What features in psoriasis patients indicate that the patient is at high risk of developing psoriatic arthritis?
Dr. Abate is a member of the DermWorld Editorial Advisory Workgroup.
By Mallory Abate, MD, FAAD, December 1, 2023
In this month’s Clinical Applications column, DermWorld Editorial Advisory Workgroup member Mallory Abate, MD, FAAD, talks with Luigi Naldi, MD, about his JAAD paper, ‘Variables associated with joint involvement and development of a prediction rule for arthritis in patients with psoriasis. An analysis of the Italian PsoReal database.’
DermWorld: How do you know when to refer a psoriasis patient to rheumatology?
Dr. Naldi: The most obvious reason to refer a psoriasis patient to a rheumatologist is joint or tendon swelling and pain — namely signs of arthritis and/or enthesitis. Particular attention should be paid to pain and/or stiffness in the lower back, hips, and buttocks. The involvement of the temporo-mandibular joint should not be overlooked. It is characterized by limited opening of the mouth, unilateral pain during jaw movement, joint tenderness, and crepitus. In any case, limiting focus to overt symptoms may lead to delayed interventions. A more proactive approach is required. Hence, the importance of rules to stratify patients according to their risk of arthritis and of imaging, particularly ultrasound assessment.
DermWorld: What features of their psoriasis make them more high risk for developing psoriatic arthritis?
Dr. Naldi: This is a crucial question. Usually, arthritis follows skin involvement by years. There is a need for predictive instruments. We have developed a simple prediction rule based on the Italian Psocare and Psoreal registries. In the final model, females ages 40-59 years with a BMI ≥25 and a presence of palmoplantar lesions and disease severity requiring systemic treatment were highly predictive of arthritis in a five-year interval. The use of screening tools may also be helpful. Various screening questionnaires are available, such as the Psoriasis Epidemiology Screening Tool (PEST) and the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire.
DermWorld: When should you grab for a biologic that has joint indications versus one that doesn’t?
Dr. Naldi: I would prefer a biologic treatment with a joint indication in all the patients with overt symptoms of arthritis, and in patients at a higher risk of developing arthritis according to the rules I mentioned earlier. The incidence of arthritis in psoriasis patients with initial skin involvement is in the order of 1-2 cases per 100 patient-years. In principle, early treatment aimed at effectively controlling inflammation and symptoms of psoriasis may minimize the likelihood of developing psoriatic arthritis. However, we do not have clear evidence of a treatment that can guarantee the prevention of arthritis.
DermWorld: I think that it is easy to ask a psoriatic patient if they have joint pain, and then if they do, refer them to rheumatology. But if a patient asked a dermatologist, ‘Am I at high risk for developing arthritis?’ I think this would be a much more difficult question for us all to answer. How would you recommend that we respond?
Dr. Naldi: The answer, in my opinion, should be tailored to everyone’s specific needs and circumstances. I would provide simple information on the rate of occurrence of arthritis, on early symptoms, and on risk factors including body weight and disease severity.
DermWorld: Is there any other advice you would give to dermatologists?
Dr. Naldi: Maintaining a healthy lifestyle is important. We should spend some more time motivating our patients to lose weight if they are overweight or obese, to adopt a balanced diet, and to get regular exercise.
Luigi Naldi, MD, is the director of the Department of Dermatology at Ospedale San Bortolo in Vincenza, Italy, and is president of Centro Studi GISED in Bergamo, Italy. His paper appeared in JAAD. Dr. Naldi was supported by BMS to conduct an analysis of data from the Italian database Psoreal. He has received grants from Abbvie, Almirall, Janssen, Leo, Novartis, Sanofi.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.
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