Download Psoriatic arthritis in practice : How to detect

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Psoriatic arthritis in practice :
How to detect ?
How to diagnose ?
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Pascal RICHETTE
Hôpital Lariboisière, Paris
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The patient: a 57 year-old man, with a history
of psoriatic nail dystrophy for 10 years
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Past history:
- Dyslipidemia
- Hyperuricemia (urate levels: 7 mg/dl)
Current oral medications
- Atorvastatin (20mg/d)
- Acetaminophen (up to 4g/d): acute painful
knee
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Physical examination
-  Overweight (BMI 27 kg/m2)
-  Blood pressure: normal
-  Swollen knees (left > right)
Is this a Psoriatic Arthritis ?
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Time
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Why should dermatologists know everything on PsA ?
Earlier diagnosis: better outcomes
ACR, 2009
The psoriasis incidence cohort comprised 1,633 subjects.
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(psoriasis diagnosed between January 1, 1970 and
December 31, 1999)
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The cumulative incidence of PsA at 5, 10, and 20 years following psoriasis was
1.7% (95% CI1.0–2.3%),
3.1% (95% CI 2.2–4.1%)
5.1% (95% CI 3.7–6.6%)
“the estimated prevalence was
13.8%”
Tip 1: to know classification criterias for PsA
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Example: Caspar criteria
To meet the criteria of the Classification of Psoriatic Arthritis (CASPAR)
Study Group, a patient must have inflammatory articular disease (joint,
spine, or enthesial) with 3 points from 5 categories.
Semin Arthritis Rheum 2004
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Criteria of Fournie
Vasey and Espinoza
McGonagle
Gladman
Moll and Wright
Bennett
ESSG
Classification criteria rather
than diagnostic criteria +++
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SF analysis
• ≥ 2000 cells/mm3
• No strains (no septic arthritis)
• No crystals (no gout)
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Meaning of
SYNOVIAL FLUID ANALYSIS: THE
Inflammatory arthritis ? KEY FOR NOSOLOGIC
CLASSIFICATION OF ARTHRITIS
Tip 2: clinical examination
• Peripheral arthritis: dactylitis +++. Examine the feet.
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Take off the shoes/socks: it might be worthwhile.
• Enthesitis: ask for the presence of talalgia (pain under the heel)
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(Calin/Berlin criteria)
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• Spinal involvement (5-25%): inflammatory low back pain
Sensibility to NSAIDs +++
1)  MONO/OLIGO/POLYARTHRITIS C
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• Peripheral arthritis
-  mono-/oligoarthritis, DIP joint involvement, dactylitis
2 diag ≠… Helliwell et al; JR 2009
2) ENTHESITIS ig
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Enthesis Frequent involvement of calcaneum: talalgia But also the knees (supra/infra patellaire tendon)… C
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Ultrasound and PsA +++ C
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Tip 3: Imaging (X-Rays +/- MRI)
Screening questionnaires
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Ideally every psoriasis patient with musculoskeletal pain should be evaluated
by a rheumatologist, but this is not practical.
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Screening questionnaires have been developed as referral tools to
help dermatologists identify suitable individuals for referral to
rheumatologists.
1.  Psoriatic Arthritis Screening and Evaluation (PASE)
2.  Psoriasis Epidemiology Screening Tool (PEST)
3.  Toronto Psoriatic Arthritis Screening (ToPAS).
AIM: to identify individuals that might be at high risk for the development
of PsA
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Fulfilled by the patients
Gladman DD et al. Development and initial validation of a screening questionnaire for psoriatic arthritis: The Toronto
Psoriatic Arthritis Screen (ToPAS). Ann Rheum Dis 2009;68:497–501.
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Husni ME et al. The PASE questionnaire: pilot‐testing a psoriatic arthritis screening and evaluation tool. J Am Acad Dermatol 2007 Oct;57(4):581‐7;
Dominguez PL et al. Validity, reliability, and sensitivity‐to‐change properties of the psoriatic arthritis screening and evaluation questionnaire.
Arch Dermatol Res 2009 Sep;301(8):573‐9.
Ann Rheum Dis 2012;0
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To compare the performance and utility of the three PsA questionnaires (PASE,
PEST, and the ToPAS) versus a full rheumatological evaluation (CASPAR criteria)
in psoriasis patients attending dermatology clinics.
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The assessment of PsA was carried out in
two steps.
- The first step involved completing the
questionnaires (PEST, PASE, ToPAS).
- Patients received a full rheumatological
evaluation (CASPAR)
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èPoor sensitivity performance of the three available screening tools
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Many screening
questionnaires to detect PsA
not used by dermatologists in
everyday practice
because of their complexity.
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The sensitivity and specificity were 91% and 85%,
respectively, for the cut-off value of 3.
« The EARP is fast and easy for dermatologists to use to identify early
symptoms of PsA. »
In practice,
Some questions you should ask to patients with Psoriasis
Have you ever experience back pain ?
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Have you ever experience pain in
knees, wrists, hands or feet ?
If yes,
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If yes: refer the patient to a
rheumatologist
Morning stiffness >30 minutes
Improvement in back pain with exercise
but not with rest
Awakening in the second half of the
night because of back pain
Alternating buttock pain.
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If yes,
- were these joints swollen ?
- Painful during night
- Stiffned on the morning
If yes: refer the patient to a
rheumatologist
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Role of dermatologists: corner stone
Diagnostic of PsA can be uneasy
Refer the patient to a rheumatologist
Avoid overestimation of PsA
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CONCLUSIONS….