Updated: 6/17/2021

Psoriatic Arthritis

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https://upload.orthobullets.com/topic/9050/images/psa4-50[1]_moved.jpg
https://upload.orthobullets.com/topic/9050/images/skinrash.jpg
https://upload.orthobullets.com/topic/9050/images/dactylitis.jpg
https://upload.orthobullets.com/topic/9050/images/img_0245.jpg
https://upload.orthobullets.com/topic/9050/images/pitting.jpg
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  • Summary
    • Psoriatic Arthritis is a seronegative spondyloarthropathy that presents with DIP predominant arthritis of the hands, rash with silvery plaques, uveitis, and dysmorphic nails. 
    • Diagnosis is made based on a thorough evaluation of serum labs, clinical features, and radiographic findings.
    • Treatment is usually medical management with a variety of options including corticosteroids, disease modifying anti-rheumatic drugs, and biological drugs. 
  • Epidemiology
    • Incidence
      • affect up to 5-20% of patients with psoriasis
    • Demographics
      • equally affects men and women
  • Etiology
    • Pathophysiology
      • 5 patterns of arthritis
        • asymmetric oligo/monoarticular arthritis affecting DIPJ, PIPJ, MCPJ
        • DIP-predominant arthritis
        • arthritis mutilans
        • symmetric, RF-negative polyarthritis
        • psoriatic spondyloarthropathy
    • Genetics
      • HLAB27 found in 50%
  • Presentation
    • Symptoms
      • arthritic symptoms in hands
    • Physical exam
      • rash with silvery plaques over extensor surfaces (elbows, knees)
        • typically precede joint involvement by several years (80-85% of time)
      • hands
        • dactylitis (sausage digit)
        • onychodystrophy (nail pitting)
        • onycholysis (lifting of nail plate starting distally)
        • arthritis mutilans
          • opera glass hands (la main en lorgnette)
            • excess skin from the shortening of the phalanx bones becomes folded transversely, as if retracted into one another like opera glasses
      • chronic uveitis
      • entheses such as achilles tendonitis, posterior tibial tendonitis, and plantar fasciitis
  • Imaging
    • Radiographs
      • hands
        • distal phalanx acrolysis
        • DIP arthritis
          • classic finding is "pencil-in-cup" deformity
            • simultaneous destruction of the head of the middle phalanx and expansion of the base of the distal phalanx
          • different than DJD by presence of centripetal erosions which cause joint space widening
        • small joint erosions or fusions (PIP, MCP, and wrist commonly involved)
        • fluffy periostitis (caused by periosteal ossification)
        • acroosteolysis (resorption of the distal phalanx tuft)
        • flail digits
      • spine in axial disease
        • sacroiliitis
        • syndesmophytes
        • paravertebral ossification
        • destructive discovertebral lesions
  • Studies
    • HLAB27 found in 50%
    • RA and ANA tests are usually negative
  • Treatment
    • Nonoperative
      • NSAIDS, methotrexate, sulfasalazine, cyclosporine,TNF-alpha inhibitors
        • indications
          • mainstay of treatment
            • similar to RA
    • Operative
      • digit fusion vs resection arthroplasty
        • indications
          • advanced joint disease

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Flashcards (1)
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Questions (4)

(OBQ17.129) A patient presents with the clinical images shown in Figures A-C. Which of the following is true?

QID: 210216
FIGURES:
1

Most patients with this skin condition develop arthritis

20%

(405/2067)

2

All patients that develop arthritis are positive for HLA-B27

7%

(137/2067)

3

The skin lesions respond well to systemic anti-fungal therapy

1%

(20/2067)

4

Rheumatoid factor and ANA are usually positive

18%

(362/2067)

5

DIP erosions are often centripetal

54%

(1116/2067)

L 4 A

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(OBQ11.158) A 32-year-old man has a 10-month history of bilateral toe swelling and foot pain. A clinical photo showing his toes is shown in Figure A. On examination of his feet he has tenderness along the posterior tibial tendon bilaterally which worsens with single-leg heel rise maneuvers. Standing radiographs of the feet are normal without deformity of the lesser toes. A clinical photo of his fingernails are shown in Figure B. Which of the following diagnoses is MOST likely?

QID: 3581
FIGURES:
1

Pseudogout (chondrocalcinosis)

3%

(105/3466)

2

Gout

3%

(118/3466)

3

Psoriatic arthritis

83%

(2870/3466)

4

Rheumatoid arthritis

1%

(32/3466)

5

Scleroderma (systemic sclerosis)

10%

(331/3466)

L 1 C

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(OBQ10.241) A 47-year-old man complains of long standing pain involving the right index, middle, and ring fingers. A clinical image is shown in Figure A. A radiograph is provided in Figure B. Which of the following is the most likely diagnosis?

QID: 3340
FIGURES:
1

Gout

5%

(83/1713)

2

Osteoarthritis

3%

(44/1713)

3

Rheumatoid arthritis

6%

(109/1713)

4

Septic arthritis

0%

(3/1713)

5

Psoriatic arthritis

86%

(1467/1713)

L 1 C

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EXPERT COMMENTS (4)
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