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Psoriatic Arthritis

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gouty-arthritis: Psoriatic Arthritis Presentation
As well as causing joint inflammation, psoriatic arthritis can cause tendinitis and a sausage-like swelling of the digits known as dactylitis. Radiology will give the appearance of "fluffy, new" bone.
Causes
The exact causes are not yet known, but several genetic associations have been identified.
Types of psoriatic arthritis
There are five main types of Psoriatic Arthritis:
Symmetric: This type accounts for around 50% of cases, and affects joints on both sides of the body simultaneously. This type is most similar to Rheumatoid arthritis and is disabling in around 50% of all cases.
Asymmetric: This type affects around 35% of patients and is generally mild. This type does not occur in the same joints on both sides of the body and usually only involves less than 3 joints.
Arthritis mutilans (M07.1): Affects less than 5% of patients and is a severe, deforming and destructive arthritis. This condition can progress over months or years causing severe joint damage. Arthritis mutilans has also be called chronic absorptive arthritis, and may be seen in rheumatoid arthritis as well.
Spondylitis (M07.2): This type is characterised by stiffness of the spine or neck, but can also affect the hands and feet, in a similar fashion to symmetric arthritis.
Distal interphalangeal predominant (M07.0): This type of Psoriatic Arthritis is found in about 5% of patients, and is characterised by inflammation and stiffness in the joints nearest to the ends of the fingers and toes. Nail changes are often marked.
Treatments
The underlying process in Psoriatic Arthritis is inflammation, therefore treatments are directed at reducing and controlling inflammation. NSAIDs such as diclofenac and naproxen are usually the first line medication.
Other treatment options for this disease include joint injections with corticosteroids - this is only practical if a few joints are affected.
If acceptable control is not achieved using NSAIDs or joint injections then second line treatments with immunosuppressants such as methotrexate or leflunomide are added to the treatment regimen. An advantage of immunosuppressive treatment is that it also treats the psoriasis in addition to the arthropathy.
Recently, a new class of therapeutics developed using recombinant DNA technology called Tumor necrosis factor-alpha inhibitors have come available, for example, infliximab, etanercept, Golimumab and adalimumab. These are becoming increasingly commonly used but are usually reserved for the most severe cases. As more is learned regarding the long-term safety of these biologic agents there is a trend toward earlier use to prevent irreversible joint destruction.
In psoriatic arthritis patients with severe joint damage orthopedic surgery may be inplemented to correct joint destruction, usually with use of a joint replacement. Surgery is effective for pain alleviation, correcting joint disfigurement, and reinforcing joint usefulness and strength.
Additional images
Magnetic resonance image of the index finger in psoriatic arthritis (mutilans form). Shown is a T2 weighted fat suppressed sagittal image. Focal increased signal (probable erosion) is seen at the base of the middle phalanx (long thin arrow). There is synovitis at the proximal interphalangeal joint (long thick arrow) plus increased signal in the overlying soft tissues indicating oedema (short thick arrow). There is also diffuse bone oedema (short thin arrows) involving the head of the proximal phalanx and extending distally down the shaft.
Magnetic resonance images of the fingers in psoriatic arthritis. Shown are T1 weighted axial (a) pre-contrast and (b) post-contrast images exhibiting dactylitis due to flexor tenosynovitis at the second finger with enhancement and thickening of the tendon sheath (large arrow). Synovitis is seen in the fourth proximal interphalangeal joint (small arrow).
(a) T1-weighted and (b) short tau inversion recovery (STIR) magnetic resonance images of lumbar and lower thoracic spine in psoriatic arthritis. Signs of active inflammation are seen at several levels (arrows). In particular, anterior spondylitis is seen at level L1/L2 and an inflammatory Andersson lesion at the upper vertebral endplate of L3.
Magnetic resonance images of sacroiliac joints. Shown are T1-weighted semi-coronal magnetic resonance images through the sacroiliac joints (a) before and (b) after intravenous contrast injection. Enhancement is seen at the right sacroiliac joint (arrow, left side of image), indicating active sacroiliitis.
References
Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0071380760.
James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0721629210.
About psoriatic arthritis, National Psoriasis Foundation, http://www.psoriasis.org/about/psa/, retrieved 2008-08-31
Liu Y, Helms C, Liao W, et al. (March 2008). "A genome-wide association study of psoriasis and psoriatic arthritis identifies new disease loci". PLoS Genet. 4 (3): e1000041. doi:10.1371/journal.pgen.1000041. PMID 18369459. PMC 2274885. http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1000041.
Rahman P, Elder JT (March 2005). "Genetic epidemiology of psoriasis and psoriatic arthritis". Ann. Rheum. Dis. 64 Suppl 2: ii379; discussion ii401. doi:10.1136/ard.2004.030775. PMID 15708933. PMC 1766868. http://ard.bmj.com/cgi/pmidlookup?view=long&pmid=15708933.
External links
National Psoriasis Foundation
Psoriasis Cure Now nonprofit advocacy group
The Psoriasis and Psoriatic Arthritis Alliance (PAPAA) - UK national charity
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Diseases of the skin and subcutaneous tissue (integumentary system) (L, 680-709)
Infections
Bacterial
skin disease
Staphylococcus (Staphylococcal scalded skin syndrome, Impetigo, Boil, Carbuncle) Strep (Impetigo) Corynebacterium (Erythrasma)
Viral
skin disease
Wart Molluscum contagiosum Erythema infectiosum Exanthema subitum Herpes simplex (Herpetic whitlow, Eczema herpeticum)
General
Cellulitis (Paronychia) Acute lymphadenitis Pilonidal cyst Pimple (Pustule)
Bullous
disorders
acantholysis (Pemphigus, Transient acantholytic dermatosis) Pemphigoid (Bullous, Cicatricial, Gestational) Dermatitis herpetiformis
Inflammatory
Dermatitis
and eczema
Atopic dermatitis Seborrhoeic dermatitis (Dandruff, Cradle cap) Contact dermatitis (Diaper rash, Urushiol-induced contact dermatitis) Erythroderma Lichen simplex chronicus/Prurigo nodularis Itch (Pruritus ani, Pruritus scroti, Pruritus vulvae) Nummular dermatitis Dyshidrosis Pityriasis alba
Papulosquamous
disorders
Psoriasis (Psoriatic arthritis) Parapsoriasis (Pityriasis lichenoides et varioliformis acuta, Pityriasis lichenoides chronica, Lymphomatoid papulosis) other pityriasis (Pityriasis rosea, Pityriasis rubra pilaris) other lichenoid (Lichen planus, Lichen nitidus)
Urticaria
Dermatographic urticaria Cold urticaria Cholinergic urticaria Solar urticaria
Erythema
Erythema multiforme/
drug eruption
Stevens-Johnson syndrome Toxic epidermal necrolysis Erythema nodosum Acute generalized exanthematous pustulosis
Other erythema
Erythema annulare centrifugum Erythema marginatum Keratolytic winter erythema Necrolytic migratory erythema Erythema toxicum
Radiation-related
disorders
Sunburn actinic rays (Actinic keratosis, Actinic cheilitis) Polymorphous light eruption (Acne aestivalis) Radiodermatitis Erythema ab igne
Pigmentation/
Dyschromia
hypopigmentation (Albinism, Vitiligo) hyperpigmentation (Melasma, Freckle, Caf au lait spot, Lentigo/Liver spot, Acanthosis nigricans, Acral acanthotic anomaly)
Other skin
keratosis/hyperkeratosis (Seborrheic keratosis, Callus) other epidermal thickening (Ichthyosis acquisita, Palmoplantar keratoderma)
skin ulcer (Pyoderma gangrenosum, Bedsore)
Cutaneous Markers of Internal Malignancy (Florid cutaneous papillomatosis, acanthosis nigricans, sign of Leser-Trelat)
atrophic (Lichen sclerosus, Acrodermatitis chronica atrophicans)
necrobiosis (Granuloma annulare, Necrobiosis lipoidica) other granuloma (Granuloma faciale, Pyogenic granuloma)
cutaneous vasculitis (Livedoid vasculitis, Erythema elevatum diutinum)
Connective
tissues
collagen disease: Keloid
localized connective tissue disorders: Lupus erythematosus (Discoid lupus erythematosus, Subacute cutaneous lupus erythematosus) Scleroderma/Morphea Linear scleroderma Calcinosis cutis Sclerodactyly Ainhum
integument, SF, LCT navs: anat/physio, noncongen/congen/neoplasia, symptoms+signs/eponymous, proc
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Musculoskeletal disorders: Arthropathies (M00-M19, 711-719)
Arthritis
(monoarthritis/
polyarthritis)
Inflammation
(Neutrophilia)
Infectious
Septic arthritis Tuberculosis arthritis Reactive arthritis (indirectly)
Noninfectious
Seronegative spondyloarthropathy: Reactive arthritis Psoriatic arthritis Ankylosing spondylitis
Rheumatoid arthritis: Juvenile idiopathic arthritis Adult-onset Still's disease Felty's syndrome
Crystal arthropathy: Gout Chondrocalcinosis
Noninflammatory
Osteoarthritis: Heberden's node Bouchard's nodes
Other
hemorrhage (Hemarthrosis) pain (Arthralgia) Osteophyte Hypermobility villonodular synovitis (Pigmented villonodular synovitis) Joint stiffness
joint navs: anat, non-congenital arthropathies/deformities/dorsopathies/soft tissue arthropathy/congenital, eponymous signs, proc
Categories: Arthritis | Psoriasis | Rheumatology

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