Nail Enthesis Ultrasound in Psoriasis and Psoriatic Arthritis: A Report from the 2016 GRAPPA Annual Meeting

Ultrasound nail assessment in patients with psoriasic arthritis: is there an association of findings with clinical scores?

BACKGROUND

Psoriatic arthritis can involve several domains. Due to its multifaceted nature and its frequent comorbidities such as depression, obesity, osteoarthritis and fibromyalgia, it is difficult to monitor these patients because the clinical scores involve subjective data. High-resolution ultrasound probes allowed the evaluation of more superficial structures, such as the nails and their synovio-entheseal framework, in close relationship with the enthesis of the distal extensor digitorum tendon. Nail ultrasound studies vary in terms of the parameters and fingers studied and in their findings.

OBJECTIVES

To describe the most significant sonographic nail changes and the most affected fingers in psoriatic arthritis and to verify the association of nail ultrasound findings with clinical scores (nail psoriasis severity index (NAPSI), ankylosing spondylitis disease activity score with C-reactive protein (ASDAS-CRP), minimal disease activity (MDA), disease activity index for psoriatic arthritis (DAPSA)).

METHODS

This was a cross-sectional study with 52 patients with psoriatic arthritis at the Hospital de Clínicas do Paraná and 50 controls. A total of 1016 nails were analyzed (517 from patients with psoriatic arthritis and 499 from controls). Ultrasonography of the nails of the 10 fingers was performed to assess the trilaminar appearance, measure the distance from the nail bed, identify synovitis of the distal interphalangeal joints and the presence of a power Doppler signal from the nail matrix/nail bed. The captured images were independently evaluated by a rheumatologist with expertise in musculoskeletal ultrasound. Data analysis was performed using IBM SPSS Statistics v.28.0.0 software, and the association of nail plate changes, nail bed distance and power Doppler signal with the NAPSI, DAPSA, MDA and ASDAS-PCR were calculated. Spearman correlation coefficients were estimated to analyze the correlations between pairs of quantitative variables. Student's t test and the Mann‒Whitney U test were used to compare quantitative variables, and Fisher's exact test was used to compare categorical variables between patients and controls. The nonparametric Mann‒Whitney U and Kruskal‒Wallis tests were used to compare groups according to the MDA or DAPSA classification.

RESULTS

The Doppler signal of the nail matrix and nail bed was more frequently identified in patients (44.2%) than in controls (6%), and the difference in the mean power Doppler signal between the two groups was significant (p < 0.001). Changes in the nail plate were more common in the right thumb (44.2%), left thumb (36.5%) and second finger on the right hand (32.7%). The number of fingers with nail plate changes, enthesitis, paratendinitis, grayscale synovitis and DIP involvement in the distal interphalangeal joints was higher among patients with psoriatic arthritis (p < 0.001). There were found some correlations between US findings and clinical scores: ultrasound nail involvement and the NAPSI score (p = 0.034), the number of fingers and mean change in the nail plate and the ASDAS-CRP (p = 0.030). DAPSA (remission/low activity versus moderate/high activity) was associated to the mean change in the nail plate (p < 0.013).

CONCLUSIONS

Nail ultrasound has the potential to assist in the capturing of the actual disease activity status in patients with psoriatic arthritis.

Ultrasonographic Insights into Peripheral Psoriatic Arthritis: Updates in Diagnosis and Monitoring

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis associated with psoriasis, characterized by heterogeneous clinical manifestations and variable disease progression. Ultrasonography has emerged as a valuable tool in the diagnosis and monitoring of PsA, providing real-time visualization of joint and soft tissue abnormalities. This review highlights recent advancements in ultrasonographic techniques for the assessment of PsA, including the identification of typical features, the role of power Doppler imaging in detecting active inflammation, and the potential of ultrasound for guiding treatment decisions. Additionally, we discuss the utility of ultrasound in assessing treatment response and monitoring disease progression in patients with PsA, with a focus on novel imaging modalities. By elucidating the evolving role of ultrasonography in PsA management, this article aims to enhance clinicians' understanding of its utility in facilitating early diagnosis, optimizing treatment strategies, and improving patient outcomes.

Ultrasonographic and power doppler parameters of nails fail to differentiate between onychodystrophy in patients with psoriasis vulgaris or psoriatic arthritis

BACKGROUND

Nail involvement is frequent in patients with psoriasis (Pso) and psoriatic arthritis (PsA) and there is a relationship between nail involvement and inflammation of the enthesis. The main objective of the present study is to describe the ultrasound findings and clinical characteristics of nails from patients with psoriasis and psoriatic arthritis with and without nail dystrophy.

METHODS

A cross-sectional study including consecutive patients with PsO and PsA was carried out. The study patients were divided into 4 groups, totaling 120 participants. Group 1: patients with psoriasis vulgaris and clinically normal nails; Group 2: patients with psoriasis vulgaris and onychodystrophy; Group 3: patients with psoriatic arthritis and clinically normal nails; Group 4: patients with psoriatic arthritis and onychodystrophy; All patients were submitted to dermatological and rheumatological clinical analysis. Ultrasound examinations was performed by a single examiner, blinded to all clinical data, with ultrasound high resolution, in B-mode or gray-scale (GS), Power Doppler (PD) and Spectral Doppler.

RESULTS

A significant difference was found between the groups regarding the variable Psoriasis Area and Severity Index (PASI) (p = 0.008) and body surface area (BSA) (p = 0.005), with patients with psoriatic arthritis having lower PASI and BSA compared to patients with only cutaneous psoriasis. A positive relationship was found with the average ultrasound thickness of the nail bed and the Nail Psoriasis Severity Index (NAPSI) in correlation analysis (rho = 0.344). When we grouped patients with psoriasis and psoriatic arthritis, there was no significant difference between the cutaneous psoriasis groups and the psoriatic arthritis groups in terms of nail plate GS (p = 0.442), nail bed PD (p = 0.124).

CONCLUSION

Greater nail bed thickness indicates early psoriatic nail disease, as confirmed in our study correlating NAPSI with nail bed thickness. Ultrasonography is a low-cost exam, promising in the evaluation, showing that the ultrasound grayscale is consistent with those who have dystrophic nails, but it can't distinguish psoriasis from psoriatic arthritis, even in those with nail dystrophy.

Assessment and Monitoring of Nail Psoriasis with Ultra-High Frequency Ultrasound: Preliminary Results

Psoriatic onychopathy is one of the clinical presentations of psoriasis and a well-known risk factor for the development of psoriatic arthritis. High-frequency ultrasounds (HFUS > 20 MHz) have recently been used to evaluate the nail apparatus of healthy and psoriatic subjects. The aim of our study was to detect by means of ultra-high-frequency ultrasound (UHFUS 70-100 MHz) alterations of the nail bed and matrix in patients with psoriatic onychopathy and to monitor these parameters during the treatment with monoclonal antibody (mAb). We enrolled 10 patients with psoriatic onychopathy and naive to previous biologic therapies. Patients were evaluated at baseline, after 1 month and after 3 months from the beginning of mAb therapy by a complete clinical assessment and US evaluation. A UHFUS examination with a 70 MHz probe was performed on the thumbnail (I), the index fingernail (II) and the nail with greater clinical impairment (W). The following measurements were analyzed: nail plate thickness (A), nail bed thickness (B), nail insertion length (C), nail matrix length (D) and nail matrix thickness (E). Among the various parameters analyzed, some measures showed a statistically significant decrease with p-value < 0.05 (t0 WA = 0.52 mm vs. t2 WA = 0.42 mm; t0 WB = 2.8 mm vs. t2 WB = 2.4 mm; t0 WE = 0.76 mm vs. t2 WE = 0.64 mm; t0 IIA = 0.49 mm vs. t2 IIA = 0.39 mm). In conclusion, UHFUS could represent a viable imaging technique for the real-time evaluation and monitoring of psoriatic onychopathy, thus supporting the clinical parameters and revealing any subclinical signs of early drug response.

Ultrasound Can Be Usefully Integrated with the Clinical Assessment of Nail and Enthesis Involvement in Psoriasis and Psoriatic Arthritis

Objectives: This study aimed to examine and compare the findings of nail and enthesis ultrasonography in patients with psoriasis and psoriatic arthritis. Methods: We identified 154 patients with psoriatic arthritis and 35 patients with psoriasis who were treated at Chang Gung Memorial Hospital, Taiwan, between September 2018 and January 2019. Results: There were significant differences in the Nail Psoriasis Severity Index scores and Glasgow Ultrasound Enthesitis Scoring System scores between patients with psoriasis and those with psoriatic arthritis. B-mode ultrasonography revealed that onychopathic changes were more common in the psoriasis group. The psoriatic arthritis group showed a higher proportion of lower-limb enthesopathy, with significant differences in distal patellar ligament thickness and Achilles tendon thickness. Conclusion: The findings of nail ultrasonography were more severe in psoriasis cases, and the ultrasonographic findings of enthesopathy of the lower limb were more severe in cases of psoriatic arthritis.

Usefulness of Ultrasound Examination in the Assessment of the Nail Apparatus in Psoriasis

The assessment of psoriatic nail changes in everyday practice is based exclusively on clinical symptoms that do not reflect the entire disease process in the nail apparatus. The use of imaging methods, especially widely available and inexpensive ultrasonography, creates the possibility of additional revealing and assessing grayscale of morphological changes of the ventral nail plate, nail bed, and matrix, as well as the attachment of the finger extensor tendon to the distal phalanx. What is more, it enables the assessment of inflammation severity in the power Doppler technique. A qualitative classification of nail plate morphological changes corresponding to the severity of psoriatic nail changes has been developed so far and attempts are being made to develop a quantitative method to assess not only the presence of changes but also the severity of inflammation. Nail ultrasonography is not commonly performed, although published studies indicate the possible use of this technique in the assessment of psoriatic changes in nail structures. It can be particularly useful in subclinical changes imaging, preceding clinical manifestation of psoriatic nail changes, enthesopathy: subclinical and in the course of psoriatic arthritis, as well as in the assessment of treatment efficacy. This review article aims to summaries the research on ultrasonography of the nail apparatus which has been carried out so far, taking into account its applicability in clinical practice.

Psoriatic arthritis

Psoriatic arthritis (PsA) is a type of inflammatory arthritis that is included within the spondyloarthritis, a group of rheumatological diseases characterized by different clinical manifestations and associated comorbidities, that can compromise the quality of life of patients. The diagnosis of PsA is sometimes difficult due to an enormous clinical and radiological variability, including six different domains of involvement: peripheral joint, axial skeleton, skin psoriasis, nail psoriasis, enthesitis and dactylitis. Currently, there are no biomarkers that allow the detection of PsA in patients with psoriasis, so a high level of suspicion is important, mainly by dermatologists, but also by other specialists, such as family doctors. Advances in the knowledge of new immunological mechanisms and joint management by rheumatologists and dermatologists have made it possible to improve the therapeutic approach in patients with PsA.

Improving Imaging Modalities in Early Psoriatic Arthritis: The Role of Ultrasound in Early Diagnosis of Psoriatic Arthritis

Objective: Despite recent advances, early diagnosis of psoriatic arthritis (PsA) remains a challenge in clinical practice. Ultrasound (US) could be a useful tool for the diagnosis and management of PsA. The objective of this review was to determine the role of US in early diagnosis of PsA.

Methods: We have performed a literature review aiming to evaluate studies on US findings in psoriasis and their predictive value of progression to PsA, as well as studies on US features specific for PsA in comparison with other conditions.

Results: A total of 40 studies were included. Sixteen studies assessed US findings in psoriasis, of which only 3 prospectively evaluated the role of US in predicting progression to PsA. Patients with PsA had a greater frequency of US abnormalities, in particular enthesitis and Power Doppler(PD) signal compared to patients with psoriasis only. In the longitudinal studies, psoriatic patients with higher enthesopathy scores at baseline were more likely to progress to PsA. Twenty-four studies evaluated US abnormalities in PsA and compared them to other conditions. Most specific US features that distinguish PsA from psoriasis were PD signal and erosions in joints and entheses. Extra-synovial changes, including peri-tendinous dermal soft tissue oedema with associated PD signal and flexor tendon enthesopathy, as well as thickening of the pulleys in the flexor tendons were highly characteristic for PsA, as they were frequently found in PsA patients, but in none of the RA patients. US-detected entheseal abnormalities in particular erosions and PD signal were more frequent in patients with PsA compared to fibromyalgia.

Conclusion: Despite the wide use of US in PsA, more research is needed to identify predictive factors of progression to PsA in patients with psoriasis, as well as to determine most specific US features that differentiate PsA from other conditions.

Nail and enthesis assessment in patients with psoriatic disease by high frequency ultrasonography: findings from a single-centre cross-sectional study

PURPOSE

To characterize nail and enthesis abnormalities using high frequency ultrasound (HFUS) in patients with psoriasis (PSO), psoriatic arthritis (PSA) with PSO, and PSA sine PSO.

MATERIAL AND METHODS

Patients with PSO, PSA with PSO, and PSA sine PSO were evaluated and compared in a cross-sectional single centre study. Nail and enthesis abnormalities were evaluated by HFUS using high frequency probes (27 MHz). After a descriptive assessment, Brown University Nail Enthesis Scale (BUNES) and Madrid Sonography Enthesitis Index (MASEI) were used to assess nail and enthesis, respectively.

RESULTS

Fifty-nine patients were enrolled (19 PSO, 22 PSA with PSO, 18 PSA sine PSO). In patients with PSO and in those with PSA and PSO, HFUS evaluation identified the following nail alterations characterised by thickened matrix, inhomogeneous echogenicity of the nail bed, and increased blood flow by power Doppler. In 38.9% patients with PSA sine PSO, a subclinical nail involvement was described. No difference was observed comparing BUNES values in three groups. In PSA patients with PSO and in those with PSA sine PSO, HFUS assessment of entheses mainly showed a hypoechoic aspect and thickness of the tendon, focal cortical erosion, and ossification. A subclinical enthesis involvement in 47.4% patients with PSO was observed. No difference was reported comparing MASEI values in three groups.

CONCLUSION

Qualitative and quantitative abnormalities of nail and enthesis were demonstrated by HFUS in patients with PSO, PSA with PSO, and PSA sine PSO, suggesting a practical additional tool to be used in clinical settings. Furthermore, HFUS highlighted a subclinical nail involvement in patients with PSA sine PSO and enthesis subclinical alterations in patients with PSO.

The relationship between the nail and systemic enthesitis in psoriatic arthritis

Objective

Psoriatic nail disease is more common in PsA than in isolated skin psoriasis (PsO). The nail is closely integrated to the DIP joint entheses. US data have shown that those patients with nail disease in PsO are more likely to have systemic enthesitis. We examined whether there was a relationship between nail disease, DIP enthesitis and systemic enthesitis in established PsA.

Methods

Forty-six PsA participants with nail disease underwent US scanning of the nail unit and the DIP entheses along with peripheral entheseal sites according to the Madrid sonographic enthesitis index (MASEI).

Results

At the finger level, there was a mild to moderate correlation between nail US changes and both clinical nail disease and DIP enthesis changes (DIP US) [Spearman correlation (r_S) = 0.30, P < 0.001 and r_S = 0.16, P < 0.001, respectively]. At the patient level, there was a moderate correlation between the nail US score and nail psoriasis severity index score and DIP US (r_S = 0.33, P = 0.024 and r_S = 0.43, P = 0.003, respectively). At the patient level, there was also a positive correlation between a higher nail US score and the active peripheral enthesitis score (MASEI-active) (r_S = 0.35, P = 0.018). When power Doppler was part of nail US score, similar results were demonstrated at both the finger and patient levels.

Conclusion

This study has demonstrated the utility of nail US imaging and the close relationship, on scanning, between the DIP entheses and the nail unit. In PsA, we have seen a correlation between active US changes at the nail and peripheral enthesitis, which requires further analysis.

Trial registration

ClinicalTrials.gov, https://clinicaltrials.gov, NCT03955861.

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.

Apremilast improves quality of life and ultrasonography parameters in patients with nail psoriasis: A prospective cohort study

Specific studies on apremilast for nail psoriasis are lacking. Our objective was to evaluate the nail-specific patient-reported outcomes, clinical efficacy, ultrasound (US) parameters, and safety of apremilast for nail psoriasis. We conducted a prospective cohort study including adult patients with plaque and nail psoriasis with a fingernail Nail Psoriasis Severity Index (NAPSI) score of 12 or more. Patients were treated with apremilast 30 mg b.i.d. for 52 weeks. Forty-five patients were included. At week 52, the Nail Assessment in Psoriasis and Psoriatic Arthritis (NAPPA) Patient Benefit Index global weighted score was 2 or more in 52% of patients and NAPPA Quality of Life and fingernail NAPSI improved by 57% and 53%, respectively. US parameters improved from week 16 onwards. Target nail NAPSI improvements were higher for nail matrix scores (60%) than for nail bed scores (38%, p < 0.001). Baseline target nail bed NAPSI was associated with not achieving a target nail 50% reduction in NAPSI score at week 52 in the bivariate analysis (p = 0.024). Safety was consistent with the known apremilast profile. Results from apremilast therapy for 52 weeks in patients with psoriasis and predominant nail disease show significant improvements in nail-specific quality of life, clinical signs, and structural restoration on US, suggesting that apremilast may be considered in the treatment of nail psoriasis.

Ultrasonographic and resistance index evaluation of nails in psoriatic arthritis, psoriasis, and control groups: a cross-sectional study

BACKGROUND

Nail psoriasis occurs frequently in patients with psoriatic disease, it can lead to functional impairment, pain, discomfort, decreased quality of life and can also be a predictor for the development of arthritis. Early recognition of this condition can provide early and effective treatment and prevent structural impairment. This study aims to identify nail ultrasonographic characteristics in three groups: psoriasis (PsO), psoriatic arthritis (PsA) and controls patients, to determine if the ultrasonography (US) can identify early signs of nail psoriatic impairment or local inflammation. We conducted nail US to determine nail matrix resistance index (NMRI), nail bed resistance index (NBRI), and power Doppler (PD) and grayscale (GS) parameters in these 3 groups.

METHODS

Single-center, cross-sectional study. GS, PD, and spectral doppler images of bilateral 2nd and 3rd fingernails were acquired from 35 PsO, 31 PsA, and 35 controls patients. An US equipment with an 18 MHz linear transducer for GS and 8.0 MHz for PD was used. PD, NMRI, NBRI, nail plate thickness (NPT), nail bed thickness (NBT), nail matrix thickness (NMT), and morphostructural characteristics of the trilaminar structure (TS) were evaluated in saved images, blind.

RESULTS

Mean NMRI and NBRI did not differ between groups. Linear regression analysis detected no relationships between PsO or PsA and NMRI or NBRI. Nail PD grade did not differ between groups. Type I and IV TS changes were more frequent in PsO; types II and III changes were more frequent in PsA (p < 0.001). NPT was greater in PsA and PsO groups than controls: PsA 0.73 ± 0.14 mm, PsO 0.72 ± 0.15 mm, Controls 0.67 ± 0.10 mm (p = 0.001).

CONCLUSION

Echographic TS characteristics of the nail plate and NPT evaluated by GS are useful and can distinguish PsO and PsA nails from controls. NMRI, NBRI, and US nail microcirculation parameters could not distinguish psoriatic nails.

TRIAL REGISTRATION

72762317.4.0000.5327 (Certificate of Presentation of Ethical Appreciation - CAAE - Plataforma Brasil) Avaiable in  https://plataformabrasil.saude.gov.br/login.jsf .

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.

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.

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

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

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.

Prologue: 2016 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)

The 2016 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) was held in Miami, Florida, USA, and attended by rheumatologists, dermatologists, and representatives of biopharmaceutical companies and patient groups. As in previous years, GRAPPA members held a symposium for trainees to discuss their research in psoriatic disease with experts in the field. A strategic planning session was convened by the Steering Committee this year to review the work of GRAPPA since its inception in 2003. Other subjects featured during the annual meeting included a partnership with KPMG LLP (UK) to conduct interviews at research centers worldwide to analyze the process of care in psoriasis and psoriatic arthritis (PsA); a discussion of the effects of interleukin 17–related pathways on the skin and joints in psoriasis and PsA; summaries of recently published treatment recommendations and related guides; 4 separate discussions of psoriasis patient examinations; updates from working groups in the Outcome Measures in Rheumatology and the International Dermatology Outcome Measures; a discussion of patient centricity from GRAPPA’s patient research partners; and an update of research and educational projects from GRAPPA. In this prologue, we introduce the papers that summarize that meeting.