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Chief complaint

Swelling and erythematous plaques with painful sensation for right leg for over a month.

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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.

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• Hx of suspected RCC of R't nephrectomy.• Occupation:木匠• 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.

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Psoriatic Arthritis

A complex and severe disabling disease

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Introduction to Psoriatic Arthritis (PsA)• Chronic progressive, inflammatory disorder of the joints and skin1

– Characterized by osteolysis and bony proliferation1

– Clinical manifestations include dactylitis, enthesitis, osteoperiostitis, large joint oligoarthritis, arthritis mutilans, sacroiliitis, spondylitis, and distal interphalangeal arthritis1

• PsA is one of a group of disorders known as the spondyloarthropathies2

• Males and females are equally affected3

• PsA can range from mild nondestructive disease to a severely rapid and destructive arthropathy3

– Usually Rheumatoid Factor negative3

• Radiographic damage can be noted in up to 47% of patients at a median interval of two years despite clinical improvement with standard DMARD therapy4

1Taylor WJ. Curr Opin Rheumatol. 2002;14:98–103.2Mease P. Curr Opin Rheumatol. 2004;16:366–370.

3Brockbank J, et al. Exp Opin Invest Drugs. 2000;9:1511–1522.4Kane D, et al. Rheumatology. 2003;42:1460–1468.

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Spondyloarthritis, Psoriasis and PsASpondyloarthritis (SpA)• The prevalence of SpA is comparable to that of RA (0.5–1.9%)1,2

Psoriasis (Pso)• Psoriasis affects 2% of population• 7% to 42% of patients with Pso will develop arthritis3

Psoriatic Arthritis• A chronic and inflammatory arthritis in association with skin psoriasis4

• Usually rheumatoid factor (RF) negative and ACPA negative5

– Distinct from RA • Psoriatic Arthritis is classified as one of the subtypes of spondyloarthropathies

– Characterized by synovitis, enthesitis, dactylitis, spondylitis, skin and nail psoriasis4

1Rudwaleit M et al. Ann Rheum Dis 2004;63:535-543; 2Braun J et al. Scand J Rheumatol 2005;34:178-90;3 Fitzgerald “Psoriatic Arthritis” in Kelley’s Textbook of Rheumatology, 2009;

4Mease et al. Ann Rheum Dis 2011;70(Suppl 1):i77–i84. doi:10.1136/ard.2010.140582;5Pasquetti et al. Rheumatology 2009;48:315–325

Juvenile SpA

Reactivearthritis

Arthritis associated with

IBD

PsA

UndifferentiatedSpA (uSpA)

Ankylosingspondylitis (AS)

RA: Rheumatoid arthritis

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Psoriatic Arthritis

ACR Slide Collection on the Rheumatic Diseases; 3rd edition. 1994.Data on file, Centocor, Inc.

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Epidemiology of PsA• Recent review undertaken to 20061,2

− Incidence Europe+North America: 3 to 23.1 cases/105

Japan 0.1 case/105 − Prevalence

Europe+North America 20 and 420 cases/105

Japan 1 case/105

• Population-based study/Minnesota (CASPAR criteria)2,3

− Incidence 7.2 cases/105 (men 9.1, female 5.4)

− Prevalence 158 cases/105

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 physicians4

1 Alamos et al. J Rheumatol 2008;35:1354-8;2Wilson F et al. J Rheumatol 2009;36:361-7;

3Editorial by Chaudran. J Rheumatol 2009;36:213-5; 4Takata et al. J Dermatol Sci. 2011 Nov;64(2):144-7

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Signs and Symptoms• Morning stiffness lasting >30 min in 50% of patients1

• Ridging, pitting of nails, onycholysis – up 90% of patients vs nail changes in only 40% of psoriasis cases2,3

• Patients may present with less joint tenderness than is usually seen in RA1

• Dactylitis may be noted in >40% of patients2,4

• Eye inflammation (conjunctivitis, iritis, or uveitis) — 7–33% of cases; uveitis shows a greater tendency to be bilateral and chronic when compared to AS2

• Distal extremity swelling with pitting edema has been reported in 20% of patients as the first isolated manifestation of PsA5

1Gladman DD. In: Up To Date. Available at: www.uptodate.com. Accessed December 3, 2004. 2Taurog JD. In: Harrison's Online McGrawHill. Available at: http://www3.accessmedicine.com/popup.aspx?

aID=94996&print=yes. Accessed January 2,2005.3Gladman DD. Rheum Dis Clin N Amer. 1998;24:829–844.

4Veale D, et al. Br J Rheumatol. 1994;33:133–38.5Cantini F, et al. Clin Exp Rheumatol. 2001;19:291–296.

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Main Features of PsA

Helliwell PS & Taylor WJ. Ann Rheum Dis 2005;64(2:ii)3-8Fitzgerald “Psoriatic Arthritis” in Kelley’s 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

1Gladman 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;64:188–190; 4Lawry M. Dermatol Ther

2007;20:60-675Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6Yamamoto 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

Skin Involvement

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 patients6-8

• Psychosocial burden• Reactive depression • Higher suicidal ideation• Alcoholism

Metabolic Syndrome3-5

• Hyperlipidemia• Hypertension• Insulin resistent • Diabetes • Obesity Higher risk of Cardiovascular disease (CVD)

Ocular inflammation1

(Iritis/Uveitis/ Episcleritis)

IBD2

Comorbidities in PsA Patients

1Qieiro et al. Semin Arth Rheum 2002;31:264; 2Scarpa et al. J Rheum 2000;27:1241; 3Mallbris et al. Curr Rheum Rep 2006;8:355; 4Neimann et al. J Am Acad Derm 2006;55:829; 5Tam et al. 2008;47:718; 6Kimball et al. Am J Clin Dermatol 2005;6:383-392;

7Naldi et al. Br J Dermatol 1992;127:212-217; 8Mrowietz U et al. Arch Dermatol Res 2006;298(7):309-319

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Hallmark Clinical Features in PsA

D a c ty lit is E n th e s it is

P so ria tic A rth rit is

Ritchlin C. J Rheumatol. 2006;33:1435–1438.Helliwell PS. J Rheumatol. 2006;33:1439–1441.

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Dactylitis

ACR Slide Collection on the Rheumatic Diseases; 3rd edition. 1994.1Brockbank J, et al. Ann Rheum Dis. 2005;64:188–190.

2Veale D, et al. Br J Rheumatol. 1994;33:133–38.

• Diffuse swelling of a digit may be acute, with painful inflammatory changes, or chronic wherein the digit remains swollen despite the disappearance of acute inflammation1

• Also referred to as “sausage digit”1

• Recognized as one of the cardinal features of PsA, occurring in up to 40% of patients1,2

• Feet most commonly affected1

• Dactylitis involved digits show more radiographic damage1

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Definition of Enthesitis

• Entheses are the regions at which a tendon, ligament, or joint capsule attaches to bone1

• Inflammation at the entheses is called enthesitis and is a hallmark feature of PsA1,2

• Pathogenesis of enthesitis has yet to be fully elucidated2

• Isolated peripheral enthesitis may be the only rheumatologic sign of PsA in a subset of patients3

1McGonagle D. Ann Rheum Dis. 2005;64(Suppl II):ii58–ii60.

2Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338–343.3Salvarani C. J Rheumatol. 1997;24:1106–1140.

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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 ofjoint 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

SpondyloarthropathiesAxial and Peripheral AMOR criteria (1990) ESSG criteria (1991)

Axial Spondyloarthritis ASAS classification 2009

Ankylosing spondylitisPrototype 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-ii44Taylor et al. Arthritis & Rheum 2006;54:2665-73

Van der Heijde et al. Ann Rheum Dis 2011;70:905-8

ESSG: European Spondyloarthropathy Study GroupASAS: Assessment of Spondyloarthritis International SocietyCASPAR: 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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TreatmentMedical treatment regimens include the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs). DMARDs include the following :MethotrexateSulfasalazineCyclosporineLeflunomideBiologic agents, such as the anti–TNF-alpha medications

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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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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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se.PSORIASIS SIGNIFICANTLY IMPAIRS

QUALITY OF LIFE• Fear of contagion from others (“modern day

lepers”)• Low self esteem (“something’s wrong with me”)• Need to cover up (“I don’t 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