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Updated: Feb 28 2023

Psoriatic Arthritis

  • 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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