demographics and physician specialty assessed the effect of flare status.

RESULTS

Among 2238 patients (586 from the US, 1652 from Europe) managed by 572 physicians, physician-reported flare was present for 168 patients (7.5%), and self-reported flare was present for 95 patients (10% of available data). Mean (SD) flare count over 12 months was 2.2 (4.9), lasting on average 16.4 (16.2) days. Flare status was linked to worse PROs. Patients who had not flared in the last 12 months or had never flared had a higher quality of life, lower overall work impairment, and a lower degree of disability compared with patients who were currently experiencing a flare (all; P < 0.01).

CONCLUSION

Actively experiencing a flare adversely affected QOL, disability, and work productivity. PsA flares should be routinely assessed and managed in clinical care.

An overview of psoriatic arthritis including clinical manifestations, assessment, diagnostic criteria, investigations, drug management and GRAPPA guidelines

Psoriatic arthritis (PsA) is a chronic and often progressive inflammatory disease, occurring in up to 30% of patients with psoriasis. Assessment of patients with PsA requires consideration of all disease domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, skin psoriasis, psoriatic nail disease, uveitis and inflammatory bowel disease. Co-morbidities and related conditions should all be considered including: obesity, metabolic syndrome, cardiovascular disease, anxiety/depression, liver disease, chronic infections, malignancy, osteoporosis, fibromyalgia and reproductive health.

Comorbidity in Adult Psoriasis: Considerations for the Clinician

Psoriasis is associated with several comorbidities ranging from cardiovascular comorbidity and mental disorders to other immune mediated inflammatory diseases. However, most of these co-morbidities are often overlooked or diagnosed late. Furthermore, evidence suggests that comorbidities are undertreated. Here, we provide an overview of comorbidities in psoriasis and present a simple rundown of considerations of relevance to the clinician. We hope that this review may raise clinicians' awareness of comorbidities in psoriasis and provide simple guidance regarding screening tools and treatment decisions in psoriasis with comorbidities.

Residual Disease Associated with Suboptimal Treatment Response in Patients with Psoriatic Arthritis: A Systematic Review of Real-World Evidence

OBJECTIVE

This systematic literature review aimed to identify and summarise real-world observational studies reporting the type, prevalence and/or severity of residual symptoms and disease in adults with psoriatic arthritis (PsA) who have received treatment and been assessed against remission or low disease activity targets.

METHODS

Patients had received treatment and been assessed with treat-to-target metrics, including minimal disease activity (MDA), Disease Activity Index in PsA (DAPSA) and others. MEDLINE, Embase® and the Cochrane Database of Systematic Reviews (CDSR) were searched using search terms for PsA, treatment targets and observational studies. Screening of search results was completed by two independent reviewers; studies were included if they reported relevant residual disease outcomes in adults with PsA who had received one or more pharmacological treatments for PsA in a real-world setting. Non-observational studies were excluded. Information from included studies was extracted into a prespecified grid by a single reviewer and checked by a second reviewer.

RESULTS

Database searching yielded 2328 articles, of which 42 publications (27 unique studies) were included in this systematic literature review. Twenty-three studies reported outcomes for MDA-assessed patients, and 14 studies reported outcomes for DAPSA-assessed patients. Physician- and patient-reported residual disease was less frequent and/or severe in patients reaching targets, but often not absent, including when patients achieved very low disease activity (VLDA) or remission. For example, studies reported that 0-8% patients in remission according to DAPSA (or clinical DAPSA) had > 1 tender joint, 25-39% had Psoriasis Area and Severity Index (PASI) score > 1 and 0-10% had patient-reported pain > 15. Residual disease was usually less frequent and/or severe among patients achieving MDA-assessed targets versus DAPSA--assessed targets, especially for skin outcomes.

CONCLUSION

The findings demonstrate a need for further optimisation of care for patients with PsA.

Profilin-1 prevents psoriasis pathogenesis through IκBζ regulation

Profilin-1 (PFN-1) is an actin-binding protein that regulates actin polymerization, cell proliferation, apoptosis, angiogenesis, and carcinogenesis. Its dysregulation has been reported in diverse pathologic diseases; however, the role of PFN-1 in psoriasis has not yet been elucidated. In this study, we demonstrate that PFN-1 expression is increased in both skin and serum of patients with psoriasis. PFN-1 was markedly expressed in the epidermis of psoriatic lesions and its expression positively correlated with psoriasis severity. IL-17A treatment of keratinocytes increased the PFN-1 expression, whereas TNF-α induced the PFN-1 expression and secretion. In addition, knockdown of PFN-1 with shRNA resulted in an altered expression of psoriasis-associated inflammatory markers, HBD-2, S100A7, S100A9, and Ki67, and recombinant PFN-1 suppressed the IL-17A-induced inflammatory response in keratinocytes. Interestingly, recombinant PFN-1 also suppressed IL-17A-induced IκBζ, an important player in immune response in psoriasis. Collectively, our results show that PFN-1 acts as a negative regulator of psoriatic inflammation through suppression of IκBζ, and the balanced level of PFN-1 is important for the IκBζ regulation. Thus, the expression of PFN-1 can be used as a biomarker for psoriasis severity, and it can be considered as a possible target for the treatment of psoriasis.

A Joint Consensus of Rheumatologists and Dermatologists on Early Detection and Effective Management of Psoriatic Arthritis: India's Perspective

Psoriatic arthritis (PsA) is a chronic inflammatory disease with clinical manifestations, including inflammatory arthritis and the presence of psoriasis (PsO). The present consensus statement evaluated the early diagnosis and treatment approaches in the management of psoriasis and psoriatic arthritis by rheumatologists and dermatologists. For PAN India representation, a panel of eight rheumatologists and five dermatologists from different institutes in India were constituted. These thirteen experts were divided into two groups (rheumatologists group and dermatologist group) who received a set of questionnaires each for diagnosis and treatment approaches in the management of psoriasis and psoriatic arthritis. Based on the responses received, a panel discussion took place, where the experts identified the early diagnostic criteria for PsA considering: Clinical signs and symptoms, and questionnaire-based PsA screening, which includes Psoriasis Epidemiology Screening Tool (PEST) for dermatologists and Classification Criteria for Psoriatic Arthritis (CASPAR) for rheumatologists. The experts also recommended shift from conventional disease-modifying anti-rheumatic drugs (DMARDs) to biologics like secukinumab, when there is extensive skin involvement and TNF inhibitors when there is extensive joint involvement. Overall, the objective of the consensus was to assist rheumatologists and dermatologists in the early diagnosis and management of patients of PsA and PsO in their clinical practice.

Relation of NSAIDs, DMARDs, and TNF Inhibitors for Ankylosing Spondylitis and Psoriatic Arthritis to Risk of Total Hip and Knee Arthroplasty

OBJECTIVE

Ankylosing spondylitis (AS) and psoriatic arthritis (PsA) often affect the hip and/or knee. If effective, treatments might reduce risk of total hip or total knee arthroplasty (THA/TKA). We evaluated risk of THA/TKA related to use of medical therapies in AS/PsA.

METHODS

We conducted a nested case-control study using 1994-2018 data from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims, laboratory results, and enrollment records for commercial and Medicare Advantage enrollees. Among those with AS/PsA, THA/TKA cases were matched up to 4 controls by sex, age, AS/PsA diagnosis, diagnosis year, insurance type, obesity, and prior THA/TKA. We assessed AS/PsA treatment 6 months prior to THA/TKA, including disease-modifying antirheumatic drugs (DMARDs) and tumor necrosis factor inhibitors (TNFi), alone or in combination, stratified by nonsteroidal antiinflammatory drug (NSAID) use. We evaluated the relation of treatment to risk of THA/TKA using conditional logistical regression with adjustment for confounders.

RESULTS

Among 16,748 adults with AS, there were 444 THA/TKA cases and 1613 matched controls. Among 34,512 adults with PsA, there were 1003 cases and 3793 controls. Adjusted ORs for treatment category and THA/TKA ranged from 0.60 to 1.92; however, none were statistically significant. Results were similarly null in several sensitivity analyses.

CONCLUSION

Odds of THA/TKA were not reduced with any combinations of NSAIDs, DMARDs, or TNFi among persons with AS or PsA. Given current utilization patterns in this population of US adults with AS and PsA, these medical therapies did not appear to be associated with less end-stage peripheral joint damage.

Tofacitinib in psoriatic arthritis patients: skin signs and symptoms and health-related quality of life from two randomized phase 3 studies

Background

Psoriatic arthritis (PsA) is a chronic, systemic immune‐mediated inflammatory musculoskeletal disease. The onset of dermatologic symptoms often precedes rheumatic manifestations. Tofacitinib is an oral Janus kinase inhibitor for the treatment of PsA that has been shown to improve dermatologic symptoms in patients with PsA.

Objectives

To investigate the efficacy of tofacitinib in improving dermatologic endpoints in adult patients with active PsA.

Methods

This analysis included data from two placebo‐controlled, double‐blind, phase 3 studies in patients with active PsA and an inadequate response (IR) to ≥1 conventional synthetic disease‐modifying antirheumatic drug (csDMARD) who were tumor necrosis factor inhibitor (TNFi)‐naïve (OPAL Broaden; NCT01877668) or an IR to ≥1 TNFi (OPAL Beyond; NCT01882439). Patients had active plaque psoriasis at screening and received a stable dose of one csDMARD during the study. Patients were randomized to tofacitinib 5 mg twice daily (BID), 10 mg BID, adalimumab 40 mg subcutaneous injection once every 2 weeks (OPAL Broaden only) or placebo (to Month 3). Dermatologic endpoints: Psoriasis Area and Severity Index (PASI) total score; PASI90 overall; PASI75 and PASI90 by baseline PASI severity; Physician’s Global Assessment of Psoriasis; Nail Psoriasis Severity Index; Dermatology Life Quality Index total and sub‐dimension scores; Itch Severity Item; and Patient’s Global Joint and Skin Assessment‐Visual Analog Scale‐Psoriasis question.

Results

In patients with active PsA, including those stratified by mild or moderate/severe dermatologic symptoms, greater improvements from baseline and percentage of responders were observed in tofacitinib‐treated patients vs. placebo for the majority of analyzed dermatologic endpoints at Months 1 and 3, and improvements were maintained to Month 12 in OPAL Broaden and Month 6 in OPAL Beyond. Similar effects were observed in adalimumab‐treated patients vs. placebo in OPAL Broaden across dermatologic endpoints.

Conclusions

Tofacitinib provides a treatment option for patients with active PsA, including the burdensome dermatologic symptoms of PsA.

Evaluation of the Economic Burden of Psoriatic Arthritis and the Relationship Between Functional Status and Healthcare Costs

OBJECTIVE

This analysis aimed to evaluate the economic burden of patients with psoriatic arthritis (PsA) on the UK healthcare system and estimate the relationship between functional status and direct healthcare costs.

METHODS

Functional status [measured using the Health Assessment Questionnaire-Disability Index (HAQ-DI)], demographics, disease history, and healthcare resource use data were extracted from a cohort of patients at the Royal National Hospital for Rheumatic Diseases, Bath, UK. Each resource use item per patient was then allocated a unit cost. Linear regression models were used to predict costs as a function of HAQ-DI. Medication costs were not included in the primary analysis, which was carried out from the UK National Health Service perspective.

RESULTS

Data were available for 101 patients. Mean HAQ-DI score was 0.84 (SD 0.75) and mean age at HAQ-DI measurement was 57.8 (SD 10.7). Total annual healthcare costs per patient, excluding medication costs, ranged between £174 and £8854, with a mean of £1586 (SD £1639). A 1-point increase in HAQ-DI score was associated with an increase in total costs of £547.49 (standard error £224), with secondary care consultations appearing to be the primary factor. Subgroup analyses suggested higher cost increases in patients with HAQ-DI scores of 2-3 and with a disease duration > 10 years.

CONCLUSION

Patients with PsA place a significant economic burden on the healthcare system. Functional status is highly correlated with costs and appears to be driven mainly by the cost of secondary care consultations. Results were similar to previous studies in rheumatoid arthritis populations.

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.

Psoriatic arthritis screening: a systematic review and meta-analysis

OBJECTIVE

To systematically review the accuracy and characteristics of different questionnaire-based PsA screening tools.

METHODS

A systematic review of MEDLINE, Excerpta Medical Database, Cochrane Central Register of Controlled Trials and Web of Science was conducted to identify studies that evaluated the accuracy of self-administered PsA screening tools for patients with psoriasis. A bivariate meta-analysis was used to pool screening tool-specific accuracy estimates (sensitivity and specificity). Heterogeneity of the diagnostic odds ratio was evaluated through meta-regression. All full-text records were assessed for risk of bias with the QUADAS 2 tool.

RESULTS

A total of 2280 references were identified and 130 records were assessed for full-text review, of which 42 were included for synthesis. Of these, 27 were included in quantitative syntheses. Of the records, 37% had an overall low risk of bias. Fourteen different screening tools and 104 separate accuracy estimates were identified. Pooled sensitivity and specificity estimates were calculated for the Psoriatic Arthritis Screening and Evaluation (cut-off = 44), Psoriatic Arthritis Screening and Evaluation (47), Toronto Psoriatic Arthritis Screening (8), Psoriasis Epidemiology Screening Tool (3) and Early Psoriatic Arthritis Screening Questionnaire (3). The Early Psoriatic Arthritis Screening Questionnaire reported the highest sensitivity and specificity (0.85 each). The I2 for the diagnostic odds ratios varied between 76 and 90.1%. Meta-regressions were conducted, in which the age, risk of bias for patient selection and the screening tool accounted for some of the observed heterogeneity.

CONCLUSIONS

Questionnaire-based tools have moderate accuracy to identify PsA among psoriasis patients. The Early Psoriatic Arthritis Screening Questionnaire appears to have slightly better accuracy compared with the Toronto Psoriatic Arthritis Screening, Psoriasis Epidemiology Screening Tool and Psoriatic Arthritis Screening and Evaluation. An economic evaluation could model the uncertainty and estimate the cost-effectiveness of PsA screening programs that use different tools.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Enthesitis and Dactylitis in Psoriatic Disease: A Guide for Dermatologists

Psoriatic arthritis (PsA) is an inflammatory arthritis that is estimated to affect approximately 30% of patients with psoriasis. Enthesitis and dactylitis, two hallmarks of PsA, are associated with radiographic peripheral/axial joint damage and severe disease. Clinical symptoms of enthesitis include tenderness, soreness, and pain at entheses on palpation, whereas dactylitis is recognized by swelling of an entire digit that is different from adjacent digits. Both ultrasound and magnetic resonance imaging can be used to diagnose enthesitis and dactylitis, especially in patients in whom symptoms may be difficult to discern. Delayed treatment of PsA can result in irreversible joint damage and reduced quality of life. Thus, it is recommended that dermatologists monitor patients with psoriasis for these two early and important manifestations of PsA.

Imaging in Psoriatic Arthritis-Insights About Pathogenesis of the Disease

PURPOSE OF REVIEW

Heterogeneity is a hallmark of PsA as musculoskeletal inflammation can affect different tissues including the synovial joint, tendons, entheses, bursa, and bone.

RECENT FINDINGS

Relying on clinical examination for investigating underlying mechanisms in PsA is limited by the inherent inaccuracies of examination of the joints, enthesis, and spine. In addition, unlike synovial-centered diseases, histology is hard to obtain for the entheses and spine, limiting the knowledge for different manifestations of PsA. These limitations prompted the use of imaging modalities to improve our understanding of the underlying mechanisms in PsA. Imaging modalities can identify and quantify the extent of inflammation and damage in the synovial joints, entheses, and tendons which all contribute to the heterogeneity of PsA. This review summarizes the contribution of imaging to the understanding of the underlying mechanisms of different clinical manifestations of PsA.

Abatacept in the treatment of psoriatic arthritis: biological and clinical profiles of the responders

Abatacept (CTLA4Ig), a selective T-cell costimulation modulator, has been approved for the treatment of psoriatic arthritis patients with an inadequate response to conventional synthetic disease-modifying antirheumatic drugs, but not for those with uncontrolled skin lesions, nor with axial involvement. In this review, we will try to interpret such a differential efficacy of abatacept on the psoriatic arthritis clinical domains, on the basis of its differential effectiveness on the diverse T-cell subsets at different sites. Clinical and biological profiles of possible responders to abatacept will be provided.

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.

Validation of the Toronto Psoriatic Arthritis Screen II (TOPAS II) questionnaire in a Turkish population

OBJECTIVE

To evaluate the TOPAS II questionnaire validation in a Turkish population.

METHODS

The Turkish translation of ToPAS II was sent to us by the developer authors of the original index. Subjects were recruited from dermatology, physical medicine and rehabilitation, and rheumatology outpatient clinics. All patients' demographic parameters and ToPAS II questionnaire results were recorded. After patients completed the questionnaire they were assessed by a rheumatologist according to a standard protocol which includes a complete history, detailed physical examination, laboratory tests and CASPAR criteria. Receiver operating characteristics (ROC) assessed to obtain sensitivity and specificity of Turkish version of ToPAS II questionnaire.

RESULTS

One hundred and fifty subjects were recruited in the study. The mean age of subjects was 41.07 years (SD 12.59) and the 58% of subjects were female. There were 46 subjects from psoriasis group, 43 subjects from psoriatic arthritis (PsA) group, 41 subjects from physical medicine and rehabilitation group and 20 subjects from rheumatology (non-PsA) group. The area under the ROC curve was 0.99 which means as excellent predictor and optimum cut-off threshold to discriminate patients diagnosed with PsA was 8 according to this ROC curve analysis. The overall sensitivity and specificity based on cut-off threshold of 8, were 95.8 and 98%, respectively.

CONCLUSION

The Turkish version of ToPAS II has high sensitivity and specificity. It is simple, not time consuming and useful tool to screen for PsA in both patients with and without psoriasis.

Psoriatic arthritis: new evidence for old concepts

PURPOSE OF REVIEW

The review gives an updated overview of some of the new concepts in the management of psoriatic arthritis (PsA): early diagnosis, remission as an objective, treat-to-target, and treatment guidelines.

RECENT FINDINGS

Early diagnosis, targeting remission as part of a treatment strategy, and new guidelines providing evidence-based support to these concepts are main topics in recent publications.

SUMMARY

Dermatologists and rheumatologists should work together to reduce the number of patients remaining undiagnosed, and the time to do so.Remission definition in PsA is still controversial. There is good evidence and convincing arguments for both multidimensional measures, such as minimal disease activity, or unidimensional ones, as disease activity index for PsA. New data on the analysis of tight control of inflammation in early PsA trial showed that the strategy might not be cost-effective on the short term, and that oligoarthritis is less benefited.The new European League Against Rheumatism and Group for Research and Assessment of Psoriasis and PsA recommendations exhibit differences. Methotrexate and tumor necrosis factor inhibitors are favored in European League Against Rheumatism guidelines, whereas other conventional synthetic disease-modifying antirheumatic drugs and biologics are equally positioned in Group for Research and Assessment of Psoriasis and PsA recommendations.