Psoriatic Arthritis

Question 1

Important Aspects from the Hx

Answer 1

-Patient has psoriasis: A family history of psoriasis may reveal hereditary pattern
- Usually develops between 35-55 years, but can occur at any age
- 15% of psoriasis pateints develop psoriatic arthritis
in 20% of patients, arthritis appears before psoriasis

Question 2

Common Ssx

Answer 2

Systemic signs: Typical of system inflammatory conditions: Fever fatigue, weight loss etc,

Arthritis

• Pain; heat; swelling; decreased ROM, usually low-grade inflammation
• Morning stiffness and fatigue
• Commonyl affects wrist, knees, ankles, SIJs and DIPs of fingers and toes
• Sausage fingers/ Dactylitis

Enthesitis

Inflammation of periarticular soft sissue

Tendinitis

Nail lesions occur in about 40-45% of paients with psoriasis

Conjunctivitis

Question 3

List the slinical sub-types of PsA

Answer 3

Asymmetric Arthritis (Oligoarthritis)
Distal interphalangeal arthritis (Peripheral type)(uncommon)
Symmetric Arthritis (Common
Arthritis Mutilans (Rare)
Axial arthritis (Sponylitis & Sacroilitis) (rare)

Question 4

Asymmmetric Arthritis

Answer 4

• Generally mildest form
• Most common presentation of PsA
• Asymmetric involvement of 1-3 large and small joints; digits of the hands and feet are usually affected first; Usually, fewer than 5 joints are affected at any one time.
• main joitns affected:
• — Small joints: DIPs usually, also PIPs and MCPs
• — Large joints: Knee hip ankle or wrist
• when hands are involved; dactylitis may occur

Question 5

Distal Interphalangeal Arthritis

Answer 5

• Usually affects men
• Main joints affects: DIPs in the fingers and toes
• Nail and skin changes are common and may be prominent
• –Nail Pitting: Ice pick-like depression in the nail plate
• – Yellow-orange nail discoloration
• – Onycholysis: separation of nail from the nail bed
• – Nail ridging
• – Nail splitting

Question 6

Symmetric arthritis

Answer 6

• Similar to RA but usually milder with less deformity; may evolve from Asymmetric form
• Affects women more than men
• Symmetric joint involvemtn commonly affect >4 joints
• – Commonly affects: fingers and toes
• – Also affects: Wrists, elbows and ankles
• Occasionally severe and disabling, causing joint deformity
• May have prominent nail involvement, significant paronychitis & swelling of the digital tuft
• Psoriasis associted with this form tends to be severe

Question 7

Arthritis Mutilans (rare)

Answer 7

• Severe, erosive, destructive and deforming and disabling arthritis
• Asymmetric
• Structures affected
• – Commonly affects: small joints (esp DIPs) of the hands and feet; shortening of digits because of severe joint or bone lysis
• – Also affects: neck or lower back
• — Enthesitis is common
• Observe exacerbations (often coincide with flares in the psoriasis) & remissions

Question 8

Axial arthritis (Spondylitis & Sacroilitis)(less common)

Answer 8

• Asymmetric; often unilateral involvement
• Usually affects men
• Stiffness, pain & reduced ROM
• Structures affected
• – Commonly affects: cx spine, lumbar spine, sacroiliac joints
• – Also affects peripheral joints in the hands, arms, hips, legs and feet
• – Enthesitis common

Question 9

Extra-articular manifestations

Answer 9

• Mucous membrane lesions (less common) e.g.
• — Small, painless ulcers on the soft palate and tongue; usually resolve with or without treatment in a few days or weeks
• urethritis
• GIT manifestations: Dysentery: mild recurrent abdominal complaints and diarrhoea
• Cardiac Manifestations: Valvular lesions: especially aortic regurgitation
• Ocular manifestations
• – Conjunctivitis is the most common conidition
• – redness of the eye
• – blurred vision
• — eye irritation
• – photophobia
• Generalised fatigue

Question 10

Differential diagnoses

Answer 10

• The ssx of PsA are simlar to RA, gout & ReA. RA is usually symmetric and may have rheumatoid nodules. Nodules are not present in PsA. The simultaneous presence of psoriatic skin lesions and typical nail lesions supports a diagnosis of PsA.