Psoriatic Arthritis: A Guide for Dermatology Nurses

Alice B. Gottlieb, MD, PhD

Disclosures

Dermatology Nursing. 2003;15(2) 

In This Article

Abstract and Introduction

Psoriatic arthritis (PsA) affects people in the prime of life, causing functional impairment and diminished quality of life. Etanercept, the first FDA-approved therapy, and other immunobiologics, offer hope for favorable long-term outcomes. It is imperative that dermatology nurses learn more about the basic immunology of psoriasis and PsA and the role of immunomodulation in their treatments.

Psoriatic arthritis (PsA) is a progressive, chronic, inflammatory form of arthritis in combination with the skin lesions of psoriasis and accompanied by fatigue, severe joint pain, and swelling (National Psoriasis Foundation [NPF], 2002). Psoriasis usually precedes arthritic symptoms by several years (Espinoza, 1992, as cited in Mease, 2001) and as a result, dermatologists are often the first physicians to diagnose and treat patients with PsA. Dermatologists should be aware of, and vigilant for, the arthritic symptoms that accompany psoriasis. Dermatology nurses play an integral role as patient educators, and in providing practical information and emotional support for their patients. Optimal outcomes are possible with early recognition and intervention. Recently, etanercept, a systemic biologic therapy, received an indication from the FDA as the first approved therapy for PsA.

PsA has a significant impact on a patient's quality of life and joint function. Unfortunately, PsA too often goes unrecognized until significant joint damage has occurred (NPF, 2002). Joint damage often occurs early in disease, yet functional impairment may not emerge until later stages (Mease, 2001). In a recent survey by the NPF, 84% of the 27,000 individuals surveyed stated that PsA has a moderate-to-significant impact on their daily activities; 75% lose sleep or sleep poorly; 69% find their disease interferes with educational, vocational, or social activities; and 25% are dissatisfied with their therapy (NPF, 2002).

There are five clinical subgroups of PsA (see Table 1 ). Inflammatory, asymmetric oligoarthritis/polyarthritis is the most common. PsA occurs in approximately 5% to 7% of people with psoriasis (Espinoza, van Solingen, Cuellar, & Angulo, 1998). Among those with moderate-to-severe psoriasis, up to 40% may be affected (Gladman, 1998). Most reports estimate there are 350,000 to 400,000 Americans with PsA; however, the NPF survey suggests that as many as 1 million adults in the United States have the disease (Gladman, 1998; NPF, 2002). Typically, PsA appears between the ages of 30 to 55 and occurs with equal frequency in men and women (Mease, 2001).

The exact pathogenic mechanism for PsA is not completely understood, although recent evidence suggests a multifactorial interplay of genetics, environment, and the immune system (Espinoza et al., 1998). Infections (including strep), physical trauma, certain human leukocyte antigen haplotypes, and inflammatory mediators, including tumor necrosis factor (TNF), are associated with the disease process (Espinoza et al., 1998; Schur, 2001).

All individuals with psoriasis and especially those with an asymmetric, inflammatory arthritis accompanied by morning stiffness should be evaluated for PsA. A thorough assessment includes questions about joint pain and arthritic symptoms and whether symptoms fluctuate with clinical exacerbations of psoriasis. PsA is diagnosed on the basis of the clinician's assessment of the patient's medical history and physical examination. There are no specific diagnostic tests for PsA. Rheumatoid factor is generally negative (Gladman, 1992). Clinicians sometimes rely on x-rays to confirm the diagnosis and rule out other disease. Characteristic clinical manifestations, joint, skin, and radiologic findings of PsA are listed in Table 1 and Table 2 (Gladman, 1998). The diagnosis is sometimes subtle and may be difficult to distinguish from other diseases, including gout, Reiter's syndrome, rheumatoid arthritis, osteoarthritis, dermatomyositis, or fibromyalgia (Schur, 2001).

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