Current treatments and recommendations for Psoriatic Arthritis

The aims of treatment for psoriatic arthritis (PsA) are to control inflammation, normalise functions and impacts on patients and prevent complications of the disease and its treatment. Over the past decade, treatment options for PsA have expanded with the availability of many more novel therapeutic agents. However, the treatment decisions and pathways for the use of these drugs are not always straightforward. There is a need to tailor the choice of medication to the individual patient, taking into account the type of their disease and consideration of other factors such as their co-morbidities. A treat to target approach is recommended with the aim to get the patient into a state of remission or low disease activity (whichever target is chosen). Both European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) have recently published updated guidance in 2018–2019. In this section, we will summarise the evidence for therapies in PsA and review the similarities and differences in these two sets of recommendations.     

Clinical features of psoriatic arthritis

Psoriatic arthritis (PsA) is associated with decreased quality of life. As delayed diagnosis may lead to progressive joint destruction and long-term disability, the key clinical features of PsA should be recognizable to a wide range of clinicians to facilitate early diagnosis. In addition to assessment and identification of skin and nail lesions, which occur in up to 85% of those with musculoskeletal manifestations, clinicians should be aware of both the peripheral and axial manifestations of musculoskeletal disease reviewed here. Peripheral joint diseases include polyarticular, oligoarticular, distal, and arthritis mutilans subtypes, and cognizance of these patterns of disease, as well as periarticular manifestations, including dactylitis and enthesitis, is useful for swift diagnosis of PsA. Axial psoriatic arthritis (axial PsA), also known as the spondylitis subtype, may be limited to the spine and sacroiliac joints, but may also affect peripheral structures. Meticulous history-taking and physical examination and familiarity with appropriate imaging studies are often necessary to distinguish axial-PsA from other differential diagnoses. Swift diagnosis and treatment are necessary to both control PsA disease and mitigate the risks of the many associate comorbidities that may accompany it.     

Psoriatic Arthritis Exacerbated by Salmonella Infection

Psoriatic arthritis (PsA) is an inflammatory joint disease in which environmental factors, particularly trauma and infections, are thought to play an important role. The authors describe the case of a patient with a mild and long-untreated form of PsA which was severely exacerbated by Salmonella typhimurium infection. This case confirms the importance of infectious agents in the occurrence and course of PsA. Received: 19 February 1999 / Accepted: 21 September 1999     

Considerations for the definition of remission criteria in psoriatic arthritis

ObjectivesPsoriatic arthritis (PsA) is an autoimmune disease that can cause progressive structural damage of the joints and irreversible disability. The potentially achievable results of biologic therapy for PsA has led to the view that disease remission should be the goal of treatment. However, the heterogeneity of disease manifestations and need for validated outcome measures makes defining remission in PsA challenging. This article evaluates proposed criteria for defining remission in PsA and discusses how these criteria can be applied in clinical practice.MethodsA primary literature search was conducted in PubMed to identify articles discussing potential PsA treatment goals or targets, including minimal disease activity. English-language publications from the last 10 years were included in this assessment.ResultsThere are 5 clinical domains in PsA that must be considered when evaluating remission: synovitis, enthesitis, dactylitis, spondylitis, and psoriasis/nail psoriasis. Due to variability in the completeness of remission and time to achieve remission with different therapies between these domains, remission should be measured clinically through a combination of objective measures, or a composite assessment tool. Composite measures are more efficient than unidimensional instruments in measuring remission, but remission rates differ between the available composite indices.ConclusionAlthough the concept of remission as a treatment goal in PsA is gaining acceptance among rheumatologists, further work is necessary to develop a broadly acceptable definition of remission.     

Subsets in Psoriatic Arthritis formed by Cluster Analysis

The aim of the study was to create subgroups among psoriatic arthritis patients on the basis of dermatological features, clinical pattern of arthritis, and laboratory, immunological and radiological findings. Data on 100 patients were expressed in a standardised form and entered into hierarchical cluster analysis according to Ward”s method. Seven subgroups were created. Fifty-six patients with mild psoriasis were sorted into a “polyarticular group”. Two “RA-like groups” were formed, differing from each other serologically and in axial involvement. In an “oligoarticular group” (18 patients) serious skin disease and female gender predominancy were found to be characteristic. Eight patients with polyarticular arthritis were assigned to an “erythrodermal group”, in which polyarticular arthritis, mutilating, severe arthritis and a history of erythroderma were characteristic. Close to this group on the dendrogram eight women were sorted into a “distal form”. Sausage fingers were frequent, and nail dystrophy was present in every case. In a “pustular group” (three patients) the different type of skin involvement was considered and nail dystrophy was common. In the newly created subgroups not only the arthritic status, but also the type of the skin disease, played a determining role. Received: 23 November 1999 / Accepted: 7 July 2000     

Enthesitis in psoriatic arthritis

Objectives

It is increasingly recognized that enthesitis in patients with psoriatic arthritis (PsA) is of clinical importance. We review data on the detection, assessment, and treatment of enthesitis and its related dactylitis in PsA.

Methods

We searched Pubmed with the search terms psoriatic arthritis or psoriasis in combination with enthesitis, enthesopathy, and treatment, or enthesitis in combination with imaging.

Results

One hundred fifty-seven papers were selected. Enthesitis occurs frequently in PsA and may be asymptomatic or painful. It can also affect patient's function and quality of life. New imaging modalities, such as ultrasonography and magnetic resonance imaging, have revealed that enthesitis may be the initial osteoarticular inflammatory site in patients with PsA. Enthesitis indices have been developed and should be incorporated in clinical trials. Dactylitis, a characteristic and frequent manifestation of PsA can be tender or not tender and is prognostic of disease progression. Treatment of enthesitis includes non-steroidal anti-inflammatory drugs, classical DMARDs, and adjunctive local steroid injections. In inadequate response, TNFα inhibitors are used.

Conclusions

Enthesitis and dactylitis are important manifestations of PsA, and their evaluation is increasingly used in drug trials and clinical practice.