Psoriatic arthritis: General recommendations

  • Dermatologists are strongly encouraged to consider the possible concurrent diagnosis of psoriatic arthritis in patients presenting with psoriasis.  Although a history and screening examination for psoriatic arthritis should be performed at every visit, there are as yet no broadly validated, user friendly, sensitive and specific screening tools available specifically for dermatologists to use.  The development of one such instrument is in progress. The Psoriatic Arthritis Screening and Evaluation (PASE) tool was developed to screen psoriasis patients for signs and symptoms of inflammatory arthritis.29   In pilot testing, 69 patients with known psoriasis and PsA before the initiation of systemic therapy were screened utilizing a 15 item questionnaire.  Utilizing this self administered patient tool, a PASE total score ≥47 distinguished PsA from non-PsA patients (largely patients with osteoarthritis) with 82% sensitivity and 73% specificity.  Larger studies of the PASE will be necessary to verify its value as a screening tool for PsA.  Dermatologists uncomfortable evaluating or treating patients with psoriatic arthritis should refer patients who they suspect may have psoriatic arthritis to rheumatologists.
  • Upon diagnosis of psoriatic arthritis, patients should be treated and/or referred to a rheumatologist in order to alleviate signs and symptoms, inhibit structural damage, and improve quality of life parameters.
  • Methotrexate or TNF blockade or the combination of these therapies is considered first-line treatment for patients with moderate to severely active psoriatic arthritis.  Although there are no prognostic indicators to identify these patients early, approximately 50% of patients with psoriatic arthritis may develop structural damage.
  • Not all patients with psoriatic arthritis require treatment with methotrexate or TNF blockade.  Patients with mild psoriatic arthritis can be successfully treated with NSAIDs or intraarticular injections of corticosteroids.
  • Since the clinical trial ACR20 efficacy data at the primary endpoint with all three FDA approved TNF blockers for the treatment of psoriatic arthritis are roughly equivalent, the choice of which TNF agent to utilize is an individual one with the degree and severity of cutaneous involvement an important consideration.
  • Common safety concerns need to be considered when treating patients who have psoriatic arthritis with TNF inhibitors.  

Reference 

29. Husni ME, Meyer KH, Cohen DS, Mody E , Qureshi AA. The PASE questionnaire: pilot-testing a psoriatic arthritis screening and evaluation tool. J Am Acad Dermatol 2007;57:581-7.


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Citation note

When referencing this guideline in a publication, please use the following citation: Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JY, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008 May;58(5):851-64. 

 


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