Distal Interphalangeal Joint Involvement Research Articles

Distal interphalangeal joint involvement in patients with rheumatoid arthritis: Where are we?

Rheumatoid arthritis (RA) usually affects the wrist, metacarpophalangeal joint, and proximal interphalangeal joint of the hands. However, the distal interphalangeal (DIP) joints may also be involved in RA patients. In this study, we aimed to evaluate the frequency and associated factors of DIP joint erosion in patients with RA. Medical records of patients with RA were reviewed retrospectively. Patients with major trauma affecting DIP joints, osteoarthritis, erosive osteoarthritis, psoriatic arthritis, systemic sclerosis, calcium pyrophosphate dihydrate disease, and gout were excluded. Anteroposterior hand X-rays were evaluated and patients were divided into groups according to autoantibody profile. We reviewed 1213 patients with a mean age of 54.3 ± 12.5 years; 82.8% of them were female, and 95.4% had RA-type erosive changes. The DIP erosion rate was 12%. DIP involvement was generally unilateral and asymmetric, with the 3rd finger being the most commonly affected joint. Patients with DIP erosions had a significantly longer disease duration (p = 0.036). Older age was an independent predictive factor for DIP erosion (p = 0.001). In this large-sample study, we reported DIP joint involvement in patients with RA. Advanced age could have affected the results because hand erosions increase above 50 years in a healthy population. Our results may provide a different perspective on joint involvement in RA.

Nail and distal interphalangeal joint involvement parallel each other in psoriatic arthritis.

Nail and distal interphalangeal joint involvement parallel each other in psoriatic arthritis.

P170 Ixekizumab significantly improved quality of life and joint pain in patients with psoriatic arthritis, nail disease and distal interphalangeal joint involvement from SPIRIT-H2H

Abstract Background/Aims Among adults with psoriatic arthritis (PsA) in the SPIRIT H2H study, 65% had nail psoriasis (PsO) at baseline and of these, 96.2% had simultaneous distal interphalangeal joint (DIP) disease in ≥ 1 digits at baseline. This analysis describes the impact of ixekizumab (IXE) and adalimumab (ADA) on quality of life (QoL), function and joint pain. Methods This post-hoc analysis included patients from SPIRIT-H2H (NCT03151551) treated with either IXE or ADA who had simultaneous nail and DIP involvement (swelling or tenderness) in ≥ 1 digits at baseline. Nail PsO was measured using Nail Psoriasis Severity Index (NAPSI). Joint involvement was measured by tender/swollen joint count scores. Joint pain was measured by patient’s assessment of pain using Visual Analogue Scale (100 mm). QoL measures included Dermatology Life Quality Index (DLQI), Health Assessment Questionnaire-Disability Index (HAQ-DI) and Short Form-36 Mental and Physical Component Summary Scores (SF-36 MCS/PCS). Patients were evaluated at baseline and Week 4, 8, 12, 16, 24, 32, 40, and 52. Joint pain and SF-36 MCS/PCS changes from baseline were analysed using a mixed effects model of repeated measures. Proportions of patients achieving DLQI ≤1 or HAQ-DI change ≥0.35 (minimal clinically important difference) were analysed using logistic regressions. Non-responder imputation and modified baseline observation carried forward methods were used for missing data. Results 354 SPIRIT-H2H patients had a NAPSI total score >0 and DIP involvement in ≥ 1 digits simultaneously at baseline (IXE, N = 186 and ADA, N = 168). Among them, IXE-treated patients had a significant improvement in joint pain at Week 4 and a larger improvement in joint pain over 52 weeks vs ADA-treated patients. In addition, a larger proportion of IXE-treated patients achieved a DLQI score of 0 or 1, and these statistically significant differences were observed as early as Week 4 and sustained at each visit over 52 weeks. IXE-treated patients also experienced statistically significant improvements in SF-36 MCS at Week 4, 12 and 32 compared to ADA-treated patients; numerically greater improvements in favor of IXE were sustained at all other visits. IXE-treated patients showed a larger improvement in SF-36 PCS over 52 weeks vs ADA-treated patients, and these differences reached statistical significance at Week 24 and 32. Similar proportions of patients treated with IXE or ADA showed a clinically important improvement in HAQ-DI. Conclusion In patients with simultaneous nail and DIP involvement in ≥ 1 digit at baseline, IXE treatment resulted in significant improvements across multiple QoL measures, and greater improvements in joint pain compared to ADA treatment. These data may help health care providers make clinical decisions concerning the care of PsA in patients with nail and DIP involvement. Disclosure C. Ritchlin: Consultancies; C. Ritchlin has received consulting fees and/or honoraria and/or grant support from: AbbVie, Bristol-Myers Squibb, Eli Lilly and Company, Janssen, Novartis, Pfizer, UCB Pharma. A. Kavanaugh: Consultancies; A. Kavanaugh has received consulting fees and/or honoraria from: AbbVie, Eli Lilly and Company, Janssen, Novartis, Pfizer, UCB Pharma. L. Kristensen: Consultancies; L.E. Kristensen has received consulting fees and/or honoraria and/or research support from: Pfizer, AbbVie, Amgen, UCB Pharma, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly and Company, Janssen. J. Merola: Consultancies; J. F. Merola is a consultant and/or investigator for: Amgen, Bristol-Myers Squibb, AbbVie, Dermavant, Eli Lilly and Company, Novartis, Janssen, UCB Pharma, Sanofi-Regeneron, Sun Pharma, Biogen, Pfizer. B. Strober: Corporate appointments; B. Strober has been serving as an Editor-in-Chief for the Journal of Psoriasis and Psoriatic Arthritis; and serving as scientific co-director and investigator for CorEvitas Psoriasis Registry. Consultancies; B. Strober has served as a speaker for and/or has received consulting fees and/or honoraria from: AbbVie, Alamar, Alumis, Almirall, Amgen, Arcutis, Arena, Aristea, Asana, Boehringer Ingelheim. Shareholder/stock ownership; reports having stock options in Connect Biopharma, Mindera Health. Honoraria; He is also a consultant for Immunic Therapeutics, Kangpu Pharmaceuticals, Bristol-Myers-Squibb, Connect Biopharma, Dermavant, Evelo Biosciences, Incyte, Janssen, Leo, Eli Lilly and Company, Maruho. Grants/research support; He is also a consultant for Meiji Seika Pharma, Mindera Health, Protagonist, Nimbus, Novartis, Pfizer, UCB Pharma, Sun Pharma, Regeneron, Sanofi-Genzyme, Union Therapeutics, Ventyxbio, vTv Therapeutic. J. Lisse: Consultancies; J. Lisse is employee and stockholder of Eli Lilly and Company. R. Bolce: Shareholder/stock ownership; R. Bolce is employee and stockholder of Eli Lilly and Company. C. Sapin: Shareholder/stock ownership; C. Sapin is employee and stockholder of Eli Lilly and Company. J. Pustizzi: Shareholder/stock ownership; J. Pustizzi is employee and stockholder of Eli Lilly and Company. D. McGonagle: Consultancies; D. McGonagle has received consulting fees and/or honoraria and/or research grants from: AbbVie and Eli Lilly and Company. Grants/research support; His funding sources include or have included the Wellcome Trust-EPSRC, UK NIHR, ARUK, MRC UK and EU FP7 programme.

Association of the clinical components in the distal interphalangeal joint synovio-entheseal complex and subsequent response to ixekizumab or adalimumab in psoriatic arthritis.

To assess the frequency of simultaneous distal interphalangeal (DIP) joint disease and adjacent nail psoriasis (finger unit) among patients with psoriatic arthritis (PsA) and compare the efficacy of the interleukin (IL)-17A antagonist ixekizumab (IXE) and the tumour necrosis factor (TNF)-α inhibitor adalimumab (ADA). This post hoc analysis evaluated the simultaneous occurrence of DIP joint involvement (tenderness and/or swelling) and adjacent nail psoriasis among patients with PsA from the SPIRIT-H2H (NCT03151551) trial comparing IXE to ADA. Among patients with simultaneous DIP joint involvement and adjacent nail psoriasis in ≥ 1 digit at baseline, treatment effects were assessed through week 52 for each affected finger unit; 'finger unit' defines the connected DIP joint and adjacent nail of an individual digit. A total of 354 patients had simultaneous DIP joint involvement and adjacent nail psoriasis in ≥ 1 finger unit at baseline. Among them, 1309 (IXE = 639, ADA = 670) finger units had baseline DIP joint tenderness and/or swelling and adjacent nail psoriasis. Proportions of affected finger units achieving complete resolution were significantly higher with IXE vs ADA as early as week 12 (38.8% vs 28.4%, p< 0.0001) and at all post-baseline assessments through week 52 (64.9% vs 57.5%, p= 0.0055). In this study cohort, patients with DIP joint involvement almost always had adjacent nail psoriasis. Greater resolution of DIP joint tenderness, swelling, and adjacent nail psoriasis was achieved at all timepoints over 52 weeks through targeting IL-17A with IXE than TNF-α with ADA, which is noteworthy given prior comparable musculoskeletal outcomes for both drug classes.

P169 Treatment effects of ixekizumab and adalimumab at the individual digit level with nail and distal interphalangeal joint involvement in patients with psoriatic arthritis

Abstract Background/Aims Psoriatic nail disease is intimately linked to adjacent distal interphalangeal joint (DIP) disease, and it is important to ascertain whether DIP-nail complex behaves differently under different biological therapies. The aim of this analysis is to assess the effect of ixekizumab (IXE) and adalimumab (ADA) at the individual digit level using the Nail Psoriasis Severity Index (NAPSI) and NAPSI resolution in patients with psoriatic arthritis (PsA) with concomitant nail involvement. Methods This post hoc analysis included patients from SPIRIT-H2H (NCT03151551) treated with either IXE or ADA who had baseline nail disease (NAPSI total score &amp;gt;0) and DIP involvement, with either tenderness or swelling, at the individual digit level for each hand. Nail disease was assessed using the NAPSI scoring system, a measure of nail bed and nail matrix involvement combined for a total maximum score of 80. Proportions of patients having a NAPSI total score &amp;gt;0 were evaluated at baseline, week 24 and week 52; post-baseline assessments were compared between treatment using Fisher’s exact test. Results Of 566 patients in the intent-to-treat SPIRIT-H2H population of, 354 patients (IXE, N = 186; ADA, N = 168) had NAPSI total score &amp;gt;0 and DIP involvement in at least 1 of 10 digits simultaneously at baseline. At week 24, the proportion of patients with nail disease (NAPSI &amp;gt;0) was lower among patients who received IXE versus ADA across all 10 digits and was significantly lower versus ADA for 9 out of the 10 individual digits (p &amp;lt; 0.05; Table) with additional improvements out to week 52. On average, a 10% difference in the proportion of patients with NAPSI &amp;gt;0 at week 24 between IXE and ADA at the individual digit level was observed, favouring IXE. Similarly, numerically greater improvements were observed with IXE compared to ADA regardless of whether nail bed, nail matrix, or NAPSI total score was assessed. Conclusion These data demonstrate that in patients with PsA with nail involvement, there was a significant advantage of IXE over ADA in resolving nail involvement at the individual digit level as measured by NAPSI. Disclosure D. McGonagle: Consultancies; Eli Lilly and Company, AbbVie. Member of speakers’ bureau; Eli Lilly and Company. Grants/research support; Eli Lilly and Company. Other; BSR attendance support from Eli Lilly and Company. A. Kavanaugh: Consultancies; AbbVie, UCB, Janssen, Novartis, Pfizer. I. McInnes: Consultancies; AbbVie, Amgen, BMS, Causeway Therapeutics, Cabaletta, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, Sanofi Regeneron, UCB. Grants/research support; AbbVie, Amgen, BMS, Causeway Therapeutics, Cabaletta, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, Sanofi Regeneron, UCB Pharma. Other; University of Glasgow, Vice Principal &amp; Head of College, NHS Greater Glasgow &amp; Clyde, Non exec board member, Evelo, Board of Directors, Non Exec director, Versus arthritis, Trustee. L. Kristensen: Consultancies; Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly and Company, Janssen. Member of speakers’ bureau; Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly and Company, Janssen. Grants/research support; Pfizer, AbbVie, UCB, Gilead, Biogen, Novartis, Eli Lilly and Company, Janssen. Other; study grant from Novo Nordisk A/S, institutional grant from The Oak Foundation, Cambridge Weight Plan, delivery of dietary supplements. J.F. Merola: Consultancies; Amgen, Bristol-Myers Squibb, AbbVie, Dermavant, Eli Lilly and Company, Novartis, Janssen, UCB, Sanofi, Regeneron, Sun Pharma, Biogen, Pfizer, Leo Pharma. B.E. Strober: Consultancies; AbbVie, Alumis, Almirall, Amgen, Arcutis, Arena, Aristea, Asana, Boehringer Ingelheim, Immunic Therapeutics, Bristol-Myers-Squibb, Connect Biopharma, Dermavant, EPI Health, Evelo Biosciences, Janssen, Leo, Eli Lilly and Company, Maruho, Meiji Seika Pharma, Mindera Health, Novartis, Pfizer, UCB Pharma, Sun Pharma, Regeneron, Sanofi-Genzyme, Union Therapeutics, Ventyxbio, vTv Therapeutics. Shareholder/stock ownership; Connect Biopharma, Mindera Health. Honoraria; Editor-in-Chief (honorarium): Journal of Psoriasis and Psoriatic Arthritis. Member of speakers’ bureau; AbbVie, Eli Lilly and Company, Incyte, Janssen, Regeneron, Sanofi-Genzyme. Other; Investigator: Dermavant, Investigator: AbbVie, Investigator: CorEvitas Psoriasis Registry, Investigator: Dermira, Investigator: Cara, Investigator: Novertis. J.R. Lisse: Corporate appointments; Eli Lilly and Company. Shareholder/stock ownership; Eli Lilly and Company. J. Pustizzi: Corporate appointments; Eli Lilly and Company. Shareholder/stock ownership; Eli Lilly and Company. C. Sapin: Corporate appointments; Eli Lilly and Company. Shareholder/stock ownership; Eli Lilly and Company. R. Bolce: Corporate appointments; Eli Lilly and Company. Shareholder/stock ownership; Eli Lilly and Company. C. Ritchlin: Consultancies; AbbVie, Janssen, Novartis, BMS, UCB. Member of speakers’ bureau; Pfizer, UCB, AbbVie. Grants/research support; Pfizer, AbbVie.

Distal Interphalangeal Joint Involvement May Be Associated with Disease Activity and Affected Joint Distribution in Rheumatoid Arthritis.

We investigated the relationship between distal interphalangeal (DIP) joint involvement and disease activity in 10,038 patients with adult-onset rheumatoid arthritis (RA). The affected joint distribution was investigated using the joint indices (JI) x, y, and z, corresponding to the upper and lower joints, and the predominance of large-joint involvement, respectively. DIP joint involvement (defined by the presence of tenderness and/or swelling in DIP joints) was present in 206 (2.1%) of 10,038 patients with RA. Patients with RA exhibiting DIP joint involvement were significantly younger, and more frequently women. DIP joint involvement was positively associated with Disease Activity Score-28 using C-reactive protein, and clinical variables related to high RA disease activity, including JIs x and y, and was negatively associated with JI z. JI x was significantly higher than JI y in RA patients with DIP joint involvement. An odds ratio analysis revealed that small-to-medium sized and upper-extremity joints ranked first, second, and fourth among the eight variables significantly associated with DIP joint involvement. The correlation coefficients revealed that small-sized and upper-extremity joints ranked first and second among the five significant variables. DIP joint involvement, albeit rare, is significantly associated with high RA disease activity with predominance of small-sized and upper-extremity joints.

The Effect of TNF-α Inhibitors on Nail Psoriasis and Psoriatic Arthritis-Real-World Data from Dermatology Practice.

Patients with psoriatic arthritis (PsA) often develop joint symptoms years after their initial diagnosis of psoriasis disease; therefore, dermatologists should test for and detect PsA early. In this study, we focused on patients with psoriasis with both nail and joint disease being treated with tumor necrosis factor-α inhibitors by dermatologists. We performed a noninterventional, prospective, multicenter, and open-label study to evaluate the effectiveness of adalimumab, etanercept, or infliximab over 24 months of continuous therapy in patients with moderate to severe plaque-type psoriasis (Pso) and PsA. Disease assessments with the Psoriasis Area and Severity Index, Nail Psoriasis Severity Index (NAPSI), joint assessment, Dermatology Life Quality Index (DLQI), and Health Assessment Questionnaire (HAQ) instruments were performed every 3 months for the first year and twice annually thereafter. The cohort included 100 patients with Pso, nail psoriasis, and PsA. A significant reduction of NAPSI was observed 3 months after therapy initiation compared with the baseline (mean ± SD, 22.9 ± 17.8 vs. 33.8 ± 21.4; p < 0.001). Similarly, the mean ± SD number of both tender and swollen joints decreased significantly within the first 3 months of treatment, from 10.8 ± 11.5 to 6.4 ± 10.3 (p < 0.001) and from 6.4 ± 9.5 to 3.1 ± 7.2 (p < 0.001), respectively. Additionally, the distal interphalangeal joint involvement improved throughout the observation time, and DLQI and HAQ scores decreased. Improvements in control of skin, nail, and joint symptoms were seen, as well as in patients’ quality of life and functionality. Dermatologists have an important role not only in PsA diagnosis but also in PsA long-term care.

Extension Block Pinning in Subacute/Late Bony Mallet Finger Injuries

Mallet finger is inability to fully extend a finger due to the disruption of the extensor mechanism integrity at the distal interphalangeal (DIP) joint level. Cases with DIP joint subluxation, and avulsion fractures involving more than 30% of the DIP joint surface are candidates for surgery. Subacute/late cases have poor outcomes. Investigating the success of extension block pinning in subacute/late bony mallet finger cases is aimed. Patient demographics, the rate of DIP joint involvement in plain X-rays, subluxation status of DIP joint, the time between injury and operation, the duration of the operation, complications in post-operative follow-up, extensor lag and healing status of bone were reviewed. Patient outcomes and relation with operative delay and joint subluxation were analyzed. Mean rate of DIP joint involvement of study group was 43.4 ± 6.12%. Half of the study group (n=7) had DIP joint subluxation. Mean time from injury to operation was 29.78±20.4 days. Six patients’ time from injury to operation was longer than 5 weeks. Study group had statistically significant improvement after surgery. Preoperative mean extensor lag was 15.71° ± 7.30° and postoperative mean extensor lag was 5.57° ± 8.89°(p5 weeks) and presence of subluxation did not alter the outcome (p=0.353 and p=0.149, respectively). Extension block pinning technique is a fast, easy-to-apply technique with minimal morbidity. Although it has more limited results in chronic cases, it can be used safely in the majority of cases requiring surgery.

SAT0282 Presentation Patterns in a Cohort of Patients with Psoriatic Arthritis

BackgroundArthritis is estimated to precede skin psoriasis in approximately 15% of psoriatic arthritis patients (PsA) (1). However this data is based on studies published prior to the development of the...

Relationship between psoriatic arthritis and moderate–severe psoriasis: analysis of a series of 166 psoriatic arthritis patients selected from a hospital population

The aim of the study was to assess the prevalence of moderate to severe psoriasis (MS-P) in patients with psoriatic arthritis (PsA) and the relationship between MS-P and other variables related to arthritis. One hundred sixty-six consecutive patients with PsA periodically monitored at a university hospital's PsA unit in northeastern Spain were included in the study. Patients with psoriasis were classified as having MS-P when systemic treatment for skin was required. Clinical criteria for treatment indication was BSA >10 and/or PASI >14 and/or psoriasis affecting a very sensitive area of the body. Demographic and clinical data related to arthritis were assessed, including PsA pattern, age of onset of psoriasis and arthritis, disease activity index, and treatment required over the course of the disease. Moderate-severe psoriasis were more prevalent in women (p = 0.027). One hundred nine patients (65.7%) had psoriatic nail disease, and MS-P was more frequent in these patients (40 (77%) vs. 69 (61%), p = 0.028). Patients with spondyloarthropathy were significantly associated with MS-P (7 (16%) vs. 3 (3%), p = 0.014). No statistical association was observed between severe psoriasis and the age of onset of psoriasis or arthritis, involvement of distal interphalangeal joints, laboratory findings (HLA B27, RF), functional class, or disease activity indices. We report a high prevalence of severe psoriasis among patients with psoriatic arthritis, higher in women and patients with psoriatic nail disease and axial spondyloarthropathy.

Application of the DAREA/DAPSA score for assessment of disease activity in psoriatic arthritis

Background and objectivesInstruments for measuring disease activity in psoriatic arthritis (PsA) are not yet firmly established, and most of the currently employed ones have been derived for rheumatoid arthritis. Some...

The relationship between nail- and distal phalangeal bone involvement severity in patients with psoriasis

We aimed to investigate the relationship between nail involvement and joint manifestations and whether there was a correlation between nail psoriasis severity and bone manifestations in psoriatic patients without symptomatic psoriatic arthritis in plaque type psoriasis. Thirty-one patients with nail involvement (16 men, 15 women, mean age 45.29+/-18.73) and 39 patients without nail involvement (16 men, 23 women, mean age 38.41+/-17.33) were enrolled in the study. X-ray of the hands and feet with magnification were performed. The distal interphalangeal (DIP) joint and bone (tuft of terminal phalanx) were evaluated. A scoring method was performed on the patients with nail involvement. There was no difference in DIP joint involvement in patients with or without finger- and toenail involvement (p=0.085 and p=0.062, respectively). However, the prevalence of bone involvement was higher in patients with finger- and toenail involvement than without finger- and toenail involvement (p=0.039 and p=0.021, respectively). A positive correlation was also determined between finger- and toenail psoriasis severity and bone involvement severity (r=0.379, p=0.001 and r=0.288, p=0.015).

Other seronegative spondyloarthropathies

Seronegative spondyloarthropathies are a group of overlapping forms of inflammatory joint disease, the most common conditions being ankylosing spondylitis and psoriatic arthritis. Other less common conditions include reactive arthritis, enteropathic arthritis and SAPHO (synovitis, acne, pustolosis, hyperostosis, osteitis). Shared features include a propensity to affect the spine, an association with anterior uveitis and HLA-B27, involvement of the enthesis, and the absence of rheumatoid factor. Psoriatic arthritis has several distinctive characteristics that may vary from patient to patient and include frequent involvement of distal interphalangeal joints, dactylitis, new bone formation within the enthesis, osteolysis and ankylosis. Genetic factors are important with HLA-CW6 containing haplotypes associated with psoriasis and peripheral joint inflammation and HLA-B27 associated with axial involvement especially sacroiliitis. The advent of anti-TNF antagonists provides an important new dimension to treatment options for those with progressive disease.

Apport des critères doigts — orteils dans le diagnostic précoce du rhumatisme psoriasique

Purpose To assess the value of Fournie's radiological criteria “fingers and toes” in the early diagnosis of psoriatic arthritis. Materials and methods 47 patients with psoriatic arthritis were studied retrospectively. Clinical and radiological features at the hands and fingers were assessed. Radiographic analysis was performed using Fournie's criteria. Results Of 47 patients studied, 25 patients developed hand and finger involvement. Asymmetrical joint distribution was observed in 76% of cases. Distal interphalangeal arthritis was noted in 60% of cases. Nail lesions were present in 11 cases and dactylitis in 3 cases. Eight patients had erosions of the distal interphalangeal joints. Osteolysis with pencil-in-cup deformity wasa noted in 3 cases. Ankylosis of interphalangeal joints was found in 7 cases and acro-osteolysis in 3 cases. Conclusion Psoriatic arthritis frequently affects the small joints of the hands and fingers. Asymmetrical and distal interphalangeal joint involvement are a characteristic feature of this arthropathy. Some radiological lesions are suggestive and contribute to the early diagnosis of psoriatic arthritis.

Human leukocyte antigen distribution in Israeli patients with psoriatic arthritis.

This study was designed to investigate the distribution of human leukocyte antigen (HLA) classes I and II in a group of Israeli Jewish patients with psoriatic arthritis (PsA) and identify HLA markers related to disease manifestation in PsA. Human leukocyte antigens class I and class II (both serologically and from oligotyping) were tested in a group of 50 consecutive patients with PsA, 32 with skin psoriasis (PSO), and 255 healthy persons. Data on age, gender, disease duration, and pattern of rheumatological manifestations-oligoarthritis, polyarthritis, spinal involvement, involvement of distal interphalangeal joints (DIPs), and enthesitis-were registered. Human leukocyte antigens A3, B13, and B38 alleles were found to be significantly prevalent in PsA compared with PSO patients and healthy controls. HLA-B27 was found in only two out of 50 patients with PsA. Patients with PSO and PsA had significantly increased incidence of HLA-DRB0101 and -DRB0301, while the frequency of HLA-DRB0403 was significantly higher among patients with PsA of Ashkenazi origin. We found a statistically significant association between DIP involvement and the presence of HLA-A26 and -B38, while HLA-DRB0301 was related to spinal involvement. Psoriatic arthritis in Israeli patients seems to be associated with the presence of HLA-A3, -B13, -B38, -DRB0101, and -DRB0301. HLA-B27 was not a marker of PsA in this cohort of patients, including patients with psoriatic spondyloarthropathy.

Diagnosis and management of psoriatic arthritis.

Psoriatic arthritis (PsA) is considered to be one of the spondyloarthritides, and as such has both spinal and peripheral joint involvement. In 80% of patients, psoriasis usually precedes the development of arthritis. Although there are no widely accepted diagnostic criteria, a number of distinct clinical features allow it to be distinguished from other forms of inflammatory arthritis. It affects both sexes equally, and the pattern of joint involvement is characteristic with distal interphalangeal joint involvement, asymmetry, dactylitis, flail or ankylotic deformities of digits, and the frequent presence of enthesitis and spinal involvement. It may have a pattern of joint involvement similar to rheumatoid arthritis (RA) but in these patients rheumatoid factor and the other systemic features of RA are usually absent. Radiographs frequently reveal evidence of asymmetric sacroiliitis and spinal disease, and peripheral joints, as well as showing erosions, may also demonstrate profuse new bone formation and ankylosis. Profound osteolysis producing the pencil-in-cup deformity can also occur in the same individual. It is now recognised that PsA can be a destructive arthritis with an increased morbidity and mortality. Studies of standard disease-modifying therapies have been small and frequently inconclusive because of a high placebo response rate. This may be as a result of heterogeneity in patient selection, poor assessment tools, or the difference in underlying pathogenesis and subsequent response to therapy. In meta-analyses, sulfasalazine and methotrexate have been shown to be effective. Treating the skin alone seems to have little impact on joint disease, and the relationship between skin and joints is still unclear. However, recent studies with anti-tumour necrosis factor agents, such as etanercept and infliximab, have shown considerable significant clinical benefit and provided the hope that we will at last have effective therapies for this disease.

Nailfold video capillaroscopy in psoriasis.

Changes in the microvasculature are considered to play an important part in the pathogenesis of psoriasis and its associated arthritis. The novel method of nailfold video capillaroscopy is an extension of the technique of widefield nailfold microscopy which has been of diagnostic and predictive use in the in vivo study of the microcirculation in systemic sclerosis and other connective tissue disorders. However, similar studies in patients with psoriasis and psoriatic arthritis and/or nail changes have produced conflicting results. We tested the hypothesis that any abnormalities in nailfold capillaries of either a quantitative or qualitative nature might be observed more readily in subjects with pathology adjacent to the nailfold, i.e. distal interphalangeal (DIP) joint changes and/or nail dystrophy, when using this technique. Forty-four patients with psoriasis were recruited (21 males, 23 females). Twelve patients had psoriasis alone, 13 had psoriasis and nail changes, six had DIP joint involvement with changes of psoriasis elsewhere, and 13 had psoriasis, DIP arthritis and nail changes. Capillary density and standard capillary dimensions were studied and compared with those of 44 age- and sex-matched control subjects. There was a significant (P < 0.05) decrease in capillary loop density in patients with either psoriasis plus nail disease (14.5 +/- 5.7 capillaries per 3 mm field) or psoriasis plus nail and DIP joint disease (14.3 +/- 5. 0) when compared with controls (19.2 +/- 3.8). In patients with psoriatic arthritis affecting the DIP joints, there was a statistically significant (P < 0.05) decrease in arterial and venous capillary limb diameters, and this was also seen in those with arthritis associated with nail changes. However, there was no difference in capillary dimensions between patients with psoriasis and/or nail changes when compared with normal controls. Morphological abnormalities previously described in the literature were not noted in any of our four patient groups. Our findings of diminution in both nailfold capillary bed density and dimensions of the arterial and venous capillary limbs suggest that vascular injury, previously noted in ultrastructural studies, may play a part in the pathogenesis of psoriatic arthritis. However, in contrast to previous studies, we found no specific pattern of a morphological nature of nailfold capillaries in patients with psoriasis with or without nail changes, when compared with normal controls.

Osteoarthritis associated with distal interphalangeal joint involvement in rheumatoid arthritis

A study was undertaken to investigate the relationship between the clinical and radiological findings in patients with rheumatoid arthritis (RA), osteoarthritis (OA), and combined osteoarthritis and rheumatoid arthritis (OA/RA) affecting the hands. Fifty patients were selected for each group from those attending a rheumatology clinic. The study showed a good correlation between the clinical and radiological diagnosis of combined OA/RA and that marginal erosive changes in the distal interphalangeal (DIP) joints occur more commonly in patients with rheumatoid arthritis who have coexisting osteoarthritis.

The Clinical Spectrum of Psoriatic Arthritis

Epidemiologic, clinical, radiologic and serologic evidence suggests that psoriatic arthritis is a specific entity and not the coincidental occurrence of 2 common diseases, psoriasis and rheumatoid arthritis. Psoriatic arthritis may be defined as psoriasis associated with inflammatory arthritis (peripheral arthritis or spondylitis or both) and usually a negative serologic test for rheumatoid factor. Clinical characteristics of the disease include: almost equal distribution between males and females; peripheral arthritis involving only a few small joints in asymmetical fashion; involvement of distal interphalangeal joints; sausage digits; arthritis mutilans; ankylosing spondylitis; goutlike onset; and higher frequency of nail involvement than occurs in uncomplicated psoriasis. The rash may present with arthritis, or, equally, may precede or succeed joint involvement. With regard to pain and disability, the prognosis in psoriatic arthritis is better than in rheumatoid arthritis.

The HLA system and the arthropathies associated with psoriasis.

Histocompatibility typing was carried out in 74 patients with psoriasis and an inflammatory arthropathy. In 40 patients with peripheral arthropathy characterized by distal interphalangeal joint involvement, 13 (32-5%) were HLA-B27 positive, significantly higher than the control frequency (P = 5-8 X 10 (-6). 26 of the 40 patients did not have ankylosing spondylitis or radiological sacroiliitis and 7 were HLA-B27 positive, also significantly higher than in controls (P = 0-0049). All 7 patients with psoriasis and ankylosing spondylitis without peripheral arthropathy were HLA-B27 positive. The 10 patients with ankylosing spindylitis or radiological sacroliitis who were HLA-B27 negative all had peripheral arthropathy. It is suggested that being HLA-B27 positive increases the risk of a psoriatic patient developing both peripheral arthropathy and ankylosing spondylitis. In addition, some of the genes involved in susceptibility to psoriasis also have a role in the pathogenesis of both types of arthropathy. A hypothesis is put forward that some of the genes for psoriasis may be aetiologically important in some HLA-B27 negative patients with ankylosing spondylitis.