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Show your Best III
By: Brad Moatz MSIV
• 42 y.o. male presents with R foot pain and
h/o psoriasis
• Right foot: There are large central erosions in the first -fifth metatarsophalangeal joints, with resultant pencil in
cup deformity in these joints. There is metatarsus
adductus primus, measuring 18°. There is also hallux
valgus, measuring approximately 52°. There is also mild
to moderate lateral deviation at the second - fourth
metatarsophalangeal joints. There is bony ankylosis in
the midfoot, specifically at the naviculocuneiform
articulation, as well as navicular cuboid joint. There are
diffuse enthesopathic changes throughout the foot, most
prominent at the medial and lateral aspect of the hindfoot
and midfoot. There is a prominent erosion in the dorsal
aspect of the calcaneus at the site of the Achilles' tendon
Psoriatic Arthritis - Presentation
• Patients with psoriatic arthritis present with pain
and stiffness in the affected joints
• Morning stiffness lasting more than 30 minutes
occurs in one-half of patients. The stiffness is
accentuated with prolonged immobility, and is
alleviated by physical activity.
• PE- stress pain, joint line tenderness, and
effusions in the affected joints are present, often
in an asymmetric distribution. The DIP joints and
spine are each affected in 40-50% of cases
Presentation (cont.)
• Dactylitis
• Characteristic features of psoriasis
affecting the nailbed include nail pits,
onycholysis, nailbed hyperkeratosis, and
splinter hemorrhages
• Swelling of the hands or feet with pitting
edema is sometimes a presenting feature
• Ocular inflammation occurs in some
patients with psoriatic arthritis
Radiologic Features
• The most striking radiologic feature is the
coexistence of erosive changes and new
bone formation in the distal joints; other
typical radiological changes include lysis
of the terminal phalanges, fluffy periostitis
and new bone formation at the site of
enthesitis, gross destruction of isolated
joints, "pencil-in-cup" appearance, and the
occurrence of both joint lysis and ankylosis
in the same patient
• Psoriatic arthritis
associated with pencil-incup abnormality in the
distal interphalangeal
(DIP) joints of the first
and second fingers (short
arrows), plus early
changes in the DIP joint
of the fourth finger. Other
changes include
ankylosis in the DIP joint
in the fifth finger (long
arrow) and destruction of
the wrist.
• The treatment of PsA usually begins with nonsteroidal
antiinflammatory medications (NSAIDs)
• Second-line therapies are employed when the arthritis
does not respond to NSAIDs
• Drugs such as methotrexate, PUVA, retinoic acid
derivatives, and cyclosporine A have been shown to
improve both the joint and skin manifestations of
• However, it should be noted that none of these
medications have actually been shown to prevent or
retard progression of joint damage. Inhibitors of tumor
necrosis factor-alpha (TNF) may also be effective for
both skin and joint disease