10 - 65 - PSORIATIC ARTHRITIS Flashcards
PsA characteristically involve which joints?
distal interphalangeal joints
Classification Criteria for PsA (CASPAR)
Clinical predictors of PsA
- nail psoriasis,
- severe psoriasis,
- scalp, intergluteal, or perianal psoriasis,
- presence of uveitis
psoriasis in what areas are more likely to be associated with PsA?
Scalp and intergluteal psoriasis
In PsA, what is the nail disease prevalence?
80%
- Both the nail plate and nail matrix are affected, with nail pitting being the most common
- Association of onycholysis with axial PsA has recently been described.
most common Psoriatic Arthritis Phenotype
Oligoarthritis
- These phenotypes tend to overlap with cumulative disease duration. For example, the oligoarticular presentation tends to become symmetric over time as more joints become involved
- Joint inflammation in PsA is more vascular and less tender than in rheumatoid arthritis, and joint tenderness and swelling each predict subsequent joint damage
full-thickness inflammation of a digit (finger or toe)
Dactylitis
- sign of disease severity associated with radiographic damage
- Inflammation affects the joints, entheses, and subcutaneous tissues of the digits.
- Dactylitis assessed with high-resolution MRI is characterized by multiple lesions spanning multiple musculoskeletal structures: diffuse extracapsular soft tissue edema (92%), diffuse or focal increased bone marrow edema (83%), enthesitis at the collateral ligament (75%) and extensor tendon (50%) insertions, flexor tenosynovitis (75%), synovitis (68%), signal intensity changes in the tendon pulleys (fingers), and fibrous sheaths (toes).
inflammation at entheseal sites and has an important role in PsA pathophysiology, with studies supporting a link between biomechanical damage as the initiating event of autoimmunity in PsA.
Enthesitis
- Clinically, enthesitis is diagnosed as tenderness to pressure at entheseal insertion sites.
- The most common sites of involvement are the Achilles tendons, plantar fascia, and lateral epicondyles at the elbows
has the strongest evidence for being a genetic risk factor for PsA in people with psoriasis
HLA-B27
Risk factors for axial PsA
presence of onycholysis, inflammatory back pain symptoms, PsA duration/young age at onset, positive HLA-B27, and inflammatory bowel disease
inflammatory arthritis affecting the axial skeleton leading to spondylitis and/or sacroiliitis.
Spondyloarthritis
population at greatest risk for developing PsA
people with psoriasis
risk factors associated with developing PsA have been identified in people with psoriasis:
- psoriasis type/location such as scalp and intergluteal, psoriasis severity, psoriatic nail disease, positive HLA-B27, and uveitis
- In addition to these clinical factors, the following environmental and individual factors increase the risk of PsA: physical trauma, smoking, overweight, and obese physique
Psoriatic arthritis diagnostic algorithm
window of opportunity to initiate therapy to maximize chances of minimal disease damage in Psoriatic Arthritis
6 months
first-line agents for PsA
The disease-modifying antirheumatic drugs (DMARDs) methotrexate, sulfasalazine, and leflunomide
preferred DMARD in peripheral spondyloarthritis considering risk and benefits in individual patients
Sulfasalazine
first-line biologic agents for PsA
TNF inhibitors (adalimumab, certolizumab, golimumab, etanercept, infliximab)
first-line treatment for enthesitis and axial PsA
TNF inhibitors (adalimumab, certolizumab, golimumab, etanercept, infliximab)
Reactive arthritis is typically an oligoarthritis that develops how many weeks following an enteric or urethral infection?
1 to 4 weeks
classic triad of reactive arthritis
urethral, ocular and articular inflammation
*rarely present
Inciting infections in reactive arthritis
Chlamydia trachomatis, Yersinia, Shigella, Salmonella, Campylobacter, Clostridium difficile, and Escherichia coli.
Cutaneous manifestations of reactive arthritis
keratoderma blenorrhagicum, circinate balanitis, aphthous ulcers, and nail changes.
This HLA haplotype appears to be a risk factor of reactive arthritis and is associated with a more chronic prognosis.
HLA-B27
cutaneuos manifestation of reactive arthritis characterized as inflammatory skin lesion that develops on the shaft or glans of the penis and more rarely on the scrotum
Circinate balanitis
- cutaenous manifestation of reactive arthritis that resembles a pustular psoriasis and is generally found on the **palms and soles. **
- Initially it is an erythematous vesicular lesion that develops into pustular keratotic lesions before coalescing into psoriatic-like plaques.
Keratoderma blenorrhagicum
criteria for diagnosing ReA
■ The arthritis should predominantly involve the lower limb, involve one or only a few joints, and not equally involve both sides of the body (asymmetric).
■ There should be evidence or a history of preceding infection. Although it is ideal to have a culture that is positive for an infectious agent that is recognized to be associated with this condition, if the patient has documented diarrhea or urethritis in the prior 4 weeks, laboratory confirmation is not required.
■ The patient should not have evidence that the joint itself is infected (ie, septic arthritis). Also, other causes of monoarthritis (such as gout) or oligoarthritis (such as rheumatoid arthritis) should be ruled out.
