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1

Chief complaint
Swelling and erythematous plaques with painful sensation
for right leg for over a month.
2
History of present illness
Patient is a 47 year old male with a history of psoriatic arthritis and
regularly followed up a at our OPD. He also has a history of binge
drinking leading to alcoholism, depression- social withdrawal,
insomnia, and a smoker for 25+ years. Patient suffered hip pain
and left knee pain in for about 6 months but failed to be controlled
by pain medication. Severe psoriasis arthropathy patient with large
BSA >40% was noted, he also complained of severe arthralgia of
upper and lower extremity joints. Exacerbated psoriasis with
secondary infection recently. This time he suffered from Skin
lesions which include scaly, erythematous plaques; Distal
extremity swelling with nails and DIP joint deformity, and painful
sensation of right leg for over half a month he called at keelung
hospital. Multiple erythematous plaques with silver crust were
noted on trunk , back and all extremities. Due to this problem he as
admitted for further evaluation and management.
3
Hx of suspected RCC of R't nephrectomy.
Occupation:
Personal Hx:Smoking:>1/2PPD; Drinking(+)
O:BW:68Kg, BH:172cm
Multiple psoriasis, whole body>40%BSA, limbs nails.
joint deformity(+)
skin change over L't elbow.
4
2009-04-22:
MRI:1. Avascular necrosis of left femoral head with
synovitis of left hip joint.
2. suggestive of sacroilitis,bilateral.
2013/9/16:Exacerbated skin rash over whole body
A:Psoriatic arthropathy; alcoholism; Insomnia;
Suspect L't hip AVN due to alcoholism.
P:Medication; phototherapy
Treatment effect: Stable under current medication.

5

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Psoriatic Arthritis
A complex and severe disabling
disease
7
Introduction to Psoriatic Arthritis (PsA)
Chronic progressive, inflammatory disorder of the joints and skin
1
Characterized by osteolysis and bony proliferation
1
Clinical manifestations include dactylitis, enthesitis,
osteoperiostitis, large joint oligoarthritis, arthritis mutilans,
sacroiliitis, spondylitis, and distal interphalangeal arthritis
1

PsA is one of a group of disorders known as the
spondyloarthropathies
2
Males and females are equally affected
3
PsA can range from mild nondestructive disease to a severely rapid
and destructive arthropathy
3
Usually Rheumatoid Factor negative
3
Radiographic damage can be noted in up to 47% of patients at a
median interval of two years despite clinical improvement with
standard DMARD therapy
4
1
Taylor WJ. Curr Opin Rheumatol. 2002;14:98103.
2
Mease P. Curr Opin Rheumatol. 2004;16:366370.
3
Brockbank J, et al. Exp Opin Invest Drugs. 2000;9:15111522.
4
Kane D, et al. Rheumatology. 2003;42:14601468.
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Spondyloarthritis, Psoriasis and PsA
Spondyloarthritis (SpA)
The prevalence of SpA is comparable to that of RA (0.51.9%)
1,2

Psoriasis (Pso)
Psoriasis affects 2% of population
7% to 42% of patients with Pso will develop arthritis
3

Psoriatic Arthritis

A chronic and inflammatory arthritis in association with skin psoriasis
4
Usually rheumatoid factor (RF) negative and ACPA negative
5
Distinct from RA
Psoriatic Arthritis is classified as one of the subtypes of spondyloarthropathies
Characterized by synovitis, enthesitis, dactylitis, spondylitis, skin and nail
psoriasis
4



1
Rudwaleit M et al. Ann Rheum Dis 2004;63:535-543;
2
Braun J et al. Scand J Rheumatol 2005;34:178-90;
3
Fitzgerald Psoriatic Arthritis in Kelleys Textbook of Rheumatology, 2009;
4
Mease et al. Ann Rheum Dis 2011;70(Suppl 1):i77i84. doi:10.1136/ard.2010.140582;
5
Pasquetti et al. Rheumatology 2009;48:315325
Juvenile SpA

Reactive
arthritis
Arthritis
associated with
IBD
PsA
Undifferentiated
SpA (uSpA)

Ankylosing
spondylitis (AS)

RA: Rheumatoid arthritis
9
Psoriatic Arthritis
ACR Slide Collection on the Rheumatic Diseases; 3
rd
edition. 1994.
Data on file, Centocor, Inc.
10
11
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Epidemiology of PsA

Recent review undertaken to 2006
1,2
Incidence
Europe+North America: 3 to 23.1 cases/10
5
Japan 0.1 case/10
5

Prevalence
Europe+North America 20 and 420 cases/10
5

Japan 1 case/10
5


Population-based study/Minnesota (CASPAR criteria)
2,3
Incidence
7.2 cases/10
5
(men 9.1, female 5.4)
Prevalence
158 cases/10
5
The prevalence of PsA is assumed to be larger than expected,
since enthesitis associated with PsA can develop without
symptoms or signs that are recognizable by patients themselves or
the physicians
4
1
Alamos et al. J Rheumatol 2008;35:1354-8;
2
Wilson F et al. J Rheumatol 2009;36:361-7;

3
Editorial by Chaudran. J Rheumatol 2009;36:213-5;

4
Takata et al. J Dermatol Sci. 2011 Nov;64(2):144-7
13
Signs and Symptoms
Morning stiffness lasting >30 min in 50% of patients
1
Ridging, pitting of nails, onycholysis up 90% of patients vs
nail changes in only 40% of psoriasis cases
2,3
Patients may present with less joint tenderness than is usually
seen in RA
1
Dactylitis may be noted in >40% of patients
2,4
Eye inflammation (conjunctivitis, iritis, or uveitis) 733% of
cases; uveitis shows a greater tendency to be bilateral and
chronic when compared to AS
2
Distal extremity swelling with pitting edema has been reported
in 20% of patients as the first isolated manifestation of PsA
5
1
Gladman DD. In: Up To Date. Available at: www.uptodate.com. Accessed December 3, 2004.

2
Taurog JD. In: Harrison's Online McGrawHill. Available at:
http://www3.accessmedicine.com/popup.aspx?aID=94996&print=yes. Accessed January 2,2005.
3
Gladman DD. Rheum Dis Clin N Amer. 1998;24:829844.
4
Veale D, et al. Br J Rheumatol. 1994;33:13338.
5
Cantini F, et al. Clin Exp Rheumatol. 2001;19:291296.
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Main Features of PsA
Helliwell PS & Taylor WJ. Ann Rheum Dis 2005;64(2:ii)3-8
Fitzgerald Psoriatic Arthritis in Kelleys Textbook of Rheumatology, 2009
*Low levels of RF and ACPA can be found in 5-16% of patients; **To a lesser degree than in RA
***Spinal disease occurs in 40-70% of PsA patients
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Main Features and Their Frequency
1
Gladman D et al. Arth & Rheum 2007;56:840;
2
Kane. D et al. Rheum 2003;42:1460-1468
3
Gladman D et al. Ann Rheum Dis 2005;64:188190;
4
Lawry M. Dermatol Ther 2007;20:60-67
5
Jiaravuthisan MM et al. JAAD 2007;57:1-27;
6
Yamamoto Eur J Dermatol 2011;21:660-6

Enthesopathy (38%)
2

Dactyilitis (48%)
3

DIP involvement (39%)
2

Back involvement (50%)
1

Nail psoriasis

(80%)
4, 5

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In nearly 70% of patients,
cutaneous lesions precede
the onset of joint pain, in
20% arthropathy starts
before skin manifestations,
and in 10% both are
concurrent.
6
DIP: Distal interphalangeal
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Pso patients
6-8

Psychosocial burden

Reactive depression
Higher suicidal ideation
Alcoholism

Metabolic Syndrome
3-5

Hyperlipidemia
Hypertension
Insulin resistent
Diabetes
Obesity
Higher risk of
Cardiovascular disease (CVD)
Ocular inflammation
1

(Iritis/Uveitis/ Episcleritis)
IBD
2


Comorbidities in PsA Patients
1
Qieiro et al. Semin Arth Rheum 2002;31:264;
2
Scarpa et al. J Rheum 2000;27:1241;
3
Mallbris et al. Curr Rheum Rep 2006;8:355;
4
Neimann et al. J Am Acad Derm 2006;55:829;
5
Tam et al. 2008;47:718;
6
Kimball et al. Am J Clin Dermatol 2005;6:383-392;
7
Naldi et al. Br J Dermatol 1992;127:212-217;
8
Mrowietz U et al. Arch Dermatol Res 2006;298(7):309-319
17
Hallmark Clinical Features in PsA
Dactylitis Enthesitis
Psoriatic Arthritis
Ritchlin C. J Rheumatol. 2006;33:14351438.
Helliwell PS. J Rheumatol. 2006;33:14391441.
18
Dactylitis
ACR Slide Collection on the Rheumatic Diseases; 3
rd
edition. 1994.
1
Brockbank J, et al. Ann Rheum Dis. 2005;64:188190.
2
Veale D, et al. Br J Rheumatol. 1994;33:13338.
Diffuse swelling of a digit may be acute, with painful
inflammatory changes, or chronic wherein the digit remains
swollen despite the disappearance of acute inflammation
1
Also referred to as
sausage digit
1
Recognized as one
of the cardinal
features of PsA,
occurring in up
to 40% of patients
1,2
Feet most commonly
affected
1
Dactylitis involved
digits show more
radiographic damage
1
19
20
Definition of Enthesitis
Entheses are the regions at
which a tendon, ligament, or
joint capsule attaches to
bone
1
Inflammation at the entheses
is called enthesitis and is a
hallmark feature of PsA
1,2
Pathogenesis of enthesitis
has yet to be fully elucidated
2
Isolated peripheral enthesitis
may be the only
rheumatologic sign of PsA in
a subset of patients
3


1
McGonagle D. Ann Rheum Dis. 2005;64(Suppl II):ii58ii60.

2
Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338343.
3
Salvarani C. J Rheumatol. 1997;24:11061140.
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Classification Criteria of PsA
How to diagnose PsA?
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Classical Description of PsA Using the
Diagnostic Criteria of Moll and Wright
Including 5 clinical patterns:
Asymmetric mono-/oligoarthritis (~30% [range 12-70%])
1-4

Symmetric polyarthritis (~45% [range 15-65%])
1-4

Distal interphalangeal (DIP) joint involvement (~5%)
1

Axial (spondylitis and Sacroiliitis) (HLA-B27) (~5%)
1,3
Arthritis Mutilans (<5%)
1,3

References see notes
However patterns may change over time and are
therefore not useful for classification
5

HLA: Human leucocytes antigen
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Patterns may Change Over Time and are
Therefore not Useful for Classification
McHugh et al. Rheum 2003;42:778-783
Clinical subgroups at baseline and follow-up:

Monoarthritis Monoarthritis

Oligoarthritis Oligoarthritis

DIP DIP

Polyarthritis Polyarthritis

Spondyloarthritis Spondyloarthritis

Mutilans Mutilans

No clinical evidence of
joint disease
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CASPAR Criteria for the Classification of
PsA
Inflammatory articular disease (joint, spine, or entheseal)
With 3 points from following categories:
Psoriasis: current (2), history (1), family history (1)
Nail dystrophy (1)
Negative rheumatoid factor (1)
Dactylitis: current (1), history (1) recorded by a
rheumatologist
Radiographs: (hand/foot) evidence of juxta-articular
new bone formation
Specificity 98.7%, Sensitivity 91.4%
Taylor et al. Arthritis & Rheum 2006;54: 2665-73
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Spondyloarthritis and Classification Criteria
Spondyloarthropathies
Axial and Peripheral
AMOR criteria (1990)
ESSG criteria (1991)
Axial Spondyloarthritis
ASAS classification 2009
Ankylosing spondylitis
Prototype of axial spondylitidis
Modified New York criteria 1984
Peripheral Spondyloarthritis
ASAS classification 2010
Psoriatic arthritis
From Moll & Wright 1973 to CASPAR criteria 2006
Sieper et al. Ann Rheum Dis 2009;68:ii1-ii44
Taylor et al. Arthritis & Rheum 2006;54:2665-73
Van der Heijde et al. Ann Rheum Dis 2011;70:905-8
ESSG: European Spondyloarthropathy Study Group
ASAS: Assessment of Spondyloarthritis International Society
CASPAR: Classification criteria for psoriatic arthritis
Infliximab (IFX) and Golimumab (GLM)
indications
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Treatment of PsA
Outcomes measurements
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TRIGGERS FOR PSORIASIS
Direct skin injury (Koebner phenomenon)
Discontinuation of systemic corticosteroids
Cold weather
Streptococcal pharyngitis
Emotional stress
Alcohol intake
Smoking
HIV
Medications
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Psoriatic Arthritis Response Criteria (PsARC)
Clegg D.O. et al. Arthritis Rheum 1996;39:2013.
Outcome Measure in PsA
Clinical assessment of joint improvement, no skin
assessment
Improvement in at least 2 of 4 criteria,
one of which must be tender or swollen-joint score
Physician global assessment (> 1 unit)
Patient global assessment (> 1 unit)
Tender-joint score (> 30%)
Swollen-joint score (> 30%)
No worsening in any criterion
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30
Treatment
Medical treatment regimens include the use of nonsteroidal
anti-inflammatory drugs (NSAIDs) and disease-modifying
antirheumatic drugs (DMARDs). DMARDs include the
following

:
Methotrexate
Sulfasalazine
Cyclosporine
Leflunomide
Biologic agents, such as the antiTNF-alpha medications
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31
In patients with severe skin inflammation, medications such as
methotrexate, retinoic-acid derivatives, and psoralen plus
ultraviolet (UV) light should be considered. These agents have
been shown to work on skin and joint manifestations. Intra-
articular injection of entheses or single inflamed joints with
corticosteroids may be particularly effective in some patients.
Use DMARDs in individuals whose arthritis is persistent.
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32
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BIOLOGIC TREAMENTS FOR
PSORIASIS/PSORIATIC ARTHRITIS
Alefacept (Amevive): LFA3-tip, targets CD2+ T
cells
Etanercept (Enbrel): soluble TNF- receptor
Adalimumab (Humira): human anti-TNF- mAb
Infliximab (Remicade): chimeric anti-TNF- mAb
Golimumab (Simponi): human anti-TNF- mAb
Ustekinumab (Stelara): human anti-IL-12/IL-23
mAb
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OLDER SYSTEMIC
THERAPIES FOR PSORIASIS
Phototherapy: UVB, narrow-
band UVB, PUVA, Excimer laser
Methotrexate
Acitretin (Soriatane)
Cyclosporine
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PSORIASIS SIGNIFICANTLY IMPAIRS
QUALITY OF LIFE
Fear of contagion from others (modern day
lepers)
Low self esteem (somethings wrong with me)
Need to cover up (I dont want anyone to see)
Sexual impairment
Hand/foot lesions that interfere with activities of
daily living
Itching that interferes with sleep and activities of
daily living
Arthritis that impairs activities of daily living