What Is The Evidence
Rahimi, H, Ritchlin, CT. Altered bone biology in psoriatic arthritis.. Current Rheumatology Reports. vol. 14. 2012. pp. 349-57.
Coates, LC, Anderson, RR, Fitzgerald, O. Clues to the pathogenesis of psoriasis and psoriatic arthritis from imaging: a literature review.. J Rheumatol.. vol. 35. 2008. pp. 1438-1442.
Ritchlin, CT, Colbert, R, Gladman, DD. Psoriatic Arthritis.. New Eng J Med.. vol. 376. 2017. pp. 957-970.
Gladman, DD, Antoni, C, Mease, P, Clegg, DO, Nash, P. Psoriatic arthritis: epidemiology, clinical features, course, and outcome.. Ann Rheum Dis.. vol. 64. 2005. pp. ii14-17.
Ogdie, A, Haynes, K, Troxel, AB. Risk of mortality in patients with psoriatic arthritis, rheumatoid arthritis and psoriasis: a longitudinal cohort study.. Ann Rheum Dis.. 2012.
Coates, LC, Kavanaugh, A, Mease, PJ. Group for research and assessment of psoriasis and psoriatic arthritis: treatment recommendations for psoriatic arthritis 2015.. Arthritis Rheumatol 2016 Jan 8..
Gossec, L, Smolen, JS, Ramiro, S. European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update.. Ann Rheum Dis.. vol. 75. 2016. pp. 499-510.
Eder, L, Jayakar, J, Shanmugarajah, S. The burden of carotid artery plaques is higher in patients with psoriatic arthritis compared with those with psoriasis alone.. Annals of the rheumatic diseases. vol. 72. 2013. pp. 715-20.
Complete Medical History For Diagnosing Psoriatic Arthritis
Your road to a psoriatic arthritis diagnosis starts with talking to your rheumatologist in order to share symptoms and identify risk factors. While symptoms like joint pain could suggest a number of conditions, in psoriatic arthritis, joint pain often has specific characteristics, including the following:
- Joint pain that gets better with use
- Joint redness and swelling
- Swelling of an entire finger or toe as opposed to just one joint, called dactylitis or sausage digits
- Morning stiffness that lasts more than 30 minutes
- Changes in the nails of your fingers or toes, such as holes, pitting, discoloration or softness, which occurs in 80 to 90 percent of PsA cases
When patients talk about these psoriatic arthritis symptoms, rheumatologists like Dr. Kumar hear a number of common concerns, such as My shoes dont fit, I feel stiff all over in the mornings, and I have trouble opening jars or door knobs.
Along with listening to your symptoms, your rheumatologist will want to hear about any possible risk factors for psoriatic arthritis. While this condition can affect patients of both genders at a range of ages, the following can increase your risk:
- Having psoriasis
- Having a family history of PsA, psoriasis, or associated conditions, including ankylosing spondylitis, Crohns disease, ulcerative colitis, autoimmune uveitis, and reactive arthritis
What Happens To Patients With Psoriatic Arthritis
Genes implicated in the pathogenesis of PsA include Cw6,IL-23 R alleles and Act1, a molecule in the IL-17R signaling pathway and other MHC Class I alleles , Class I major histocompatibility complex chain-related gene A . Environmental events have also been associated with the onset of psoriatic arthritis, including rubella vaccination, injury sufficient to require a medical consultation, recurrent oral ulcers, moving house and fracture requiring hospitalization.
From a clinical perspective, PsA patients can present with features of RA or spondyloarthritis . The synovial pathology is more akin to findings in spondyloarthritis than RA with infiltrating neutrophils, CD163+ macrophages, and the lack of an antibody response to the shared epitope as observed in RA.The importance of local biomechanical properties in disease pathogenesis, particularly as it relates to the enthesis, has been emphasized. The model of the synovio-entheseal complex delineates an innate immune response triggered by biomechanical and inflammatory events at the enthesis, which subsequently involve adjacent synovium and cartilage.
Mortality rates for PsA were higher than age-matched controls but recent evidence indicates that mortality may not be higher than observed in the general population. PsA patients do have higher rates of mortality from cardiovascular disease than controls.
Pharmacologic considerations
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Psoriatic Arthritis Blood Test: Anti
Blood tests that look for the presence of anti-cylic citrullinated peptide antibodies , which are inflammatory, are commonly used to diagnose rheumatoid arthritis, but anti-CCPs can also indicate psoriatic arthritis.
Roughly 8 to 16 percent of people with psoriatic arthritis will test positive for anti-CCPs, says Rubenstein.
Frequency of Testing Some physicians will perform the test yearly, says Cadet.
Access To Care Challenges
Serious racial disparities exist when it comes to access to care, both when it comes to psoriatic arthritis and in general.
Studies show differences in psoriatic arthritis based on skin color and race. For example, Black people tend to have more severe:
- Skin involvement
Despite that, they’re less likely than White people to be put on immunosuppressive drugs.
Furthermore, according to 2021 research, psoriatic arthritis is diagnosed less often in:
- Black people
- People of Asian descent
- Latinx people
People in these groups who have psoriatic arthritis often have a higher disease burden and lower quality of life because of disparities in care.
Some studies show implicit, often unconscious biases against people of color throughout the healthcare community. This is believed to have negative effects when it comes to treatment decisions and outcomes.
Some facilities have looked at disparities in their own patients. They found that poverty plays a role. But when comparing Black and White people of the same socioeconomic status, it became clear that outcomes remained worse for Black people.
Researchers call for more investigation into the impacts and disparities caused by bias in the medical profession and better education aimed at eliminating these issues.
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Ways To Alleviate Spine Pain Or Disability
Minor pain and stiffness of mild PsA can be alleviated with non-steroidal anti-inflammatory drugs . In addition, injections of corticosteroids may be used.1
For moderate to severe disease, treatments that target joint disease in PsA can reduce symptoms and prevent disease progression. Recommended treatments include disease-modifying anti-rheumatic drugs . Non-biologic DMARDs, such as methotrexate, leflunomide, or sulfasalazine, have demonstrated efficacy for peripheral arthritis but not for axial disease. Biologic DMARDs that have proven effective in clinical trials include ustekinumab , brodalumab , and secukinumab . Other DMARDs target tumor necrosis factor , a chemical that produces a wide range of inflammation in PsA. Examples of TNF blockers include etanercept , adalimumab , infliximab , golimumab , and certolizumab pegol . 4 The FDA has also recently approved Inflectra , a biosimilar to infliximab, for the treatment of PsA.5
Physical and occupational therapy can also be critical treatment approaches to both protect the involved joints and maintain function.1
Psoriatic Arthritis Imaging Test: X
X-rays, which use low-dose radiation to produce images of the inside of the body, can help your doctor make a psoriatic arthritis diagnosis and monitor progression of the autoimmune condition.
X-rays allow the doctor to see changes to the bone, says Elyse Rubenstein, MD, a rheumatologist in Santa Monica, California. In people with psoriatic arthritis, X-rays may show bone erosion, new bone formation, bone fusion, or a phenomenon called pencil in a cup, in which the ends of the bone have been eroded to a pencillike point. Any of these changes indicate that the disease is getting worse, Dr. Rubenstein says.
Frequency of Testing A doctor may take an initial X-ray to help diagnose psoriatic arthritis and rule out other forms of arthritis, such as rheumatoid arthritis, which have different patterns of joint involvement, says Rubenstein.
After that, how often you have X-rays depends on your physician and the state of your disease. Some doctors take X-rays just once a year for routine monitoring, while others may take them only when a patients condition changes.
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Psoriatic Arthritis Blood Test: C
C-reactive protein is a protein in the blood that indicates inflammation. If a blood test shows high CRP levels, you might have psoriatic arthritis, explains Dr. Husni.
Your doctor may use the test if your ESR is normal, since CRP is more accurate at detecting inflammation in some people, adds Cadet.
Again, different labs may have slightly different interpretations of readings.
Frequency of Testing CRP analysis may be done for diagnosis and then several times a year to assess whether inflammation has responded to treatment, notes Cadet.
Can A Chest X Ray Be Done For Rheumatoid Arthritis
An experimental drug for rheumatoid arthritis developed by Johnson & Johnson and GlaxoSmithKline. Using a scoring method to measure changes in joint damage as viewed by X-ray in which higher scores indicate greater structural. The thing is that the abdomen should be completely protected with lead apron and chest X-rays can be done freely.
Chest CT is more effective than chest X-ray in the detection of early COVID-19 disease. 2 However, up to 50% of patients may have a normal chest CT within the first two days after the onset of symptoms. 3 Also, other types of pneumonia may mimic COVID-19 on chest CT.
X-Ray X-rays are radiographic imaging tests that allow doctors to find locations in their patients where bone erosion is occurring at the joints. X-rays show doctors where the erosion is occurring and how quickly it is progressing. This type of progression monitoring happens when multiple x-rays are taken over time.
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Usefulness Of Ultrasound Imaging In Detecting Psoriatic Arthritis Of Fingers And Toes In Patients With Psoriasis
Giacomo Caldarola
1Department of Dermatology, Catholic University of the Sacred Heart, Largo Francesco Vito1, 00168 Rome, Italy
2Department of Bioimaging and Radiological Sciences, Catholic University of the Sacred Heart, Largo Francesco Vito1, 00168 Rome, Italy
Abstract
1. Introduction
Psoriatic arthritis is a form of inflammatory arthritis associated with psoriasis. It affects 7% to 36% of psoriatic patients in different samples and up to 1% of the global population . Moll and Wright originally described five clinical manifestations of PsA: predominantly distal interphalangeal joint disease, asymmetrical oligoarthritis, polyarthritis, spondylitis, and arthritis mutilans . Recently, the classic spectrum has been extended to encompass a number of extra-articular clinical manifestations including enthesitis , tendonitis, tenosynovitis, and dactylitis . Although PsA is commonly considered as a benign arthropathy, about 50% of patients go on to develop progressive arthritis, with joint function impairment or loss and even deformity .
2. Material and Methods
2.1. Patients
Clinical and US evaluation of fingers and toes was also performed in 50 sex- and age-matched patients with chronic plaque psoriasis but no finger and/or toe joint pain meeting the same inclusion and exclusion criteria . In this group, abnormal US findings involved X-ray examination and referral to the rheumatologist.
2.2. Ultrasound and Power Doppler Examination
2.3. Radiographic Examination
3. Results
What Happens During An X
The X-ray is performed in a radiology department.
The X-ray machine will send a beam of ionizing radiation through an X-ray tube. This energy passes through the part of the body being X-rayed and is then absorbed on film or a digital camera to create a picture. Bones and other dense areas show up as lighter shades of gray to white, while areas that don’t absorb the radiation appear as dark gray to black.
The entire test takes no more than 10 to 15 minutes.
You will feel no discomfort from the X-ray test.
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Who Needs A Test
PsA can affect anyone. It develops most frequently in young adults, but it can appear at any age.
People with psoriasis or a family history of psoriasis are more likely to develop PsA and should be aware of the symptoms.
If someone develops arthritis symptoms and has either psoriasis or a family history of it, they should ask a doctor whether their symptoms could result from PsA or another autoimmune inflammatory disorder.
This Chronic Inflammatory Arthritis Can Have Many Different Symptoms Which Is Why Its So Easy To Misdiagnose And Miss Say Rheumatologists
Like many types of inflammatory arthritis, psoriatic arthritis is an autoimmune disease that affects your joints, causing pain, stiffness, and swelling . Men and women tend to develop PsA in equal numbers, and the first symptoms usually appear when people are between the ages of 30 and 50.
People commonly associate psoriatic arthritis with psoriasis, an autoimmune disease that affects the skin, causing flares of red, silvery plaques, although you dont necessarily need to have psoriasis to develop PsA.
Up to 20 to even 30 percent of patients who have psoriasis will go on to develop psoriatic arthritis, says Rebecca Haberman, MD, clinical instructor of rheumatology at the department of medicine, NYU Langone Health in New York City. But its really only recently that psoriatic arthritis has come to the forefront of both rheumatology and dermatology. Dermatologists dont always know all of the signs or the symptoms of psoriatic arthritis to know when to refer people to a rheumatologist.
That helps to explain why some people with psoriasis arent readily diagnosed with psoriatic arthritis, says Dr. Haberman. In fact, a 2015 study published in the Journal of the American Academy of Dermatology found that about 15 percent of patients with psoriasis had undiagnosed PsA.
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How Does Psoriatic Arthritis Affect The Spine
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Psoriatic arthritis , the chronic inflammatory arthritis associated with psoriasis, can affect any joint in the body. The disease varies widely among patients. When it affects the spine, it is often referred to as one of the following:
- Psoriatic Spondylitis, which refers to inflammation in the joints between the vertebrae
- Sacroiliitis, which refers to inflammation in the joints between the spine and the pelvis and can be asymmetrical 1
PsA in the spine may also be called axial arthritis. PsA in the spine may present as inflammatory low back pain and show evidence of inflammation on x-rays, although MRI is generally the gold standard for imaging axial disease.1,2
Psoriatic spondylitis shares similarities with ankylosing spondylitis. Both are inflammatory diseases that may have a link to the HLA-B27 gene, which is a gene that is known to predispose people to several rheumatic diseases. While there are several genes linked to PsA, the highest predictive value is found with HLA-B27.3
Differential Diagnostic Value Of Mri
Most studies have compared patients with known diagnoses. MRI has generally not been able to distinguish between peripheral PsA and RA, even though some findings are characteristic for PsA, and dynamic contrast-enhanced MRI has shown similar patterns in PsA as in RA, and in osteoarthritis .
Of note, no studies have documented that MRI in an early undifferentiated arthritis cohort can be used to differentiate PsA from other arthritides.
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Imaging Studies For Diagnosing Psoriatic Arthritis
In addition to laboratory tests, imaging studies can help your rheumatologist see whether the appearance of your bones and tissues suggests you could have PsA or another condition. Depending on your case and circumstances, your doctor may order one or more of the following tests:
X-ray: A radiograph image of your affected joints as well as your spine if that appears to be affected will help your doctor see marginal bone erosions, which means bone being eaten away where it meets a ligament or tendon. This would suggest PsA. Ankylosis may also be seen in very severe PsA. But a negative X-ray may simply mean the PsA is in an early stage, so additional imaging could be needed.
Ultrasound: A sonogram of the affected joints can help your doctor see disease activity and damage in tendons and ligaments. In cases of psoriatic arthritis, your doctor may see inflammation of tendons and joints or erosions where bone has been eaten away by immune cells.
MRI: Magnetic resonance imaging can be especially helpful in allowing your doctor to investigate back pain you might have associated with PsA.
Chances are, if youre seeing a rheumatologist because you have concerns about having psoriatic arthritis, youve already seen quite a few different doctors or health care providers by now. We know this process can be exhausting and exasperating. We are here for you to help make things easier.
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Which Is A Hall Mark Feature Of Sarcoidosis
Approximately 6% of all patients with sarcoidosis develop a psoriatic arthritis form of arthritis. The hall-mark feature of psoriatic arthritis is dactylitis, characterized by sausage-shaped digits. The patho-physiology in psoriatic arthritis in sarcoid may be different from that of nonsarcoid dactylitis.
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Blood Tests Can Be Confusing
PsA patients often test positive for blood markers of inflammation, such as C-reactive protein or erythrocyte sedimentation rate . But psoriatic arthritis is considered a seronegative arthritis, which means that it doesnt have telltale antibodies the way rheumatoid arthritis does with rheumatoid factor and anti-CCP. This can cause confusion between PsA and seronegative rheumatoid arthritis, in which RA patients dont have these antibodies either. Seronegative RA occurs in 20 to 30 percent of RA cases. Read more here about seronegative RA vs. seropositive RA.
Radiographic Findings In Axial Psa
In the spine PsA can have a slightly different pattern of radiographic features than axial Spondiloarthritis . Syndesmophytes are often bulkier than those seen in SpA, may be paramarginal, asymmetric and may skip vertebral levels. Better seen on anteroposterior view than on lateral view and more often thoracolumbar than cervical . Radiography of the spine can be used for monitoring cumulative changes, particularly new bone formation .
Fig. 3
a Syndesmophytes at the anterosuperior endplate of L3 and L4 vertebrae and Romanus lesions at the anterior endplate of T12, L1 and L2 vertebrae . b Square vertebrae and barrelshaped vertebrae show straightening or convex bulging of the ventral aspect of the vertebral body, mainly in the thoracolumbar junction and lumbar segments as a result of inflammation. c Right lateral syndesmophyte at the superior endplate of L4 vertebra and sacroiliac ankyloses
In the sacro-iliac joints , axial radiographs in patients with PsA may reveal changes identical to those seen in ankylosing spondylitis with symmetric sacroiliitis. However, asymmetric sacroiliitis, is highly suggestive of PsA.
It is recommended radiography of the SIJ as first line modality for diagnosis of sacroiliitis as part of axial SpA, followed by MRI if radiography is negative/inconclusive . However, MRI of the SIJ is the preferred initial imaging method in patients with short disease duration and young patients .
Fig. 4Fig. 5Fig. 6Fig. 7
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