Early Diagnosis Of Psoriatic Arthritis Research Articles

Assessment of four screening tools and retrieval of key questions to detect undiagnosed psoriatic arthritis in Chinese patients with psoriasis: A multicenter study.

Several screening tools have been developed to facilitate early diagnosis of psoriatic arthritis (PsA); however, their performance varied greatly across different studies. In this study, we validated and compared the performance of four screening tools in detecting undiagnosed PsA Chinese patients with psoriasis, and determined the key questions and their weights. The four screening tools were the Early Arthritis for Psoriatic Patients (EARP) questionnaire, Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire, Psoriasis and Arthritis Screening Questionnaire (PASQ), and Psoriasis Epidemiology Screening Tool (PEST). The receiver-operator curve (ROC) with area under curve (AUC) was used to determine sensitivity, specificity, and accuracy. Least absolute shrinkage and selection operator and logistic regression were utilized to retrieve key questions, and a nomogram was utilized to visualize their weights. Of 482 psoriasis patients from dermatology clinics, 77 were newly diagnosed with PsA. Another 68 patients with newly diagnosed PsA from rheumatology clinics were incorporated in the analysis. ROC analysis indicated that the optimal cut-off values for EARP, PASE, PASQ, and PEST were 3, 40, 7, and 3, with corresponding sensitivities of 91.4%, 88.6%, 86.2%, and 88.5%, and specificities of 88.6%, 75.2%, 80.2%, and 83.6%, respectively. The AUC of EARP (0.925) was higher than those of PASE (0.885), PASQ (0.905), and PEST (0.827). However, none of them were sufficiently sensitive to identify pure axial PsA (sensitivities of EARP, PASQ, and PASE were 25.0%, 36.8%, and 42.1%, respectively). Twelve key questions were retrieved from these four tools to establish a nomogram with a high discrimination (C-index=0.993) and a good calibration (mean absolute error=0.014). In conclusion, to screen undiagnosed PsA, EARP has slightly better balanced sensitivity and specificity, and higher accuracy. The retrieval of key questions and nomogram signify the necessity of attributing different scores to differently weighted questions when developing a new screening tool to make it function more efficiently.

Combined Single Cell Transcriptome and Surface Epitope Profiling Identifies Potential Biomarkers of Psoriatic Arthritis and Facilitates Diagnosis via Machine Learning.

Early diagnosis of psoriatic arthritis (PSA) is important for successful therapeutic intervention but currently remains challenging due, in part, to the scarcity of non-invasive biomarkers. In this study, we performed single cell profiling of transcriptome and cell surface protein expression to compare the peripheral blood immunocyte populations of individuals with PSA, individuals with cutaneous psoriasis (PSO) alone, and healthy individuals. We identified genes and proteins differentially expressed between PSA, PSO, and healthy subjects across 30 immune cell types and observed that some cell types, as well as specific phenotypic subsets of cells, differed in abundance between these cohorts. Cell type-specific gene and protein expression differences between PSA, PSO, and healthy groups, along with 200 previously published genetic risk factors for PSA, were further used to perform machine learning classification, with the best models achieving AUROC ≥ 0.87 when either classifying subjects among the three groups or specifically distinguishing PSA from PSO. Our findings thus expand the repertoire of gene, protein, and cellular biomarkers relevant to PSA and demonstrate the utility of machine learning-based diagnostics for this disease.

Systematic review and meta-analysis: risk factors for psoriatic arthritis. Part 1.

According to epidemiological and clinical studies, every fourth patient with psoriasis develops psoriatic arthritis (PsA), and in many cases there is a destructive form of arthritis that leads to disability. Late diagnosis of PsA is associated with a significant reduction in the effectiveness of therapy. Therefore, early diagnosis of this disease is so important.Objective: to determine the methods for early detection of PsA, in particular the identification of risk factors (RFs) for its development, which will prevent the progression of the disease and the disability of patients.Materials and methods. The literature review and meta-analysis is presented in two parts. Part 1 of the systematic review included articles on exogenous RFs for the development of PsA published over the past 10 years.PubMed (MEDLINE), EMBASE, and Google Scholar databases were searched for articles published before March 1, 2021. We searched for currently registered trials in the registers of clinical trials of US (ClinicalTrials.gov), of China (Chinese Clinical Trial Registry) and the WHO InternationalClinical Trial Registry Platform. The statistical analysis was prepared in accordance with the international guidelines for systematic reviews and meta-analysis (PRISMA) using the Statistic SPSS 26.0 program (USA).Results and discussion. 957 articles published up to March 1, 2021 were identified. After further analysis, irrelevant articles were excluded. A total of 73 articles were included in the review and analysis, 32 of which were included in Part 1. The most common exogenous RFs are: mechanical injuries, medications, and psychotraumatic situations.Conclusion. PsA is a multifactorial disease. Currently, a large number of exogenous RFs for the development of this disease have been established. Knowledge of RFs and the ability to recognize them will help dermatovenereologists and rheumatologists to effectively assess and predict the patient's condition. Correction of modifiable RFs, early prescription of appropriate therapy will help to reduce the number of PsA cases, the development of functional disorders and prevent the growth of disability. However, studies on the comprehensive assessment of RFs in PsA are still insufficient. Further study of methods for the early diagnosis of PsA is needed in order to optimize its treatment.

Improving Imaging Modalities in Early Psoriatic Arthritis: The Role of Ultrasound in Early Diagnosis of Psoriatic Arthritis.

Objective: Despite recent advances, early diagnosis of psoriatic arthritis (PsA) remains a challenge in clinical practice. Ultrasound (US) could be a useful tool for the diagnosis and management of PsA. The objective of this review was to determine the role of US in early diagnosis of PsA.Methods: We have performed a literature review aiming to evaluate studies on US findings in psoriasis and their predictive value of progression to PsA, as well as studies on US features specific for PsA in comparison with other conditions.Results: A total of 40 studies were included. Sixteen studies assessed US findings in psoriasis, of which only 3 prospectively evaluated the role of US in predicting progression to PsA. Patients with PsA had a greater frequency of US abnormalities, in particular enthesitis and Power Doppler(PD) signal compared to patients with psoriasis only. In the longitudinal studies, psoriatic patients with higher enthesopathy scores at baseline were more likely to progress to PsA. Twenty-four studies evaluated US abnormalities in PsA and compared them to other conditions. Most specific US features that distinguish PsA from psoriasis were PD signal and erosions in joints and entheses. Extra-synovial changes, including peri-tendinous dermal soft tissue oedema with associated PD signal and flexor tendon enthesopathy, as well as thickening of the pulleys in the flexor tendons were highly characteristic for PsA, as they were frequently found in PsA patients, but in none of the RA patients. US-detected entheseal abnormalities in particular erosions and PD signal were more frequent in patients with PsA compared to fibromyalgia.Conclusion: Despite the wide use of US in PsA, more research is needed to identify predictive factors of progression to PsA in patients with psoriasis, as well as to determine most specific US features that differentiate PsA from other conditions.

Ambulatório conjunto de dermatologia e reumatologia para tratamento de psoríase e artrite psoriásica: experiência de um hospital terciário no sul do Brasil

Introduction: several guidelines emphasize the advantages of multidisciplinary management of patients with psoriasis (PSO) or psoriatic arthritis (PSA). Early diagnosis of PSA relates to better outcomes in 5 years. However, early diagnosis of PSA remains a challenge. Methods: retrospective cohort of patients with previous or suspect diagnosis of PSO and/or PSA who were cared for in the combined dermatology and rheumatology clinic from January 2013 to January 2017. Results: among the 55 patients previously diagnosed with PSO, 30.9% (n=17) were diagnosed with PSA. Changes in medical therapy were made for 58.5% (n = 48) of patients, mainly due to poor cutaneous or articular disease control. Imunobiologicals were the most commonly initiated class of medicine, corresponding to 35.4% (n = 17) of changes in medical therapy. Methotrexate was the second most initiated medicine (18.7%; n = 9), or with changes in its dosage or route of administration (20.8%; n = 10), totaling 39.5% (n = 19) of changes in medical therapy. There was an increase in the proportions of patients undergoing systemic therapies (79.2%; n = 65). Conclusions: this study reenforces the importance of a multidisciplinary approach in the early diagnosis of PSA and demonstrates that a combined approach between dermatology and rheumatology is feasible in Brazil, with similar outcomes to those reported in international literature.

The Digital Way to Intercept Psoriatic Arthritis.

Psoriasis (PsO) and Psoriatic Arthritis (PsA) are chronic, immune-mediated diseases that share common etiopathogenetic pathways. Up to 30% of PsO patient may later develop PsA. In nearly 75% of cases, skin psoriatic lesions precede arthritic symptoms, typically 10 years prior to the onset of joint symptoms, while PsO diagnosis occurring after the onset of arthritis is described only in 15% of cases. Therefore, skin involvement offers to the rheumatologist a unique opportunity to study PsA in a very early phase, having a cohort of psoriatic “risk patients” that may develop the disease and may benefit from preventive treatment. Progression from PsO to PsA is often characterized by non-specific musculoskeletal symptoms, subclinical synovio-entheseal inflammation, and occasionally asymptomatic digital swelling such as painless toe dactylitis, that frequently go unnoticed, leading to diagnostic delay. The early diagnosis of PsA is crucial for initiating a treatment prior the development of significant and permanent joint damage. With the ongoing development of pharmacological treatments, early interception of PsA has become a priority, but many obstacles have been reported in daily routine. The introduction of digital technology in rheumatology may fill the gap in the physician-patient relationship, allowing more targeted monitoring of PsO patients. Digital technology includes telemedicine, virtual visits, electronic health record, wearable technology, mobile health, artificial intelligence, and machine learning. Overall, this digital revolution could lead to earlier PsA diagnosis, improved follow-up and disease control as well as maximizing the referral capacity of rheumatic centers.

Clinical joints manifestations in patients with psoriatic arthritis on musculoskeletal ultrasound

To investigate the clinical joints manifestations under musculoskeletal ultrasound (MSUS) and hematological findings in patients with psoriatic arthritis (PsA), which may provide a basis for improving the early diagnosis of PsA. From September 2016 to February 2021, 328 patients with psoriasis visited the dermatological and rheumatic outpatient of the Beijing Friendship Hospital were enrolled in this retrospective study. Patients were enrolled according to a paired-design method. The PsA group included 164 patients diagnosed with PsA, and the control group included 164 patients diagnosed with psoriasis without PsA. Both groups of patients were evaluated by a rheumatoid immunologist, a dermatologist, and a sonographer. Demographic data, course of disease, severity of skin lesions, combined diseases, and previous treatment were all collected. All patients received MSUS and blood examinations. Lower extremity enthsis diseases were evaluated by Glasgow ultrasound enthesitis scoring system (GUESS). In the comparison of baseline clinical characteristics, the PsA group has longer course of psoriasis (P = 0.005), longer course of joints pain (P = 0.035), higher incidence of peripheral joints pain (P = 0.001), higher GUESS score (P < 0.001), and higher incidence of involved nails or toenails (P = 0.036) The most common joints involved were proximal interphalangeal joint (33.5%), knee (27.4%), and metacarpophalangeal joint (25.0%). Differences in clinical manifestations at different lower limb enthesitis on MSUS have also been proved. The positive incidences of rheumatoid factor (RF) (P = 0.002) and anti-cyclic citrullinated peptide (CCP) antibody (P < 0.001) in the PsA group were significantly higher than those in the control group. Binary Logistic regression showed that patients with anti-CCP antibody positive had a higher risk of active PsA compared to patients with negative antibodies in PsA group (OR: 0.626, 95%CI: 0.361-0.792, P < 0.05). In conclusion, the most common joints involved were proximal interphalangeal joint, knee, and metacarpophalangeal joint in patients with PsA, and the common types of diseased joints manifestations on MSUS were synovial thickening, fluid accumulation, bone destruction, increased blood flow signals, and attachment site inflammation. GUESS scoring systems can be used to identify PsA in patients with psoriasis. Psoriasis patients with RF and anti-CCP antibody positive were more likely to develop PsA, and anti-CCP antibody positive was a risk factor for active PsA. • GUESS scoring systems can be used to identify PsA in patients with psoriasis. • Psoriasis patients with RF and anti-CCP antibody positive were more likely to develop PsA, and anti-CCP antibody positive was a risk factor for active PsA.

Features of microcirculation in psoriatic arthritis

The literature review presents data on features of microcirculation in patients with psoriatic arthritis (PsA). The immune inflammation underlying PsA leads to increased permeability of the vascular wall, deposition of the immune complexes in it, a decreased capillary blood flow, and vascular sensitivity to sympathetic stimulation. In combination with impaired blood rheology during inflammation, these changes have a significant effect on the state of the microvasculature. Increased vascular permeability and a damaged connection between the endothelium and the extracellular matrix in PsA cause the formation of the capillaries with a pathological structure. Microscopic examination of the synovial membrane of patients with PsA shows vascular tortuosity, branching, and elongation. The duration, activity of articular inflammation, as well as severity of psoriasis are associated with the degree of microcirculatory disorders in PsA. The pathomorphological changes in the vessels of patients with PsA are detected not only in the articular tissues but also in the skin, which indicates dysregulation of angiogenesis in general. The mechanisms of the formation of new vessels with a pathological structure are not fully understood. However, most likely, an imbalance of the factors of angiogenesis and antiangiogenesis plays an important role. There is growing evidence that vascular endothelial growth factor (VEGF), transforming growth factor-beta (TGF-beta) and platelet growth factor (PDGF) are involved in the pathogenesis of PsA. At the moment, the issue of early diagnosis of PsA remains relevant, especially in cases with minor skin changes and rheumatoid-like joint lesions. Information on microcirculation obtained by capillaroscopy, video capillaroscopy, and fluorescence microscopy provides additional opportunities for a differential diagnosis of PsA, a determination of activity, and a prognosis of the disease.

Digital Approaches for a Reliable Early Diagnosis of Psoriatic Arthritis.

Psoriatic arthritis (PsA) is a chronic inflammatory disease that develops in up to 30% of patients with psoriasis. In the vast majority of cases, cutaneous symptoms precede musculoskeletal complaints. Progression from psoriasis to PsA is characterized by subclinical synovio-entheseal inflammation and often non-specific musculoskeletal symptoms that are frequently unreported or overlooked. With the development of increasingly effective therapies and a broad drug armamentarium, prevention of arthritis development through careful clinical monitoring has become priority. Identifying high-risk psoriasis patients before PsA onset would ensure early diagnosis, increased treatment efficacy, and ultimately better outcomes; ideally, PsA development could even be averted. However, the current model of care for PsA offers only limited possibilities of early intervention. This is attributable to the large pool of patients to be monitored and the limited resources of the health care system in comparison. The use of digital technologies for health (eHealth) could help close this gap in care by enabling faster, more targeted and more streamlined access to rheumatological care for patients with psoriasis. eHealth solutions particularly include telemedicine, mobile technologies, and symptom checkers. Telemedicine enables rheumatological visits and consultations at a distance while mobile technologies can improve monitoring by allowing patients to self-report symptoms and disease-related parameters continuously. Symptom checkers have the potential to direct patients to medical attention at an earlier point of their disease and therefore minimizing diagnostic delay. Overall, these interventions could lead to earlier diagnoses of arthritis, improved monitoring, and better disease control while simultaneously increasing the capacity of referral centers.

СОВРЕМЕННЫЕ ВОЗМОЖНОСТИ УЛЬТРАЗВУКОВОЙ ДИАГНОСТИКИ ПСОРИАТИЧЕСКОГО АРТРИТА

Psoriatic arthritis is a heterogeneous disease characterized by the involvement of the axial skeleton and peripheral joints and / or entheses in the pathological process. The problems of diagnosing early psoriatic arthritis are not limited to the heterogeneity of clinical manifestations of the disease. Unlike rheumatoid arthritis, there are no biomarkers for the detection of early psoriatic arthritis, and therefore verification of the diagnosis depends on the identification of specific clinical signs. Finally, the absence of psoriasis in the presence of typical clinical signs of arthritis does not permit to confirm the diagnosis in the early stages. Considering numerous difficulties of clinical and laboratory diagnostics of psoriatic arthritis, great attention is paid to non-invasive instrumental methods for diagnosing the disease at early stages. The article provides up-to-date information on the potentials of ultrasound techniques in the diagnosis of early psoriatic arthritis.

Multispectral optoacoustic tomography might be a helpful tool for noninvasive early diagnosis of psoriatic arthritis

Currently used imaging methods for diagnosis of psoriatic arthritis (PsA) frequently come along with exposure to radiation and can often only show long-term effects of the disease. The aim of the study was to check the feasibility of a new optoacoustic imaging method to identify PsA. 22 psoriasis patients and 19 healthy volunteers underwent examination using multispectral optoacoustic tomography (MSOT). The presence of arthritis was assessed via quantification of optoacoustic signal intensity of the endogenous chromophores oxy- and deoxyhemoglobin. We conducted high-resolution real-time ultrasound images of the finger joints. The semi quantitative analysis of the optoacoustic signals for both hemoglobin species showed a significant higher blood content and oxygenation in PsA patients compared to healthy controls.Our results indicate that MSOT might allow detection of inflammation in an early stage. If the data is further confirmed, this technique might be a suitable tool to avoid delay of diagnosis of PsA.

Innovative Imaging Technique for Visualization of Vascularization and Established Methods for Detection of Musculoskeletal Inflammation in Psoriasis Patients.

Psoriasis (PsO) is one of the common chronic inflammatory skin diseases. Approximately 3% of the European Caucasian population is affected. Psoriatic arthritis (PsA) is a chronic immune-mediated disease associated with PsO characterized by distinct musculoskeletal inflammation. Due to its heterogeneous clinical manifestations (e.g., oligo- or polyarthritis, enthesitis, dactylitis, and axial inflammation), early diagnosis of PsA is often difficult and delayed. Approximately 30% of PsO patients will develop PsA. The responsible triggers for the transition from PsO only to PsA are currently unclear, and the impacts of different factors (e.g., genetic, environmental) on disease development are currently discussed. There is a high medical need, recently unmet, to specifically detect those patients with an increased risk for the development of clinically evident PsA early to initiate sufficient treatment to inhibit disease progression and avoid structural damage and loss of function or even intercept disease development. Increased neoangiogenesis and enthesial inflammation are hypothesized to be early pathological findings in PsO patients with PsA development. Different disease states describe the transition from PsO to PsA. Two of those phases are of value for early detection of PsA at-risk patients to prevent later development of PsA as changes in biomarker profiles are detectable: the subclinical phase (soluble and imaging biomarkers detectable, no clinical symptoms) and the prodromal phase (imaging biomarkers detectable, unspecific musculoskeletal symptoms such as arthralgia and fatigue). To target the unmet need for early detection of this at-risk population and to identify the subgroup of patients who will transition from PsO to PsA, imaging plays an important role in characterizing patients precisely. Imaging techniques such as ultrasound (US), magnetic resonance imaging (MRI), and computerized tomography (CT) are advanced techniques to detect sensitively inflammatory changes or changes in bone structure. With the use of these techniques, anatomic structures involved in inflammatory processes can be identified. These techniques are complemented by fluorescence optical imaging as a sensitive method for detection of changes in vascularization, especially in longitudinal measures. Moreover, high-resolution peripheral quantitative CT (HR-pQCT) and dynamic contrast-enhanced MRI (DCE-MRI) may give the advantage to identify PsA-related early characteristics in PsO patients reflecting transition phases of the disease.

Development and Validation of a Sonographic Enthesitis Instrument in Psoriatic Arthritis: The GRAPPA Diagnostic Ultrasound Enthesitis Tool (DUET) Project.

Enthesitis is a key feature in psoriatic arthritis (PsA) and may be the initial site of musculoskeletal inflammation in patients with PsA. Ultrasound (US) optimizes the detection of enthesitis, but the lack of a validated sonographic enthesitis scoring system for PsA limits the ability to conduct US-based studies of approaches to improve the early diagnosis of PsA. Creating a sonographic enthesitis scoring system that reliably identifies PsA at early stages is an important step in optimizing early diagnosis and encouraging timely interventions that will ultimately improve longterm outcomes for patients with PsA. The Group for Research and Assessment of Psoriasis and PsA (GRAPPA) US working group has set a goal of improving the evaluation of enthesitis in patients with PsA by using US through the development of a Diagnostic Ultrasound Enthesitis Tool (DUET). This article summarizes the proposed DUET study design and methodology as discussed during the 2019 GRAPPA annual meeting in Paris, France.

Early diagnosis of psoriatic arthritis among psoriasis patients: clinical experience sharing

BackgroundThe early detection of psoriatic arthritis (PSA) poses a challenge to rheumatologists, even when their diagnosis is aided by sonography. In order to facilitate early detection of PSA among patients with psoriasis (PSO), we retrospectively analyzed of the relationships between serological markers and comorbidities in 629 psoriatic patients, 102 of which had PSA, while the other 527 had PSO.ResultsSerological markers were found not to be useful in distinguishing between PSA and PSO (p > 0.05 for all comparisons). The prevalence rate of PSA among PSO patients was around 19.4%. Two components of metabolic syndrome—hyperlipidemia (2.94%) and gout (4.9%)—were significantly more prevalent in PSA patients than in PSO patients (p < 0.05). The odds ratio for PSA is 15.94 in patients with hyperlipidemia with a 95% confidence interval (CI) of 1.64–154.80; meanwhile, the odds ratio for PSA is 3.83 in patients with gout with a 95% CI of 1.19–12.31. Allergic rhinitis (5.88%) was more prevalent in PSA patients than in PSO patients (p < 0.01). The odds ratio was 8.17 in patients with allergic rhinitis with a 95% CI of 2.26–29.50. Plasma hs-miR-210-3p distinguishes PSA from PSO, and its levels can also be distinguished from PSA after treated with anti-TNFα biologics agents (both p < 0.05).ConclusionsNo clinical available serology markers, but hyperlipidemia, gout, axial spondylopathy (inflammatory back pain), or allergic rhinitis, could differentiate between psoriatic arthritis from psoriasis. Plasma hs-miR-210-3p and comorbidities may differentiate psoriatic arthritis from psoriasis.Key Points• Clinical manifestations and comorbidities are different between psoriatic arthritis and psoriasis only patients.• Traditional serology markers are similar between psoriatic arthritis and psoriasis-only patients.• Plasma hs-miR-210-3p distinguishes PSA from PSO, and its levels can also be distinguished from PSA after treated with anti-TNFα biologics agents in our study.

Retention rates and identification of factors associated with anti-TNFα, anti-IL17, and anti-IL12/23R agents discontinuation in psoriatic arthritis patients: results from a real-world clinical setting.

Biologic disease-modifying antirheumatic drugs (bDMARDs) play a pivotal role in the treatment of psoriatic arthritis (PsA). Despite this, their discontinuation due to inefficacy or adverse events is often observed. The aims of this study are to describe retention rates and treatment trends of anti-TNFα, anti-IL17, and anti-IL12/23R agents in patients with PsA and to identify factors associated with bDMARDs discontinuation in a real-world clinical setting. A retrospective cohort study based on the analysis of the three Italian prescription cohorts of patients with PsA has been performed. Survival analysis was performed using Kaplan-Meier curves and Cox proportional-hazards model. During the follow up, which lasted 25.5 (12-60)months, 68 patients discontinued a bDMARD: 13 for primary failure, 12 for secondary failure, 15 for adverse events, 5 for remission, 12 because of lost at follow-up, and 11 for other causes. Cox proportional-hazards demonstrated that a shorter disease duration (HR 0.994991, 95% CI 0.9910336-0.9989647, p = 0.014) and first-line bDMARD (HR 0.5090986, 95% CI 0.3073519-0.8432722, p = 0.009) have a protective role on bDMARD retention rate, while the multivariable analysis failed in demonstrating an independent protective role of male sex on drug retention rate (p = 0.083). No significant differences in retention rate have been found regarding biologic drugs, combination therapy or monotherapy, and class of bDMARD (anti-TNFα or anti-pIL12/23R and anti-IL-17). This study shows that a shorter disease duration and treatment with a first-line bDMARD are predictors of bDMARDs retention rate, further highlighting the importance of early diagnosis of PsA. Key Points • No significant difference in retention among patients treated with anti-IL17A, anti-IL12/23R, and anti-TNFα agents has been demonstrated. • A shorter disease duration and first-line bDMARD treatment are associated with persistence in biologic treatment.

Early diagnosis of psoriatic arthritis and possibility of its control (literature review)

The article is of an overview nature and contains current data on risk factors for the development of psoriatic arthritis in patients with psoriasis. The data on the diagnosis, clinical picture of PsA and the feasibility of the early appointment of biologics medicines in order to increase efficiency and improve the prognosis of the disease are given.

Detectability of the peripheral and axial manifestations of psoriatic arthritis in patients with psoriasis in dermatological practice

Psoriatic arthritis (PsA) is a heterogeneous disease manifested by peripheral arthritis, dactylitis, spondylitis, and enthesitis. PsA is often undiagnosed by dermatovenerologists because of the difficulty in identifying a variety of clinical signs. The early diagnosis of PsA and the accurate assessment of all its symptoms are necessary for the timely choice of optimal therapy.Objective: to assess the detectability of clinical signs of PsA in patients with psoriasis in dermatological practice.Patients and methods. The investigation enrolled 103 patients (47 men and 56 women) (mean age, 44.0±13.7 years) with psoriasis (its mean duration, 10.7±10.2 years), the average prevalence and severity according to the Body Surface Area (BSA) and the Psoriasis Area and Severity Index (PASI) were 9.3±13.6% and 15.4±12.5 scores, respectively. All the patients completed the Psoriasis Epidemiology Screening Tool (mPEST) and were examined by a dermatovenerologist and a rheumatologist. The diagnosis of PsA was based on the Classification Criteria for Psoriatic Arthritis (CASPAR). The investigators evaluated arthritis, dactylitis, enthesitis, and inflammatory back pain (IBP) according to the rheumatological standards: IBP by the Assessment of SpondyloArthritis International Society (ASAS) criteria, and enthesitis by the Leeds Enthesitis Index (LEI).Results and discussion. Sixty-one (59.2%) of the 103 patients with psoriasis were found to have PsA on the basis of the CASPAR criteria and the rheumatologist's examination. The dermatovenerologist diagnosed arthritis in a significantly smaller number of cases than did the rheumatologist: in 15 (24.6%) and 35 (57.4%) of the 61 patients (p&lt;0.001), respectively. The dermatovenerologist and the rheumatologist demonstrated no significant differences in their clinical evaluation of dactylitis: it was detected in 37 (60.7%) and 40 (65.6%) of the 61 patients, respectively (p=0.32). Based on patient complaints and mPEST findings, the dermatovenerologist recorded pain in the calcaneal region in 32 (52.5%) patients. The rheumatologist identified ulnar, knee, and calcaneus enthesitis in 11 (18%), 8 (13.1%), and 25 (41%) patients, respectively. Based on complaints and mPEST findings, the dermatovenerologist detected back pain in 30 (49.2%) of the 61 patients. The rheumatologist diagnosed IBP in 21 (70%) of these 30 patients and mechanical back pain in 9 (30%). Thus, IBP was noted in 34.4% of PsA patients. Tendonitis was undiagnosed by the dermatovenerologist; the rheumatologist identified wrist tendonitis in 13 (21.3%) of the 61 patients with PsA.Conclusion. Dermatovenerologists frequently underestimate damage to the spine and entheses in patients with psoriasis. The introduction of the ASAS criteria for IBP and methods for assessing enthesitis in dermatological practice can improve the early diagnosis of axial lesion in PsA in patients with psoriasis.

THE CASE OF PSORIATIC ERYTHRODERMA AND SEVERE COMORBID PSORIATIC ARTHRITIS

Early diagnosis of psoriatic arthritis (PsA) is necessary for timely treatment and prevention of the disease progression with destruction of the joints. In most patients, comorbid PsA develops many years after the debut of the skin process. Consequently, the main role in timely diagnosis of PsA is played by a dermatologist, who is able to identify its initial signs and refer the patient to a rheumatologist. Early initiation of systemic therapy with the use of modern biological agents for progressive psoriatic arthritis and severe psoriasis can prevent the development of irreversible disability.

Multidisciplinary Management of Psoriatic Arthritis: The Benefits of a Comprehensive Approach.

Psoriatic arthritis (PsA) is a lifelong disease associated with extra-articular manifestations and several comorbidities, as well as reduced quality of life and psychosocial burden. Diagnostic delay is associated with poorer outcomes, while a short delay between symptom onset and diagnosis is linked with preservation of function. Overcoming the barriers to early diagnosis of PsA is often difficult to achieve in the absence of well-characterized disease markers and/or a definitive screening procedure. Once a diagnosis is made, approaches to care may differ between countries, but a treat-to-target approach can be advocated, with constant patient follow-up visits and specialist monitoring and treatment of comorbidities. Adequately addressing all aspects of care can help to drive patient-centered care and encourage better adherence. Given the mounting number of therapeutic options and the complexity of management of PsA, the disease can be optimally treated by a multidisciplinary approach, and a collaborative approach between rheumatologists and dermatologists can be advocated. The need for multidisciplinary management is reinforced by consensus among experts. Patient satisfaction has emerged as a central indicator of quality, and patient-centered care must remain a central goal for the care of patients with PsA. Definition of a minimum set of standards for care will help to achieve the goal of multidisciplinary care for patients with PsA. Optimal care of PsA and greater collaboration among clinicians should always be encouraged so that patients can receive the best possible quality of care.Funding: Pfizer Italy.

Clinical outcomes and feasibility of the multidisciplinary management of patients with psoriatic arthritis: two-year clinical experience of a dermo-rheumatologic clinic.

Psoriatic arthritis (PsA) is a chronic inflammatory autoimmune arthritis, occurring in patients with psoriasis (Pso), that may affect the whole musculoskeletal system but also nails, eye, and gastrointestinal tract. Dermatologists and rheumatologists usually manage Pso and PsA separately, but early diagnosis and integrated management could achieve better outcomes of both skin and musculoskeletal manifestations, thus improving the health-related quality of life (HRQoL) of patients. In this work, we have described a model of integrated dermo-rheumatologic approach for the early diagnosis of PsA and to present the outcomes of the multidisciplinary management of PsA patients after 48weeks of follow-up. Pso patients complaining musculoskeletal symptoms were enrolled in a DErmo-Rheumatologic Clinic (DERC) in order to screen, classify, and treat patients with PsA, employing an operative working procedure and a specific flowchart. The integrated dermatologic and rheumatologic management of PsA patients allowed a prompt establishment of the diagnosis and the best therapeutic approach in these patients, with a significant improvement of skin and articular diseases and, eventually, a consistent amelioration of HRQoL. Dermatologists and rheumatologists usually manage the "psoriatic disease" in separated outpatient clinics. In our study, we have demonstrated that a combined DERC, by means of a tight cooperation between the dermatologist and the rheumatologist, which use a specific working procedure and treatment flowchart, may achieve the optimal clinical management of these patients, with a consistent clinical remission of the disease and a significant amelioration of the HRQoL.