Rheumatology 2012;51:2058–2063

RHEUMATOLOGY doi:10.1093/rheumatology/kes187
Advance Access publication 9 August 2012

Original article
The early psoriatic arthritis screening questionnaire:
a simple and fast method for the identification of
arthritis in patients with psoriasis
Ilaria Tinazzi1, Silvano Adami1, Elisabetta Maria Zanolin2, Cristian Caimmi1,
Silvia Confente1, Giampiero Girolomoni3, Paolo Gisondi3, Domenico Biasi1 and

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Dennis McGonagle4

Abstract
Objective. Dermatologists usually see patients with psoriasis before arthritis develops, making them well
placed to diagnose early PsA (ePsA). This study aimed to develop a rapid and robust screening ques-
tionnaire for predicting PsA in patients with psoriasis referred to a specialized joint dermatology–rheuma-
tology combined clinic.
Methods. In all, 228 psoriasis patients naı̈ve to DMARD treatment were administered two screening
questionnaire: the new Early ARthritis for Psoriatic patients (EARP) questionnaire and the existing
Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire. The diagnostic accuracy of the two
questionnaires for the diagnosis of ePsA was compared by receiving operating characteristics curves.
Results. After psychometric analysis, a simplified questionnaire of 10 items was found to have good
internal reliability (Cronbach’s a = 0.83) and was much faster and simpler to administer than the PASE.
Both the EARP and PASE questionnaires presented similar receiving operating characteristics curves
(specificity 91.6 and 67.2 and sensitivity 85.2 and 90.7, respectively) in identifying ePsA patients by
using the cut-off value of 3 for EARP-10 and the standard cut-off value of 44 for PASE. The CASPAR
criteria for PsA were present in 61 (26.7%) of the patients at clinical presentation and in 32.9% at 1-year
follow-up, and the EARP score of 53 correlated with clinically determined arthropathy by a
CLINICAL
SCIENCE

rheumatologist.
Conclusion. The EARP questionnaire is simple and fast to administer and proved robust for the identi-
fication of PsA in the dermatological setting. Dermatologists should consider the EARP for patients
attending clinics, as it correlates well with early PsA diagnosis.
Key words: screening questionnaire, ePsA, PASE, psoriasis.

Introduction
who will develop PsA is an area of significant controversy,
PsA is an inflammatory arthritis associated with psoriasis with studies demonstrating a range from as low as 6% to
that can have either an indolent or rapidly progressive as high as 42% [1, 2]. Typically psoriasis patients initially
course. The exact proportion of patients with psoriasis seek treatment for their skin and then are referred to a
rheumatologist as arthritic symptoms develop. However,
1
concurrent PsA in psoriasis patients may be overlooked in
Unit of Rheumatology, 2Department of Public Health and Medicine,
Unit of Epidemiology and Medical Statistics, 3Department of Medicine,
dermatology and general medicine practices, particularly
Section of Dermatology and Venereology, University of Verona, in the early stages of the disease, as enthesitis-related
Verona, Italy and 4Section of Musculoskeletal Diseases, NIHR Leeds manifestations at clinically inaccessible sites may be dif-
Biomedical Research Unit, Leeds Institute of Molecular Medicine,
University of Leeds, Leeds, UK. ficult to recognize, and inflammatory markers may remain
Submitted 5 January 2012; revised version accepted 1 June 2012. normal.
Correspondence to: Ilaria Tinazzi, Unit of Rheumatology, University of
Several factors contribute to the delay in diagnosis of
Verona, P. le Scuro, 1 37134 Verona, Italy. E-mail: ilariatinazzi@yahoo.it PsA. These include the lack of awareness among patients

! The Author 2012. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com
 EARP questionnaire to detect early PsA

of the relationship between skin symptoms and joint rheumatologist. The two questionnaires were adminis-
symptoms and the absence of a specific diagnostic tered in a random sequence (1/1).
marker. Ideally every psoriasis patient with musculoskel- The PASE questionnaire [4] consists of two subscales:
etal pain should be evaluated by a rheumatologist, but this symptoms and function. The back-translation from Italian
is not practical. Accordingly, several groups developed to English yielded no appreciable differences. The pos-
screening questionnaires for use in the dermatology or sible answers consist of five categories (1–5) related to
general practice setting to identify individuals that might the level of agreement with the statement (strongly
be at high risk for the development of PsA [3–5]. These agree to strongly disagree). A total score was calculated
include the Toronto Psoriatic Arthritis Screen (ToPAS) by summing the score for each question, with a range of
screening questionnaire, the Psoriatic Arthritis Screening 15–75.
and Evaluation (PASE) questionnaire, the Psoriasis and The EARP questionnaire was developed through review
Arthritis Questionnaire [3–5] and the Psoriasis of the typical symptoms and signs seen among patients
Epidemiology Screening Tool (PEST) questionnaire [6]. with an established diagnosis of PsA. Fourteen questions

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None of these questionnaires is focused on early diagno- were jointly selected by a group of experts of the Verona
sis of PsA, and the reference population included patients University. Patients were asked about possible recent epi-
already on DMARDs. The ToPAS screening questionnaire sodes of joint swelling, enthesitis, dactylitis, and back and
[5] was also designed for family medicine to help to rec- hand morning stiffness occurring during the past 12
ognize psoriasis, nail lesions and joint manifestations. The months. The questionnaire was composed of dichotom-
other two questionnaires are focused more on the preva- ous (yes/no) items; the total score was calculated by sum-
lence of joint disease among patients with psoriasis. ming the score of each question.
Peloso et al. [3] developed the Psoriasis and Arthritis The time taken by the patient to complete the PASE and
Questionnaire, a 12-item questionnaire in a cohort of EARP questionnaires (14 items) was measured. The study
108 patients, and they found a sensitivity of 0.85 and spe- was approved by the Ethics Boards of the University of
cificity of 0.88 in predicting PsA for a score of 57. By Verona and written consent was obtained from all cases.
testing the same questionnaire in a larger cohort of psor-
Patients
iasis patients, Alenius et al. [3] could not confirm the same
diagnostic accuracy, and the cut-off was set to 4. The patients were approached to enroll in the study while
Ibrahim et al. [6] developed a five-question question- in the waiting room of the psoriasis clinic of the University
naire—the PEST—starting from a community-based of Verona. This clinic is jointly staffed by both dermatolo-
survey of people with psoriasis and found a sensitivity of gists and rheumatologists. GPs in the Verona region typ-
0.92 and specificity of 0.78 in predicting PsA. ically refer the most severe cases and possibly those with
Recently Dominguez et al. [4] developed the PASE psoriasis and joint symptoms to this particular outpatient
questionnaire, which consists of symptom and function clinic. Adults between the ages of 18 and 85 years, with an
subscales. This was predominantly designed to score established diagnosis of psoriasis that were naı̈ve to sys-
joint involvement for the early identification of PsA. temic treatment with a DMARD, were enrolled. We
However, in our hands, the PASE was cumbersome for excluded individuals known to be affected by long-stand-
patients and rather time consuming. In the present study ing PsA or with a concomitant diagnosis of RA, gout and
we evaluated a cohort of psoriasis cases using a screen- other rheumatic diseases.
ing questionnaire that was progressively simplified without
loosing diagnostic accuracy. We undertook this in a joint Rheumatological assessment
dermatology–rheumatology early psoriasis clinic, and we After filling out the questionnaires, all patients underwent
report the development of a new questionnaire—Early blood tests (CRP, ESR, RF, ACPA) and a full clinical, radio-
Arthritis for Psoriatic Patients (EARP)—that is very user graphic assessment independently of knowledge of the
friendly and easy to administer. We compared the EARP questionnaire findings. The clinical examination was per-
with the PASE, as the latter existing questionnaire was formed by an experienced rheumatologist. This included
developed for screening potential early PsA (ePsA). the 68-joint count for swelling and tender joints. The pres-
Herein we report that the EARP is a new rapid screening ence of possible enthesitis was assessed by the
method for the identification of PsA in the psoriasis clinic Maastricht Ankylosing Spondylitis Enthesis Score
of Verona University Hospital. (MASES) index [7]. Patients were also questioned about
the presence of previous bouts of dactylitis, namely,
a history of sausage-like digital swelling in the previous
Patients and methods 6 months. The Classification Criteria for Psoriatic
Arthritis (CASPAR) diagnostic criteria were applied [8].
Study design
The study was done in a randomized, investigator-blinded Statistical analysis
design. Patients completed both the EARP (initial format Statistical analyses were performed using the SPSS 17.0
having 14 questions) and the Italian translation of the (Chicago, IL, USA) and STATA10.1 software packages.
PASE questionnaire, both of which were self-administered Continuous data with normal distribution were expressed
before the patient was clinically evaluated by the as mean (S.D.); data with normal distribution with the

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Ilaria Tinazzi et al.

Shapiro–Wilk test were expressed as median (interquartile Results

range). P < 0.05 was considered significant.
Patient assessment
Principal component analysis
The initial study population included 386 patients;
To identify the number of the underlying components of
85 patients previously treated with DMARDs, 42 affected
the initial EARP-14 questionnaire, the Pearson’s correl-
by long-standing PsA and 31 with concomitant rheumatic
ation matrix was explored by means of principal compo-
disease were excluded as per protocol (Fig. 1). The 228
nent analysis (PCA) [9]; items weakly correlated with the
remaining patients had never been previously investigated
others (r < 0.20) were excluded from further analysis. The
by a rheumatologist, and all of them completed both
number of components was determined on the basis of
PASE and EARP questionnaires. The CASPAR criteria
eigenvalues of the correlation matrix >1. Item-component
were present in 61 (26.7%) of the patients at clinical pres-
correlations, i.e component loading, >0.40, in absolute
entation. The clinical characteristics of these patients are
value, were chosen to identify a simple component struc-

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listed in Table 1.
ture. At the end of this analysis, the component number
All patients had a further rheumatological assessment
was forced to one to obtain a single scale.
at the 3-month interval, and this allowed the identification
Multiple correspondence analysis phase of 14 additional cases (6.1%) of ePsA by 12 months. The
The multiple correspondence analysis phase (MCA) or clinical characteristics of this second group of patients are
homogeneity analysis (HOMALS) [10] is designed to test also listed in Table 1.
item internal homogeneity and reliability for each dimen-
sion of the PCA. This method uses the yes/no answers as Questionnaire completion and EARP refinement
nominal category responses, and enables optimal grading
for each category response of the questions (called opti- The original items of the EARP questionnaire comprised
mal weights); consequently, an optimal score for each 14 items (the EARP-14). The PASE questionnaire was
subject could be obtained. The optimal score of a subject completed in 6 (2) [mean (SD)] min, whereas the
is the sum of the optimal weights of the item options EARP-14 required 2 (1.5) min. The correlation matrix
chosen. According to the criterion of internal consistency, among the questions of the EARP-14 revealed that four
MCA computes a homogeneity index (called Guttman’s questions (q2, q4, q12, q13) were weakly correlated
Z), and the optimal reliability determined by Cronbach’s (r < 0.20) with the others and were then excluded from
a coefficient is a one-to-one transformation of Guttman’s the PCA (Table 2). The PCA identified two dominant com-
Z [11]. Good internal consistency has been suggested if ponents (eigenvalues > 1), explaining 54% of the total
Cronbach’s a > 0.70, and good homogeneity has been variance, and 75% of the pair-wise correlations of the
suggested if Guttman’s Z > 0.30 [11]. Correlations be- 10 questions examined. As all items were binary, compo-
tween each item and the total score of the questionnaire, nent loading patterns are equal to optimal item–total cor-
the total score excluding that specific item (item–rest) and relation (Table 2). This component includes the 10 items
between the optimal item and the total score were composing the final 10-item EARP questionnaire
calculated. (EARP-10), henceforth referred to as the EARP (Table 3).
The four questions removed were as follows: Do you feel
Receiver operating characteristic curves that your joints are limiting your movement? Is your back
stiff for >15 min when you wake up? Do you have plantar
The receiver operating characteristic (ROC) curves burning and pain when you walk? and Do your knees
were constructed to investigate the diagnostic perform- swell? The internal criterion index (Guttman’s Z) of the
ance of PASE and of the newly developed EARP ques- MCA/HOMALS scaling was equal to 0.394, and the
tionnaire. The area under the curve (AUC) provided a Cronbach’s a coefficient was 0.83, indicating a good scal-
measure of the overall discriminative ability of the predic- ing [11]. The raw item–total score correlations varied from
tion rule. The ROC curves were used also to identify pos- 0.79 (q1) to 0.48 (q10) (Table 2); the same trend was found
sible discriminatory cut-off points for the questionnaires for the raw item–rest correlation from 0.71 (q1) to 0.36
using the Youden test. The sensitivity and specificity were
(q10) and for the optimal item–total score correlations
determined for several cut-off values of the prediction
from 0.81 (q1) to 0.46 (q10). This suggests that the sum
score.
row scores or the sum optimal scores were good [10]
values of the true scores of the continuous uni-
Psoriasis patient follow-up dimensional factor underlying the 10-item set and are
Patients with psoriasis but without a diagnosis of PsA at useful to detect ePsA.
baseline according to the CASPAR criteria were once The ROC curves were constructed to investigate the
again evaluated after 1 year to ascertain whether clinical diagnostic performance of PASE and EARP (Fig. 2). For
PsA had evolved. The clinical examination was performed EARP, a cut-off point of 3 was found to be associated with
by an experienced rheumatologist applying the CASPAR the best diagnostic performances, whereas for PASE, the
criteria [8]. The baseline EARP scores were compared cut-off of 44 defined by the authors of the questionnaire
with the total numbers of cases with PsA at the end of was used. The measured AUC was 0.895 [standard error
this period. (S.E.) 0.030; 95% CI 0.836, 0.954] for PASE, whereas the

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 EARP questionnaire to detect early PsA

FIG. 1 Study population flow chart.

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A total of 386 patients affected by psoriasis (PsO) were included; 85 patients previously treated with DMARDs, 42
affected by long-standing PsA and 31 with concomitant rheumatic disease were excluded.

TABLE 1 Baseline characteristics of patients

PsA (n = 71) PsO (n = 147) Incident PsA (n = 14) P

Age at inclusion, mean (S.D.), years 50.1 (11.4) 49.2 (12.9) 45.8 ± 8.4 0.31
Sex, women, % 50.7 47.9 35.5 0.01
BMI, median (range) 26 (18–31) 25 (19–36) 27 (20–34) 0.58
Clinical presentation, n (%)
Polyarthritis (53) 14 (19.4)
Oligoarthritis (<3) 22 (30.5)
Dactylitis 11 (15.3)
Spinal involvement 2 (2.8)
MASES, median (IQR) 2 (0–4) 0 (0–1) 1 (0–3) 0.01
TJ 68, median (IQR) 4 (2–10) 0 (0–2) 1 (0–2) 0.01
SJ 68, median (IQR) 2 (0–5) 0 (0–1) 0 (0–1) 0.05
BASDAI, median (IQR) 3.3 (2.1–9.7) 1.4 (0.7–3.2) 1.6 (0.8–4) 0.04
PASI, mean (S.D.) 6.8 (3.18) 5.8 (2.88) 6.2 (2.54) 0.18
Onicopathy, n (%) 41 (56.9) 65 (45.7) 8 (57.1) 0.22

Baseline characteristics of the 228 patients included in the study. All these patients completed EARP and PASE questionnaires
and were followed over 1 year. PsO: psoriasis, IQR: interquartile range, TJ: tender joints, SJ: swollen joints; PASI: Psoriasis
Area and Severity Index.

AUC of EARP was slightly higher at 0.906 (S.E. 0.025; 95% 44. In the 14 patients who developed PsA within the
CI 0.857, 0.955) (Fig. 2). following year, the baseline EARP score was >3 in 10,
The EARP false-positive rate (i.e. with a score 53 but whereas a PASE score >44 was present in only 5 of the
without PsA) was 22.3% (19 of 85 patients), and the patients.
false-negative rate was 3.5% (5 of 143 patients); i.e.
ePsA patients with a score <3 on the EARP but with
Discussion
PsA. This yields a sensitivity of 85.2% and a specificity
of 91.6%. The sensitivity and specificity of the PASE was In this study we have shown that a large proportion of
90.7% (95% CI 54.3, 78.4) and 67.2% (95% CI 79.7, patients with psoriasis exhibit previously unrecognized
96.9), respectively. Sensitivity and specificity rose to signs of ePsA, and that this can be reliably collected
87.5% (95% CI 76.8, 94.4) and to 81.5% (95% CI 68.5, using the new EARP screening questionnaire. Moreover,
90.7), respectively, with a cut-off equal to 36 rather than the EARP was extremely quick to administer in

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Ilaria Tinazzi et al.

TABLE 2 Raw item–total, raw item–rest and optimal this study, the development of a PsA screening question-
item–total correlations of EARP naire, such a referral pattern would be useful. The clinical
signs of the PsA appeared within a year in an additional
Raw Raw Optimal 6.1% of patients. This is much more than that reported in
item–total item–rest item–total epidemiological surveys, where only 10% of cases de-
Question no. correlation correlation correlation velop PsA after a decade of follow-up [1]. However, in
previous studies the incidence of PsA was reported,
1 0.791 0.711 0.811
rather than assessed, and this inevitably might consider-
2 0.687 0.582 0.682
3 0.511 0.394 0.486
ably underestimate the true disease incidence.
4 0.616 0.503 0.615 Our results underline the importance of periodic
5 0.733 0.635 0.744 rheumatology assessment, or at least rheumatic symptom
6 0.666 0.554 0.674 evaluation, among psoriasis patients with tools such as
7 0.492 0.382 0.493 EARP.

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8 0.477 0.364 0.456 A delayed diagnosis of PsA may result in joint destruc-
9 0.662 0.546 0.647 tion and permanent disabilities, whereas early diagnosis
10 0.590 0.464 0.568 and prompt therapy could prevent this irreversible joint
damage [13]. The EARP questionnaire we developed
was able to identify most of the PsA patients. The EARP
questionnaire revealed an internal homogeneity, as
TABLE 3 The EARP questionnaire Guttman’s Z was equal to 0.394, and >0.30 is considered
the cut-off for high homogeneity. Cronbach’s a was 0.83,
denoting very good reliability [11] and indicating a low
Question Yes No
degree of error in measuring the characteristic of interest.
Do your joints hurt? 1 0 The question with the best item–total and optimal
Have you taken anti-inflammatory more than 1 0 item–total correlation was q1, followed by q7, which are
twice a week for joint pain in the last 3 months? the most generic questions about general joint pain or
Do you wake up at night because of low back 1 0 hand joint involvement, respectively.
pain?
The sensitivity and specificity were 91% and 85%,
Do you feel stiffness in your hands for more than 1 0
30 minutes in the morning? respectively, for the cut-off value of 3.
Do your wrists and fingers hurt? 1 0 In this study, the diagnostic accuracy of EARP was
Do your wrists and fingers swell? 1 0 somewhat superior to that achieved by PASE with the
Does one finger hurt and swell for more than 1 0 cut-off score of 44 identified by the authors [4], and it
3 days?
increased slightly when the cut-off was optimized to 36
Does your Achilles tendon swell? 1 0
Do your feet or ankles hurt? 1 0 (data not shown). However, the main problem for PASE
Do your elbow or hips hurt? 1 0 remains its complexity, which makes it unsuitable for a
quick survey in outpatient dermatology clinics. The EARP
The final 10 items of the EARP questionnaire were chosen can be administered or even self-administered within a
after the psychometric analysis. Each positive answer is couple of minutes, which favourably compares with
scored as one, and the final score is calculated by summing PASE requiring >5 min with a trained specialist.
the positive answers. The authors of the PEST questionnaire [6] used 5 items
from their original 16 questions. This questionnaire also
included questions about familiarity, patient’s thoughts
and nail assessment to identify PsA in general practice,
the psoriasis population and was useful in a real-world and the authors did not exclude known PsA cases [6]. The
setting of psoriasis patients presenting in the dermatology EARP questions focused specifically on patients’ symp-
clinical setting for the first time. Moreover, patients with toms to identify new diagnoses of PsA in a dermatological
symptoms without clinical PsA often progressed to PsA clinical setting.
within the following year. The relatively large number of An obvious limitation of this study is the lack of valid-
cases recruited and the longitudinal follow-up for 1 year ation in a different cohort of patients. This will be per-
in a dermatological setting suggest that the EARP could formed in future EARP validation studies. An additional
be a useful screening tool for ePsA. This needs validation limitation is the language of the questionnaire, which will
in a new cohort of psoriasis cases. need validation in other languages. However, the ques-
Twenty-six per cent of patients at baseline fulfilled the tions are extremely simple and intuitive and problems in
CASPAR criteria; such high prevelance rates of PsA transferring the results into different languages appear
in psoriasis have been previously reported by others unlikely. In conclusion, the EARP questionnaire we de-
[2, 12]. However, we cannot rule out a kind of referral veloped for identifying psoriasis patients with ePsA is ex-
bias, given that ours is a joint dermatology–rheumatology tremely simple and can be self-administered. Its
psoriasis clinic that might attract a larger proportion of sensitivity and specificity in identifying psoriasis
patients with joint problems. For the primary purpose of patients who should be referred for a rheumatological

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 EARP questionnaire to detect early PsA

FIG. 2 ROC curves of EARP items (A) and the PASE questionnaire (B).

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Area under the curve of PASE is 0.884 (S.E. 0.031; 95% CI 0.823, 0.9). Area under the curve of EARP-10 is 0.903
(S.E. 0.025; 95% CI 0.854, 0.952).

work-up appears to be as accurate as more complex the psoriatic arthritis screening and evalutation
tools. questionnaire. Arch Dermatol Res 2009;301:573–79.
5 Gladman DD, Schentag CT, Tom BD et al. Developement
and initial validation of a screening questionnaire for
Rheumatology key messages
psoriatic arthritis: the Toronto Psoriatic Arhritis
. ePsA identification is a difficult and controversial Screen (ToPAS). Ann Rheum Dis 2009;68:497–501.
topic. 6 Ibrahim GH, Buch MH, Lawson C, Waxman R,
. Many screening questionnaires to detect PsA are Helliwell PS. Evaluation of an existing screening tool for
not used by dermatologists in everyday practice psoriatic arthritis in people with psoriasis and the devel-
because of their complexity. opment of a new instrument: the Psoriasis Epidemiology
. The EARP is fast and easy for dermatologists to Screening Tool (PEST) questionnaire. Clin Exp Rheumatol
use to identify early symptoms of PsA. 2009;27:469–74.
7 Kaya A, Ozgocmen S, Kamanli A, Aydogan R, Yildirim A,
Ardicoglu O. Evaluation of a quantitative scoring of
Disclosure statement: The authors have declared no enthesitis in ankylosing spondylitis. J Clin Reumatol 2007;
conflicts of interest. 13:303–6.
8 Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P,
Mielants H, and the CASPAR Study Group. Classification
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