Supplement- Diagnosis and management of psoriatic arthritis

Psoriasis

Canchi Balakrishnan, Nina Madnani1

Departments of Rheumatology, ABSTRACT

and 1Dermatology, P. D.
Hinduja National Hospital, Psoriatic arthritis (PsA) is a multi-faceted disease marked by varying combinations of
Mahim, Mumbai, India
peripheral arthritis, dactylitis, spondylitis, and enthesitis. Rarely, recurrent uveitis occurs.
Skin involvement may or may not exist. However, patients with nail psoriasis have a higher
Address for correspondence:
Dr. Canchi Balakrishnan, probability of developing PsA. Untreated patients have significant morbidity and mortality.
Department of Rheumatology, Timely diagnosis and aggressive treatment of the disease can lead to lower morbidity. Drug
P. D. Hinduja National Hospital, therapy of PsA includes symptomatic therapy and therapy with disease-modifying anti-
Veer Savarkar Marg, Mahim, rheumatic drugs. Biologics are the only agents that address all the pathological changes, of
Mumbai - 400 016, India.
this chronic condition.
E-mail:
balkigurmeet@gmail.com
Key words: Biologics, dactylitis, enthesitis, psoriatic arthritis, spondylitis

INTRODUCTION of PsA. However, in about 10% to 20% of patients, there

is no history of obvious skin involvement by psoriasis.
Over the last decade, significant strides have been In these patients, one should search diligently for
made in our understanding of psoriatic arthritis (PsA). psoriasis at hidden sites such as the natal cleft, behind
There is recognition that PsA is a multi-faceted disease, the ear, in the umbilicus, and on the scalp, and for nail
often with differing pathologies at different sites.[1] changes like nail pitting, onycholysis and total nail
Patients often have varying combinations of peripheral dystrophy.
arthritis, spondylitis, dactylitis, and enthesitis. In a
proportion of patients, the presence of extra-articular Various diagnostic criteria have been proposed for
manifestations like recurrent uveitis also influences PsA[5-8] including the widely used Moll and Wright
therapeutic decisions.[2,3] Untreated patients with criteria. This criteria necessitates the presence of:
PsA have significant morbidity and probably early 1. Psoriasis vulgaris
mortality.[2,3] Increased cardiovascular mortality due 2. A negative serology for rheumatoid arthritis (RA)
to inflammation-mediated premature atherogenesis 3. Clinical features suggestive of inflammatory
has also been described.[4] Hence, there is a need to arthritis in one or more of the following patterns:
diagnose, stage, and treat this disease aggressively. a. Distal interphalangeal joint disease
b. Asymmetric, oligoarticular (< 5 joints
DIAGNOSIS OF PSA involved)
c. Symmetric, polyarticular “rheumatoid
The presence of inflammatory arthritis in a patient arthritis-like”,
with past or current psoriasis is the basis of diagnosis d. Mainly spondylitic (axial involvement)
e. Destructive arthritis (arthritis mutilans)
Access this article online
Several other diagnostic criteria have been proposed,
including those by Bennett, Vasey and Espinoza,
Quick Response Code: Website:
www.ijdvl.com
McGonagle (Modified criteria), Fournie and the
European Spondyloarthropathy Study Group (Modified
DOI:
criteria). The classification criteria for psoriatic arthritis
10.4103/0378-6323.115507
(CASPAR) have been recently described. The CASPAR
PMID:
group has also developed a simpler classification of
*****
PsA, into axial or peripheral disease.[9]

How to cite this article: Balakrishnan C, Madnani N. Diagnosis and management of psoriatic arthritis. Indian J Dermatol Venereol Leprol
2013;79:18-24.
Received: December, 2012 Accepted: March, 2013. Source of Support: Nil. Conflict of Interest: None declared.

S18 Indian Journal of Dermatology, Venereology, and Leprology | 2013 | Vol 79 | Supplement 1
Balakrishnan and Madnani Diagnosis and management of psoriatic arthritis

The group for research and assessment of psoriasis and

psoriatic arthritis (GRAPPA) has selected three simple
screening tools, which can be used by clinicians to
screen for PsA.[10] These are still undergoing validation
in population studies.
1. Toronto Psoriatic Arthritis Screening Tool (ToPAS)
2. Psoriasis Epidemiology Project (PEST)
3. Psoriatic Arthritis Screening and Evaluation
tool (PASE)
Sensitivity and specificity of the various criteria
The sensitivity of most of the above criteria has
been compared. The criteria by Vasey and Espinzoa,
McGonagle and the CASPAR criteria exhibited a
sensitivity of almost 96%. The specificity of the Figure 1: Distal interphalengeal joint (DIP) of the ring finger
various criteria was anywhere between 93% and 99%. showing erythema and swelling suggestive of arthritis. Plaque of
psoriasis also seen on the dorsum of the hand. DIP involvement
One would choose a more sensitive criteria when is never seen in RA
conducting community based studies especially of
early PsA and specific criteria when doing drug trials. will reveal the causative organism. A negative culture
should alert to the possibility of gouty arthritis.
As dermatologists, concentrating on psoriasis of the Elevated serum uric acid level helps to confirm the
skin and nail, we may be missing many cases of early diagnosis. Gouty arthritis is usually monoarticular,
arthritis. Dactylitis, a uniform sausage-like swelling of commonly involving metatarsophalangeal joint. A
the fingers and toes, and enthesitis, which is pain and radiograph of the affected joint shows lytic areas with
inflammation at the point of tendon insertion, may be sclerotic margins described as “rat bite” lesions.
early signs of arthritis in these patients. Furthermore,
nail involvement is postulated to be due to a Koebner’s INVESTIGATIONS
phenomenon secondary to enthesitis of the distal
phalanx, and may be predictive for the development of The following hematologic, serologic, and imaging
PsA.[11] Recently, Soscia et al. have studied nails with studies, although not specifically diagnostic, can be
magnetic resonance imaging (MRI), and concluded that supportive.
MRI can detect nail changes in patients of psoriasis 1. The erythrocyte sedimentation rate and
even when there is no clinical evidence in any nail.[12] C-reactive protein may be raised, but this is not
specific.
DIFFERENTIAL DIAGNOSIS 2. Rheumatoid factor test should be performed.
Although, a negative serology can rule out
PsA needs to be distinguished from other common rheumatoid arthritis, about 25% of PsA patients
forms of arthritis, viz. rheumatoid arthritis, of the rheumatoid type may have a positive or
osteoarthritis, connective tissue disease, infective, equivocal test result.[13]
and gouty arthritis. Oligoarticular disease, asymmetry, 3. HLA-B27, though not specific, is strongly
distal interphalangeal joint involvement [Figure 1], supportive of axial disease.
enthesitis, and negative serology are typical of PsA. 4. X-rays of the hands and feet may be needed
Those with rheumatoid arthritis may have, in addition, [Figure 2]. Early changes may be limited to
rheumatoid nodules and extra-articular signs without peri-articular soft tissue swelling and joint
enthesitis and central axial involvement. Osteoarthritis erosions similar to rheumatoid arthritis. Sites of
mainly involves the knee and hip joints, occurring with entheseal attachments may show periostitis and
“wear and tear” of the joints. Lupus arthritis, occurring new bone formation. Advanced cases, especially
in patients of systemic lupus erythematosus, affects of the mutilating variety, may show widespread
the wrists, hands, and knees. Anti-nuclear antibody joint destruction, with “penciling” or narrowing
(ANA) and dsDNA may be positive. An acutely swollen, of the heads of the metacarpals and metatarsals.
painful joint swelling may be seen in infective/septic Destruction of the central portion of the articular
arthritis or gouty arthritis. Culture of the joint fluid surface gives the “pencil-in-cup” appearance.

Indian Journal of Dermatology, Venereology, and Leprology | 2013 | Vol 79 | Supplement 1 S19
Balakrishnan and Madnani Diagnosis and management of psoriatic arthritis

Table 1: Measures of assessment of various domains

Domains Modes of assessment
Peripheral arthritis 68/66 tender swollen joint count, ACR, DAS
and PsARC
Spondylitis BASDAI, BASFI, BASMI
Enthesitis Leeds index, Berlin, 4-point, Mander and
MASES
Dactylitis Acute/chronic, Leeds enthesitis index, present/
absent
Skin Global assessment, PASI
ACR: American college of rheumatology, DAS: Disease activity score, PsARC:
Psoriatic arthritis response criteria, BASDAI: Bath ankylosing spondylitis
disease activity index, BASFI: Bath ankylosing spondylitis functional index,
BASMI: Bath ankylosing spondylitis metrology index, MASES: Maastricht
ankylosing spondylitis enthesitis score, PASI: Psoriasis area severity index

Figure 2: Radiograph of both hands showing fluffy periosteitis

Table 2: Staging of psoriatic arthritis
in the proximal phalanges of all fingers bilaterally. A soft tissue
swelling is seen around the middle finger of the left hand Parameter Mild Moderate Severe
suggestive of "sausage digit" Peripheral <5 joints >5 joints (S or T) >5 joints (S or T)
arthritis No damage Damage on X-ray Severe damage on
on X-ray NIR to mild Rx X-ray
With the destruction of the interphalangeal
No LOF Mod LOF NIR to mild–moderate
joints, especially the distal ones, bony ankylosis QoL minimal Mod impact on Rx
can occur. impact QoL Severe LOF
Pt. evaluation Pt. evaluation Severe impact on QoL
5. The sacroiliac changes in PsA are similar to those mild moderate Pt. evaluation severe
in ankylosing spondylitis, but with the ossification Skin BSA<5%, Non-response to BSA>10, DLQI>10
of the paravertebral tissues in the thoracic and disease PASI<5, as- topicals, DLQI, PASI>10
lumbar area occurring more laterally.[14] ymptomatic* PASI<10

6. Ultrasound and MRI are more effective for the Spinal Mild pain Loss of function Failure of response
disease No loss of or BASDAI>4
detection of enthesitis.[15] function
7. Lipid profile, HbA1C, liver function tests Enthesitis 1-2 sites >2 sites or loss of Loss of function or>2
(LFT), body mass index (BMI) for evaluating function sites and failure of
response
co-morbidities.
Dactylitis Pain absent Erosive disease Failure of response
to mild or functional loss
MANAGEMENT OF PSA Normal
function
NR: Not responding, LOF: Loss of function, QoL: Quality of life, BSA: Body
Treatment needs to be holistic and includes drug surface area, PASI: Psoriasis area severity index, DLQI: Dermatology life
therapy and management of co-morbidities such as quality index, BASDAI: Bath ankylosing spondylitis disease activity index

obesity, deranged lipid profile, abnormal liver functions,

and underlying diabetes mellitus. A BMI> 25 kg/m2 patient’s data has been entered in the grid, therapeutic
increases the risk of PsA.[16] Such patients need decisions can be made.
encouragement for dietary changes and life-style
modifications. It has been estimated that up to 50% of Various organizations have laid out treatment
untreated patients may develop persistent inflammation guidelines for PsA depending on the disease severity,
leading to joint damage culminating into disability derived from prevalent data. Prominent among
and deformation, severely limiting physical activity. these include GRAPPA,[10] European League against
However, there is paucity of data about reduction of PsA Rheumatism (EULAR),[17] and the American Academy
incidence rates if it is treated early and aggressively. of Dermatology (AAD).[18]

Assessment of PsA should begin with assessment of DRUG THERAPY OF PSA

the following five domains: skin disease, peripheral
arthritis, axial disease, enthesitis, and dactylitis. Drug therapy in PsA has been extrapolated from
Various measures of assessment are available for each drugs used to manage RA. These include those giving
of these domains [Table 1]. Based on these domains a symptomatic relief and those with disease-modifying
disease severity grid has been devised [Table 2]. Once a anti-rheumatic drugs (DMARDs) effect.

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Balakrishnan and Madnani Diagnosis and management of psoriatic arthritis

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) adverse events. Hepatotoxicity is the dreaded

side-effect and has been the topic for much debate. It
NSAIDs are used to reduce symptoms in acute episodes was generally felt that patients with PsA are more prone
of PsA. The choice of the drug depends on efficacy, to MTX hepatotoxicity than those with RA. However, it
adverse effects and co-morbidities. Long acting agents has been recently understood that it is not the psoriasis
like celecoxib[19] and nimesulide,[20] in a dose of 200- but the presence of pre-existing risk factors like a history
400 mg once daily, help to control symptoms and also of chronic viral hepatitis, consumption of excessive
to reduce morning stiffness. alcohol, hepatotoxic drugs or an inherited liver
disease, which could predispose to hepatotoxicity.[28]
CORTICOSTEROIDS Even so, it is safe to administer MTX by monitoring
the patients with serial LFTs and tests as per the
Systemic corticosteroids are usually avoided in PsA for American College of Rheumatology (ACR) guidelines.
the fear of precipitating of pustular psoriasis when they A liver biopsy should only be considered if LFTs are
are withdrawn suddenly.[21] However, when low dose persistently elevated.[29] MTX is teratogenic (Category X)
systemic steroids (≤ 7.5 mg/day of prednisolone)[22] and should be stopped in women at least 3 months
are combined with other DMARDs, good control before conception.
of symptoms can be achieved. Intra-articular
corticosteroid injections are reserved for mono/ CYCLOSPORINE A
oligoarthritis and maybe used as an adjuvant in patients
with well-controlled polyarthritis experiencing single Cyclosporine A (CyA) combines with cyclophilin
joint flares. Intra-articular injections are also helpful and forms a complex, which inhibits the intracellular
in patients experiencing dactylitis and enthesitis. enzyme, calcineurin. This reduces IL-2 (a potent
pro-inflammatory mediator) production by CD4-T
DMARDS cells. It also reduces other pro-inflammatory cytokines
such as Granulocyte-macrophage colony stimulating
Methotrexate (MTX), cyclosporine, and leflunomide factor (GM-CSF), Tumor necrosis factor-alfa (TNF-α),
(LEF) are often used as the first-line DMARDs in PsA Interleukin (IL)-1, IL-3, IL-4, IL-5, IL-6, IL-8 by
because of their ability to control both, the arthritis, inhibiting their transcription. This effectively results
and the cutaneous manifestations of psoriasis. in decreased T-cell and keratinocyte proliferation. CyA
has been used in doses ranging from 3-6 mg/kg/day
METHOTREXATE with variable outcome. Although, it shows excellent
results in reducing peripheral joint disease, its role
MTX has long been the mainstay drug for starting in controlling axial disease is dismal.[30] Potential,
therapy in PsA. However, surprisingly, a literature search irreversible nephrotoxicity is the dreaded complication
revealed only a few randomized controlled trials (RCTs) of CyA. With regular blood pressure monitoring and
demonstrating efficacy of MTX in PsA.[23-25] In a recently renal function tests, the toxicity can be kept in check.
concluded RCT to demonstrate the efficacy of MTX for Development of hypertrichosis may be a cosmetic
treatment of synovitis for PsA, no improvement was concern in women. Abrupt discontinuation of CyA
noted in symptoms of synovitis and the publication may result in a flare of psoriasis.
questioned the role of MTX as a DMARD.[26]
Another study suggested co-administration of a LEFLUNOMIDE
biologic (infliximab) for better patient outcome.[27]
MTX acts via inhibition of DNA synthesis in the Kaltwasser et al.,[31] randomized 190 patients of PsA
folate pathway, preferentially within lymphoid and psoriasis into 2 groups. One group of 95 patients
cells. It increases adenosine (anti-inflammatory) received 100 mg LEF, daily for 3 days and then 20 mg
concentration and decreases s-adenyl methionione daily up to 24 weeks. The second group (91 patients)
(pro-inflammatory) production. It is recommended to received placebo. At the end of 24 weeks, 58.9%
administer folic acid (1-5 mg/day) everyday, while on versus 29.7% were responders. The LEF group had
MTX therapy to minimize its toxicity. Early signs of higher GI symptoms and abnormal LFTs as compared
MTX intolerance include oral aphthosis, stomatitis, to the placebo group. LEF is a teratogenic drug and is
cutaneous ulceration and increased gastrointestinal contraindicated in women of childbearing potential.

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Balakrishnan and Madnani Diagnosis and management of psoriatic arthritis

Women should undergo a rapid wash-out procedure pathological changes seen in PsA. They not only control
with cholestyramine or should not become pregnant the psoriasis but also control synovitis, enthesitis,
for 2 years after the cessation of therapy. It is advisable and non-infectious inflammatory osteitis seen in PsA
that men wishing to father a child should discontinue [Table 3]. As a general consensus, biologic agents are
LEF and should also undergo the wash-out procedure. reserved for resistant disease [Table 4]. However, they
may be considered as first line for the treatment of
SULFASALAZINE (SSZ) enthesitis/dactylitis and those with predominantly
axial disease.[17]
Large RCT for SSZ in PsA are few. In a study by
Clegg Do, et al. of 264 patients comparing the Biologics target very specific components within the
efficacy of SSZ vs placebo in treating ankylosing inflammatory pathway of psoriatic disease process. Most
spondylitis revealed a trend favoring SSZ treatment widely used and studied are those which block TNF-α,
(P = 0.13). The authors concluded that SSZ at a dosage a potent pro-inflammatory cytokine. These include
of 2,000 mg/day was well-tolerated and may be more etarnercept,[37] infliximab[38,39] and adalimumab[40] all
effective than placebo in the treatment of patients with of which have received FDA approval for treatment
PsA.[32] Most of the other studies are small, precluding of PsA. Newer ones like certolizumab pegol,[41] and
meaningful conclusions. golimumab[42] have shown similar beneficial effects,
but adequate trials are still lacking. On starting therapy,
The other DMARDs used in the management of PsA functional capacity of the joints improves dramatically.
include mycophenolate mofetil,[33] azathioprine,[34] Concurrent administration of MTX improves drug
antimalarials, gold,[35,36] and penicillamine. survival, especially in patients receiving infliximab.[43]
Patients who develop reduced/no response to their
It is important to note that DMARDs in PsA have first anti-TNF-α drug can be switched over to another
their limitations. Although, some of them can control anti-TNF-α drug and this shows good improvement.[44]
psoriasis and the peripheral arthritis, they have not
been shown to be of value in the other facets of PsA Efalizumab, a humanized monoclonal antibody,
[Table 3]. which was in the market, has been withdrawn because
of it’s complication of causing progressive multifocal
BIOLOGIC THERAPY IN PSA leukoencephalopathy.[45]

Over the last decade, targeted therapy with biologic Ustekinumab is a newer humanized monoclonal
agents has revolutionized the treatment of PsA since antibody, which selectively binds to the p40 subunit
they are the only agents that can address all the of IL-12 and IL-23, and inhibits their binding to

Table 3: Efficacy of drugs in psoriatic arthritis

Drugs Psoriasis Nail Peripheral Spondylitis Enthesitis Dactylitis Extra-articular features
disease arthritis (uveitis)
NSAIDs − − + + − − −
MTX + + + − − − ±
CyA, LEF + + + − − − ±
Other DMARDs − − + − − − −
Biologic agents + + + + + + +
MTX: Methotrexate, CyA: Cyclosporine A, DMARDs: Disease-modifying anti-rheumatic drugs NSAIDs: Non-steroidal anti-inflammatory drugs, LEF: Leflunomide

Table 4: Indications for biologic agents in psoriatic arthritis

Psoriasis Nail Peripheral Spondylitis Enthesitis Dactylitis Extra-articular features
arthritis (uveitis)
Extensive Ps not NR to local NR to NSAIDs, NR to NSAIDs NR to NSAIDs NR to NSAIDs NR to local therapy,
responding to and traditional intra-articular and local and local systemic steroids and other
Phototherapy, retinoids, systemic injections and cortisone cortisone immunosuppressants
MTX and CyA retinoids, MTX traditional injections injections
and CyA DMARDs
NR: not responding, MTX: Methotrexate, CyA:Cyclosporine A, DMARDs: Disease-modifying anti-rheumatic drugs

S22 Indian Journal of Dermatology, Venereology, and Leprology | 2013 | Vol 79 | Supplement 1
Balakrishnan and Madnani Diagnosis and management of psoriatic arthritis

the receptor IL-12Rβ1. IL-23 plays a key role in the disease extent and severity have been staged. Biologic
Th17 mediated inflammatory pathway while IL-12 agents have been impressive in the management of
is a key cytokine in the Th1 inflammatory pathway. severe PsA. However, patient selection and screening
So ustekinumab can potentially inhibit both for latent tuberculosis are both important. Combined
inflammatory pathways. Early clinical studies have management by the dermatologist and rheumatologist
shown to improve dactylitis and enthesitis in PsA.[46] is required for better patient care.

Alefacept inhibits LFA-3/CD2 interaction by blocking ACKNOWLEDGMENT

the CD2 receptor on the T lymphocytes which then
prevents T-cell activation. It is important to monitor We sincerely appreciate the assistance of Dr. Kaleem Khan in
CD4 T-cell levels while on treatment with Alefacept.[47] the preparation of this manuscript.

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S24 Indian Journal of Dermatology, Venereology, and Leprology | 2013 | Vol 79 | Supplement 1