Atlas of Psoriatic Arthritis (eBook)

Philip J. Mease, MD, is a clinical professor at the University of Washington School of Medicine in Seattle, where he has also been chief resident and fellow in rheumatology, and is chief of rheumatology clinical research at the Swedish Hospital Medical Center. He is highly involved in clinical trials of new therapies for a number of rheumatic disease conditions, (including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, osteoarthritis, lupus, fibromyalgia and osteoporosis,) and is a founding organizer of GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.) Publications include numerous articles and book contributions. Philip Mease also sits on review boards for The Journal of Rheumatology, Arthritis & Rheumatism, and The Annals of the Rheumatic Diseases and has received the Medical Communicator Award of the American College of Rheumatology. Dr Mease chairs / co-chairs three working groups of OMERACT (Outcome Measures in Rheumatology): psoriatic arthritis, fibromyalgia and single joint assessment. He is also on the medical advisory boards of pharmaceutical and biotechnology companies, the Lupus Foundation, the Psoriasis Foundation, and the Northwest Arthritis & Osteoporosis Institute. With a strong interest in education, he is also a part of the speakers’ bureaus of the Arthritis Foundation, Lupus Foundation, National Psoriasis Foundation, Wyeth Ayerst, SmithKline Beecham, Genelab Technologies, Proctor & Gamble – to name but a few. Philip S. Helliwell, BM, BCh, is currently senior lecturer in rheumatology at the University of Leeds, Academic Unit of Musculoskeletal & Rehabilitation Medicine. His interests include chronic pain, disability, and communication. He has written about the Moll and Wright classification criteria for diagnosing PsA, making the case for retaining at least the two subgroups of peripheral and axial disease and splitting the peripheral disease into oligo- and polyarthritis.

Contents 5
Contributors 7
Introduction 9
References 10
Epidemiology 11
Incidence and prevalence data for PsA in published studies 12
Prevalence of PsA among patients with psoriasis 13
Predominantly DIP joint involvement in PsA 13
Oligoarthritis in patients with PsA 14
Symmetric polyarthritis in PsA 14
Arthritis mutilans in PsA 15
Spondyloarthritis in PsA 15
Change in patterns of PsA in 664 patients in an inception cohort 16
Dactylitis in fingers and toes in PsA 16
Photograph and radiograph of enthesitis in PsA 17
Adjusted mean SF-36 health survey scores for PsA sample and UK and USA general populations 17
Predictive factors for mortality in PsA 18
Factors associated with remission in PsA 18
HLA gene complex - chromosome 6 19
HLA antigens and disease progression in PsA Genetic basis of psoriasis: genome scans 20
References 21
Etiology and Pathophysiology 25
Etiology 25
Genetic factors 25
Environmental factors 25
Pathogenesis 26
Synovial membrane characteristics 26
Enthesis 26
Mechanisms of joint destruction 26
Environmental factors in the pathogenesis of RA 27
Histology of psoriatic plaque Vascular morphology in psoriatic and rheumatoid synovium 27
hybridization for VEGF and Ang-2 mRNA in patients with early PsA and RA 28
Synovial membrane characteristics – features of psoriatic synovium 28
MRI showing acute enthesitis 29
Undifferentiated SpA at baseline and 6 months after treatment 29
Distal digit osteolysis in PsA 30
Osteoclasts are prominent in the psoriatic joint Bone and cartilage destruction in PsA 30
Osteoclastogenesis pathway 31
Schematic model of osteolysis in the psoriatic joint 31
References 32
Clinical Evaluation 35
PsA clinical subgroups of Moll and Wright 36
DIP joint inflammation 37
Asymmetric oligoarthritis 37
Classic ankylosing spondylitis 38
Symmetric polyarthritis 38
Distinctive mutilation in PsA 39
Dactylitis in the hand and foot 39
Entheseal sites in PsA 40
SAPHO syndrome – palmoplantar pustulosis 40
SAPHO syndrome – abnormal radioisotope uptake in psoriasis vulgaris Eye disease in PsA 41
Pitting edema in PsA Relationship between joint symmetry and number of joints in PsA 41
Juvenile PsA 42
HIV and PsA 42
Clinical syndromes that suggest PsA 42
General diagnostic principles for PsA Flexural psoriasis 43
Left and right hand of a 67-year-old male at first presentation 44
Inflammatory articular disease (joint, spine, or entheseal) 44
Screening questions for arthritis 45
Diagnostic pointers to distinguish PsA from RA 46
References 47
Distinguishing PsA from other SpAs 47
Imaging 49
Plain radiographs of patients with arthritis mutilans 50
Plain radiograph of ‘whittling’ in PsA 50
Plain radiograph of characteristic changes in finger in chronic PsA – classic periostitis 51
Inflammatory polyarthritis in chronic PsA 51
Multiple peri-articular bone erosions in PsA patient receiving combination therapy 52
PsA with rheumatoid-like features – ulnar deviation of the MCP joints 52
PsA with rheumatoid-like features – fibular deviation of the toes 53
Monoarthritis of the right wrist in patient with PsA 53
Syndesmophytes in PsA 54
Enthesophytes in PsA 54
Ultrasonographs showing capsular edema in PsA 55
Ultrasonography of patellar tendon enthesitis in PsA 55
Ultrasonographs of plantar fasciitis and patellar tendonitis 55
Ultrasonography and MRI of plantar faciitis in PsA 56
MRI of the hands in PsA – capsular-based edema 56
Use of MRI in early PsA 57
MRI of knee of HLA-B27-positive patient with PsA 57
MRI of patient with SAPHO syndrome 58
Scintigraphy and MRI of patient with SAPHO syndrome 58
Imaging of sacroiliac joints of patient with HLA-B27-positive PsA 59
CT scan of pelvis of PsA patient showing sacroiliitis 59
References 60
Skin and Psoriasis 63
Pathophysiology 63
The Psoriasis Phenotype 63
MHC and non-MHC psoriasis loci 64
Histopathology of psoriasis 65
Examples of plaque-type psoriasis 65
Examples of plaque-type psoriasis 66
Examples of partially cleared psoriasis 66
Guttate psoriasis 67
Psoriatic flare 67
Distribution of psoriasis 67
Palmoplantar psoriasis 68
Pustular psoriasis 69
Erythrodermic psoriasis 69
Psoriatic nail disease 70
References 70
Juvenile Psoriatic Arthritis 73
Introduction 73
Clinical Features of Juvenile Psoriatic Arthritis 73
Dactylitis 73
Psoriasis 73
Uveitis 73
Growth Disturbances 74
Other Systemic Manifestations of JPsA 74
Imaging 74
Treatment 74
Outcome and Prognosis 74
Differential diagnosis of musculoskeletal disorders in children 75
Definition of JIA 75
Comparison between the classification systems for JIA, JCA, and JRA 76
JIA and subtypes 76
JPsA 77
Guttate psoriasis 77
Epidemiology of JIA 78
Clinical features of JPsA 78
a) JPsA patterns of joint disease at onset 79
b) Joint involvement in JPsA 79
Oligoarticular-onset JPsA 79
Asymmetrical small joint involvement in JPsA 80
Symmetrical DIP involvement in JPsA Polyarticular JPsA 80
Psoriasis skin rash 80
Destructive small joint disease in JPsA 81
Oligoarticular-onset JIA or oligoarticular JPsA? 81
Knee arthritis and asymmetrical growth 81
Micrognathia 82
JPsA of the left foot and asymmetrical growth 82
Dactylitis 83
Dactylitis in the foot 83
Enthesitis 84
Case history: dactylitis in the left foot 84
Heel and foot pain in children 85
Psoriasis at the umbilicus 85
Acute anterior uveitis 86
Koebner phenomenon 86
Nail changes 86
Chronic anterior uveitis 87
Recommended ophthalmologic monitoring for patients with JIA 87
MSUS image of an adolescent with JPsA 87
Medicines used to treat inflammatory arthritis in children 88
References 89
The Management of Psoriatic Arthritis 91
Therapy of PsA 93
Therapeutic targets in PsA 93
Who will progress aggressively? 94
Measures of PsA outcome 94
Trial-verified benefit of traditional DMARDs in PsA 95
Sulfasalazine in PsA: PsARC response at 36 weeks 95
Leflunomide in PsA: ACR20 and PsARC results 95
Pathophysiology of PsA 96
Role of cytokines and cytokine inhibitors in chronic inhibition 96
Key actions attributed to TNF 97
Cytokine inhibition 97
TNF inihibition 98
Design elements in current PsA trials 99
Demographics of etanercept phase III trial 99
Results of phase III trial of etanercept in PsA 100
Etanercept in PsA: radiographic progression mean change in TSS through 24 months 101
IMPACT 2: study design/subject disposition 101
Infliximab in psoriasis/PsA therapy: phase III study 101
Infliximab reduces inflammation in PsA (IMPACT 2) 102
ADEPT study design 102
Adalimumab in PsA: ACR response at weeks 12 and 24 ( ADEPT) 103
HAQ mean change from baseline at week 12 and 24 (ADEPT) 103
Adalimumab in PsA: ACR response at weeks 12 and 24 ( ADEPT) 103
Mean change in mTSS at week 24 (ADEPT) 104
Safety issues of anti-TNF therapy 104
PsA: new therapies on the horizon 105
T-cell activation requires two signals 105
PsA open-label study: alefacept 106
Example of an adaptive aid: a wrist splint 106
PsA: strategizing therapy choice 106
References 107
Treatment of Psoriasis 109
Definition of the PASI 110
Dermatology Life Quality Index 111
Topical therapies for psoriasis 111
Overview of phototherapy for psoriasis 113
Overview of systemic agents for psoriasis 115
Biologic agents currently available or in late-phase trials for psoriasis 116
Alefacept, a fully humanized fusion protein 117
PASI response and efficacy of alefacept in two phase III studies 117
PASI 75 response to etanercept in a phase II trial 118
Percentage of patients achieving PASI 75 or PASI 50 in efalizumab- treated ( 1 mg/ kg/ wk) and placebo groups 118
Adalimumab efficacy at weeks 12, 24 and 60 119
Randomized placebo-controlled trials with infliximab 120
References 120
Index 125