International multicenter psoriasis and psoriatic arthritis reliability trial for the assessment of skin,joints, nails,and dactylitis

Objective

Clinical trials in psoriasis and psoriatic arthritis (PsA) involve assessment of the skin and joints. This study aimed to determine whether assessment of the skin and joints in patients with PsA by rheumatologists and dermatologists is reproducible.

Methods

Ten rheumatologists and 9 dermatologists from 7 countries met for a combined physical examination exercise to assess 20 PsA patients (11 men, mean age 51 years, mean PsA duration 11 years). Each physician assessed 10 patients according to a modified Latin square design that enabled the assessment of patient, assessor, and order effect. Tender joint count (TJC), swollen joint count (SJC), dactylitis, physician's global assessment (PGA) of PsA disease activity (PGA‐PsA), psoriasis body surface area (BSA), Psoriasis Area and Severity Index (PASI), Lattice System Physician's Global Assessment of psoriasis (LS‐PGA), National Psoriasis Foundation Psoriasis Score (NPF‐PS), modified Nail Psoriasis Severity Index (mNAPSI), number of fingernails with nail changes (NN), and PGA of psoriasis activity (PGA‐Ps) were assessed. Variance components analyses were carried out to estimate the intraclass correlation coefficient (ICC), adjusted for the order of measurements.

Results

There is excellent agreement (ICC ≥0.80) on the mNAPSI, substantial agreement (0.6 ≥ ICC < 0.80) on the TJC, PASI, and NN, moderate agreement (0.4 ≥ ICC < 0.60) on the PGA‐Ps, LS‐PGA, NPF‐PS, and BSA, and fair agreement (0.2 ≥ ICC < 0.40) on the SJC, dactylitis, and PGA‐PsA. The only measure that showed a significant difference between dermatologists and rheumatologists was dactylitis (P = 0.0005).

Conclusion

There is substantial to excellent agreement on the TJC, PASI, NN, and mNAPSI among rheumatologists and dermatologists.     

Human leukocyte antigen and clinical and demographic characteristics in psoriatic arthritis and psoriasis in Chinese patients

OBJECTIVE: Psoriasis and psoriatic arthritis (PsA) are interrelated disorders. To date, no study has compared the differences of genes between patients with PsA and psoriasis and healthy controls in a Chinese population. We conducted a retrospective study to determine the human leukocyte antigen (HLA) -A, -B, -Cw, -DR, and -DQ alleles in Chinese patients with PsA and psoriasis. METHODS: HLA studies were performed using polymerase chain reaction sequence-specific oligonucleotide (PCR-SSO) genotyping methods in 91 patients with PsA and 80 with psoriasis and 75 controls. Age at disease onset, sex, disease duration, enthesitis, and uveitis were also analyzed. RESULTS: Among the patients with PsA and psoriasis, the frequency of HLA-B27 was significantly higher in PsA and HLA-A*30, -Cw*06, -DR*07 in psoriasis compared with controls. In contrast, HLA-B*58 was more common in controls than in PsA and psoriasis groups, and the prevalence of HLA-DR*17 was significantly higher in controls than in those with psoriasis. Comparing PsA and psoriasis, the prevalence of HLA-B*27 and HLA-Cw*12 were more common in PsA patients, while the prevalence of HLA-DR*07 was higher in those with psoriasis (p < 0.05). Among PsA patients, the association between HLA-B*27 and axial joint involvement and uveitis was significant (p < 0.05). CONCLUSION: Certain HLA alleles are found in Chinese patients with psoriasis (HLA-A*30, -Cw*06, -DR*07) and PsA (HLA-B*27). Psoriasis patients with the HLA-B*27 and/or -Cw*12 may have higher risk of developing PsA. Ours is the first study to assess the genetic role of HLA in patients with psoriasis and PsA in a Chinese population.     

Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: A population‐based study

Objective

To determine the incidence and disease‐specific predictors of clinically recognized psoriatic arthritis (PsA) in patients with psoriasis.

Methods

We identified an incidence cohort of psoriasis subjects age ≥18 years diagnosed between January 1, 1970 and December 31, 1999 in a population‐based setting. Psoriasis diagnoses were validated by confirmatory diagnosis in the medical record. Incident and clinically recognized PsA subjects were classified according to the Classification of Psoriatic Arthritis (CASPAR) criteria. Cox proportional hazards models were used to identify predictors of PsA within the psoriasis cohort.

Results

The psoriasis incidence cohort comprised 1,633 subjects. Of these, 40 were diagnosed with PsA concurrently with psoriasis and were excluded from analysis. The remaining 1,593 psoriasis subjects had a mean age of 43 years and 50% were men. Over 20,936 person‐years of followup, 57 subjects were clinically recognized with new‐onset PsA, with a cumulative incidence of 1.7% (95% confidence interval [95% CI] 1.0–2.3%), 3.1% (95% CI 2.2–4.1%), and 5.1% (95% CI 3.7–6.6%) at 5, 10, and 20 years following psoriasis incidence, respectively. Psoriasis features associated with higher risk of PsA were scalp lesions (hazard ratio [HR] 3.89, 95% CI 2.18–6.94), nail dystrophy (HR 2.93, 95% CI 1.68–5.12), and intergluteal/perianal lesions (HR 2.35, 95% CI 1.32–4.19). Calendar year was not associated with risk of PsA (P = 0.15), indicating that the likelihood of PsA in psoriasis subjects did not change over time.

Conclusion

In this population‐based study, <10% of patients with psoriasis developed clinically recognized PsA during a 30‐year period. Psoriasis features associated with a higher likelihood of PsA were nail dystrophy, scalp lesions, and intergluteal/perianal psoriasis.     

Psoriatic arthritis and psoriasis: differential diagnosis

Psoriasis frequency ranges from 1 to 3 % in white population, and arthritis occurs in 10–40 % of psoriasis patients, representing a relevant health issue. Psoriatic arthritis (PsA) is an inflammatory arthropathy, associated with psoriasis, in which ocular-, intestinal-, metabolic-, and cardiovascular-related manifestations can variably coexist. In order to favor early PsA and psoriasis diagnosis, it is crucial to rule out other conditions that can resemble the disease and delay appropriate therapeutic approach. Therefore, the aim of this review is to focus on PsA and psoriasis differential diagnosis.     

Efficacy and safety of leflunomide in the treatment of psoriatic arthritis and psoriasis: a multinational, double-blind, randomized, placebo-controlled clinical trial

OBJECTIVE: Current treatment options for psoriatic arthritis (PsA) are limited. Leflunomide, an oral pyrimidine synthesis inhibitor, is highly effective in the treatment of rheumatoid arthritis, and small studies have suggested similar efficacy in PsA. We undertook this double-blind, randomized, placebo-controlled trial to evaluate the efficacy and safety of leflunomide in patients with PsA and psoriasis. METHODS: One hundred ninety patients with active PsA and psoriasis (at least 3% skin involvement) were randomized to receive leflunomide (100 mg/day loading dose for 3 days followed by 20 mg/day orally) or placebo for 24 weeks. The primary efficacy end point was the proportion of patients classified as responders by the Psoriatic Arthritis Response Criteria (PsARC). Additional efficacy (joint and skin involvement), safety, and quality-of-life assessments were performed. RESULTS: At 24 weeks, 56 of 95 leflunomide-treated patients (58.9%; 95% confidence interval [95% CI] 48.4-68.9) and 27 of 91 placebo-treated patients (29.7% [95% CI 20.6-40.2]) were classified as responders by the PsARC (P < 0.0001). Significant differences in favor of leflunomide were also observed in the proportions of patients achieving modified American College of Rheumatology 20% improvement criteria, improvement in the designated psoriasis target lesion, and mean changes from baseline in Psoriasis Area and Severity Index scores and quality-of-life assessments. Diarrhea and alanine aminotransferase increases occurred at higher rates in the leflunomide group. No cases of serious liver toxicity were observed. CONCLUSION: Leflunomide is an effective treatment for PsA and psoriasis, providing a safe and convenient alternative to current therapies.     

Clinical features of psoriatic arthritis in Korean patients with psoriasis: a cross-sectional observational study of 196 patients with psoriasis using psoriatic arthritis screening questionnaires

The prevalence and clinical features of psoriatic arthritis (PsA) in psoriasis patients vary widely in different countries, and studies on Korean population are rarely reported. The aim of this study was to investigate the clinical features of PsA in a Korean population of patients with psoriasis by using psoriatic arthritis screening questionnaires. A cross-sectional observational study was conducted, and consecutive psoriatic patients were evaluated for PsA by using two kinds of psoriatic arthritis screening questionnaires: Psoriatic Arthritis Screening and Evaluation tool (PASE) and Psoriasis Epidemiology Screening Tool (PEST). Psoriatic patients with higher score in screening questionnaires were referred to rheumatologist for confirmative diagnosis of PsA. Among 196 psoriasis patients screened by PASE and PEST, total prevalence of PsA was 11.2 % (n = 22/196) with 59.1 % of the cases being newly diagnosed. Compared with patients without PsA, patients with PsA had more extensive psoriasis, higher frequency of pustular and inverse type of psoriasis, and lower frequency of plaque type of psoriasis. Spondylitis was the most common manifestation pattern, followed by polyarthritis, oligoarthritis, predominant distal interphalangeal arthritis, and arthritis mutilans. Our findings are consistent with a low prevalence of PsA among patients with psoriasis in Asia. We also confirm a spondylitis as the most common pattern of PsA in Korea. PsA screening questionnaires can be a simple and useful tool to screen PsA in patients with psoriasis.     

Initiative for quality in psoriasis and psoriatic arthritis

Psoriasis is a common and severe skin disease. Up to 30% of psoriasis patients develop psoriatic arthritis (PsA), another severe disease that contributes significantly to the burden of psoriatic disease in patients. The treatment of patients with both psoriasis and PsA is particularly challenging, because different strategies are often followed, and considerable resources are needed for these chronic inflammatory diseases. Of note, psoriasis patients tend to be undertreated. Efforts to improve the management of psoriasis and PsA are urgently needed, to incorporate improvement of patient outcomes by promotion of best practice from both the medical and the pharmacoeconomic perspective. These are the goals of the Quality Movement in the USA and of quality management in general. The need for evidence-based guidance on safety, efficacy, overall outcome, and cost-effectiveness is being addressed by numerous initiatives striving to generate practice guidelines, control costs, and optimize cost-effectiveness of treatments. The 2007 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis's (GRAPPA) Initiative for Quality aims to secure and improve management of psoriasis and PsA, elaborating on these evidence-based guidelines by defining major domains of quality and creating a checklist that identifies physicians who can administer state-of-the-art medical services to patients who need their services.     

Genetic epidemiology of psoriasis and psoriatic arthritis

Psoriasis and psoriatic arthritis (PsA) are interrelated disorders, as most patients with PsA also have psoriasis. Thus it is not surprising that epidemiological and immunogenetic studies have uncovered important links between these two disorders. Both disorders are highly heritable, and the prevalence of psoriasis is 19 times higher among first degree relatives of probands with PsA compared with the general population. Multiple human leucocyte antigen (HLA) associations are shared between psoriasis and PsA, though the magnitudes of these associations differ between the diseases. Genome-wide linkage studies have noted overlapping regions of significance for these two disorders within and outside the major histocompatibility complex (MHC) region. Thus, exploration of the genetic basis of psoriasis will likely strengthen the contention of an underlying genetic susceptibility for PsA and vice versa.     

The ultrasound imaging module: a report from the GRAPPA 2010 annual meeting

In a plenary session at the 2010 meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), the use of sonography for evaluating articular disease and enthesitis in psoriasis and psoriatic arthritis (PsA) was reviewed. Ultrasound can readily demonstrate signs of synovitis, erosions, and osteoproliferation. There is a need to develop ultrasound joint indices to evaluate and follow PsA longitudinally. Sonography is able to depict ultrastructural features of enthesitis, as well as increased vascularity. Sonographic signs of subclinical enthesitis in patients with psoriasis have been reported by 2 groups, 1 of which has reported limited longitudinal data that suggest baseline composite enthesitis scores may predict future risk of PsA. Although recent studies have studied mostly lower extremity entheses, further work is needed to clarify if other areas need to be included, especially within the framework of the synovial entheseal complex. The study design of the PREPARE (Prevalence of Psoriatic Arthritis in Adults with Psoriasis) trial was also presented.     

Genetics of psoriasis and psoriatic arthritis: update and future direction

Psoriasis and psoriatic arthritis (PsA) both have substantive genetic determinants. Numerous candidate regions and genes have now been replicated in disease susceptibility, and to a lesser extent in disease expression, in both disease entities. Intensive efforts are now under way or are being planned to perform genome-wide association scans (GWAS) in psoriasis and PsA. A major determinant of success for GWAS is likely to be accumulation of multiple large well-phenotyped cohorts, sophisticated data management, and verification of the findings. At the 2007 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members of the GRAPPA genetics committee presented a discussion of the genetics of psoriasis and PsA, including future trends. This article is a summary of that presentation and a review of the literature.     

Angiogenesis in psoriasis and psoriatic arthritis: Clues to disease pathogenesis

Psoriasis is a common chronic dermatosis occurring in 2% of the population and associated with an inflammatory arthritis—psoriatic arthritis (PsA)—in up to 40% of cases. PsA accounts for approximately 15% of patients attending early synovitis clinics, therefore it represents the second most common diagnostic category after rheumatoid arthritis. There are a number of common pathogenic features that link the skin and the joint inflammatory processes. Angiogenesis appears to be a fundamental inflammatory response early in the pathogenesis and significant abnormalities of vascular morphology and angiogenic growth factors have been described in psoriasis and PsA. This paper will explore the recent published evidence to support the hypothesis that dysregulated angiogenesis provides a primary pathogenic mechanism in psoriasis skin and in the PsA joint.     

Current challenges in the genetics of psoriatic arthritis: a report from the GRAPPA 2009 annual meeting

Psoriasis and psoriatic arthritis (PsA) are heterogeneous diseases. While both have a strong genetic basis, it is strongest for PsA, where fewer investigators are studying its genetics. Over the last year the number of independent genetic loci associated with psoriasis has substantially increased, mostly due to completion of multiple genome-wide association studies (GWAS) in psoriasis. At least 2 GWAS efforts are now under way in PsA to identify novel genes in this disease; a metaanalysis of genome-wide scans and further studies must follow to examine the genetics of disease expression, epistatic interaction, and gene-environment interaction. In the long term, it is anticipated that genome-wide sequencing is likely to generate another wave of novel genes in PsA. At the annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in Stockholm, Sweden, in 2009, members discussed issues and challenges regarding the advancement of the genetics of PsA; results of those discussions are summarized here.     

Cardiovascular and other comorbidities in patients with psoriatic arthritis: a comparison with patients with psoriasis

Objective

To determine whether the presence of psoriatic arthritis (PsA) is associated with greater comorbidity, in particular cardiovascular morbidity, compared to psoriasis without arthritis.

Methods

Six hundred eleven patients with PsA were recruited from the University of Toronto Psoriatic Arthritis Clinic and 449 psoriasis without arthritis patients were recruited from the University of Toronto Psoriasis Cohort. The clinical database was used to identify the prevalence of cardiovascular and other comorbidities in both PsA and psoriasis without arthritis patients. Univariate and multivariate logistic regression analyses were conducted to estimate odds ratios (ORs), comparing the odds of ever having a given comorbid disease in PsA patients with those in psoriasis without arthritis patients. Covariates included age, sex, education, smoking status, severity and duration of psoriasis, medication status, and other comorbidities.

Results

The prevalence of hypertension, obesity, hyperlipidemia, type 2 diabetes mellitus, and at least 1 cardiovascular event in PsA patients was 37.1%, 30.0%, 20.7%, 12.0%, and 8.2%, respectively. This was significantly higher than in psoriasis without arthritis patients, with unadjusted ORs ranging from 1.54 to 2.59. In the multivariate analyses, hypertension remained significantly elevated (adjusted OR 2.17). PsA was also significantly associated with infections not treated with antibiotics (presumably viral), neurologic conditions, gastrointestinal disorders, and liver disease (adjusted ORs 2.83, 4.76, 21.53, and 7.74, respectively). Infections treated with antibiotics and depression/anxiety were relatively common in PsA, with a prevalence of 30.5% and 20.7%, respectively. However, this was not significantly different from psoriasis without arthritis after multivariate adjustments.

Conclusion

The results suggest that inflammatory joint disease may play a role in both cardiovascular and noncardiovascular morbidity in PsA.     

Validation of Sinhala version of Psoriasis Epidemiology Screening Tool

Clinical Rheumatology - Psoriatic arthritis (PsA) occurs in one-third of patients with psoriasis and mostly remains undetected leading to debilitating deforming arthritis, eventually. The Psoriasis...     

Comorbidities of psoriatic arthritis -- metabolic syndrome and prevention: a report from the GRAPPA 2010 annual meeting

Psoriatic arthritis (PsA) is associated with serious comorbidities such as increased cardiovascular risk, hypertension, depression, and reduced quality of life. Patients with psoriasis have been observed to have an increased incidence of metabolic syndrome compared with the general population; recently, this has also been observed in patients with PsA. This review focuses on the comorbidities associated with PsA, with an emphasis on risks of coronary artery disease and metabolic syndrome. We also discuss the development of a comprehensive approach for the management of comorbidities of PsA. The review summarizes a presentation at the 2010 annual meeting of GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis).     

Systematic review of treatments for psoriatic arthritis: an evidence based approach and basis for treatment guidelines

Psoriatic arthritis (PsA) is a chronic systemic inflammatory disorder characterized by the association of arthritis and psoriasis. In addition to a heterogeneous and variable clinical course, PsA is complex and multifaceted and may include prominent involvement in the peripheral and axial diarthrodial joints, the skin and nails, and in periarticular structures such as entheses. A central mission of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) is to develop guidelines, based upon the best scientific evidence, for the optimal treatment of patients with PsA. We outline the specific methods and procedures used in this evidence-based, systematic review of treatments for PsA, which we hope will provide a basis for future treatment guidelines.     

Strategies for biomarker development in psoriatic disease: a report from the GRAPPA 2010 annual meeting

Psoriatic disease includes psoriasis and associated comorbidities (arthritis, uveitis, inflammatory bowel disease, cardiovascular disease, metabolic syndrome, and anxiety/depression) and is remarkably diverse in disease presentation and course. The marked heterogeneity of musculoskeletal involvement in psoriatic arthritis (PsA) presents major challenges to clinicians regarding diagnosis, risk stratification, and management. Members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) have begun collaborative efforts to develop biomarkers that can assist in the diagnosis and management of patients with psoriasis and related comorbidities. This brief review provides a rationale for biomarker research in PsA, consideration of types and sources of biomarkers, and examples of important biomarker studies in PsA, followed by a review of trial designs for biomarker research and a discussion of potential funding sources.     

Etanercept treatment of psoriatic arthritis: safety, efficacy, and effect on disease progression

OBJECTIVE: Etanercept has been shown to improve the articular and cutaneous manifestations of psoriatic arthritis (PsA). In this study, we further evaluated the safety, efficacy, and effect on radiographic progression of etanercept in patients with PsA. METHODS: Patients with PsA (n = 205) were randomized to receive placebo or 25 mg etanercept subcutaneously twice weekly for 24 weeks. Patients continued to receive blind-labeled therapy in a maintenance phase until all had completed the 24-week phase, then could receive open-label etanercept in a 48-week extension. Efficacy and safety were evaluated at 4, 12, and 24 weeks and at 12-week intervals thereafter. Radiographs of the hands and wrists were assessed at baseline and 24 weeks, at entry to the open-label phase, and after 48 weeks in the study. RESULTS: Etanercept significantly reduced the signs and symptoms of PsA and psoriasis. At 12 weeks, 59% of etanercept patients met the American College of Rheumatology 20% improvement criteria for joint response, compared with 15% of placebo patients (P < 0.0001), and results were sustained at 24 and 48 weeks. At 24 weeks, 23% of etanercept patients eligible for psoriasis evaluation achieved at least 75% improvement in the Psoriasis Area and Severity Index, compared with 3% of placebo patients (P = 0.001). Radiographic disease progression was inhibited in the etanercept group at 12 months; the mean annualized rate of change in the modified total Sharp score was -0.03 unit, compared with +1.00 unit in the placebo group (P = 0.0001). Etanercept was well tolerated. CONCLUSION: Etanercept reduced joint symptoms, improved psoriatic lesions, inhibited radiographic progression, and was well tolerated in patients with PsA.     

Psoriasis and psoriatic arthritis video project: an update from the 2010 GRAPPA annual meeting

Changes in severity of psoriasis and psoriatic arthritis (PsA) are assessed in clinical trials by a variety of physical examination instruments. At the 2010 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members were updated on the development and availability of modules that teach these instruments. Web-based interactive multimedia presentations for psoriasis assessments have been completed, including modules for Psoriasis Area and Severity Index and Body Surface Area, 5-point and 6-point Physician Global Assessment, the original and modified Nail Psoriasis Severity Index, the Palmar-Plantar Pustular Psoriasis Area and Severity Index, and the Psoriasis Scalp Severity Index. Rheumatology modules will include assessment of tender and swollen joints, and evaluations of enthesitis, dactylitis, and axial disease. Each module will include the background and rationale for each tool, demonstration video of each examination, diagrams and photographs to emphasize teaching points, and an optional examination at the end. The rheumatology modules have been recorded but were not yet available for review at the meeting. The dermatology modules are currently in use by pharmaceutical and biotechnology companies engaged in research on treatments for psoriasis and PsA. The next phase of this project includes analysis of interobserver reliability, translation into languages other than English for international users, and other proposed studies.     

Screening und Frühdiagnostik der Psoriasisarthritis

Psoriasis arthritis (PsA) encompasses many diverse clinical symptoms. Epidemiological data about the prevalence in general, predisposed age groups, prevalence of joint, spine, enthesis, and extra-articular manifestations are very heterogeneous. Even for the PsA specialist the clinical picture is not always easy to differentiate from other overlapping or clinically similar disease entities. This paper tries to give some guidance on how to screen for and how to detect PsA early in the population of psoriasis patients on the basis of the Mainz PsA screening and early diagnosis algorithm.