The Role of the Dermatologist in Identification and Treatment of the Early Stages of Psoriatic Arthritis

Skin Therapy Letter. 2008;13(4):4-8. 

In This Article

Clinical Presentation

There appears to be great variability in the case definition for PsA. One such definition, proposed by Moll and Wright, defines PsA as "an inflammatory arthritis associated with psoriasis and usually with a negative serological test for rheumatoid arthritis."[5] Due to the broad spectrum of PsA there has been a need to create subgroups ( Table 1 ).

Characteristic features of psoriatic arthritis include: swelling, erythema, warmth, and inflammation of the affected joint. PsA can present with asymmetrical joint distribution,involving more joints over time and progressing as an oligoarticular/polyarticular disease. Almost any joint can be involved including peripheral (e.g., the DIPs) and/or axial joints (e.g., spine and sacroiliac joints). PsA can also manifest with involvement of periarticular structures such as tenosynovitis (inflammation of the tendon sheath), dactylitis or "sausage digit" (inflammation of entire digit), and enthesitis (insertion of the tendon).[4]

As with other sero-negative spondylarthropathies, there can also be extra-articular manifestations of PsA. These features may include inflammation of the eye, mucousmembranes, urinary system, and cardiovascular system (i.e., iritis, conjunctivitis, aortic dilation, and urethritis).[6]

There does not appear to be a difference in the prevalence of psoriasis between the sexes,[7] however, the onset of disease seems to be earlier in women.[8] The onset of psoriasis is bimodal with a median age of onset at 29.1 years.[9] Those with early disease can have a greater body surface area involved, unstable psoriasis, frequent relapses, and a higher incidence of guttate psoriasis and nail involvement.[9,10]

Patients with later onset tend to have a more stable course and less severe disease, but more frequent palmoplantar pustulosis.[9,10]

The temporal sequence of disease onset can vary, making the diagnosis of PsA difficult. As high as 75%-80% of psoriasis patients will present with cutaneous manifestation 5-10 years prior to the onset of joint complaints.[4,11] There can exist a flare in arthritis with or without a coinciding flare of psoriasis.[4]

The majority of patients with PsA have mild or moderate cutaneous manifestation,12 and 80%-90% of this population have nail lesions.[12,13] However, 46% of patients with psoriasis (no affected joints) have nail involvement.[13] The extent and severity of both skin and joint disease correlate closely with the severity of psoriatic nail involvement, however this association is more commonly found in the DIP arthritis form of PsA.[14]

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