Treatment of Enthesitis, Dactylitis and Nail Lesions in Psoriatic Arthritis
Purpose of review
Psoriatic arthritis (PsA) is an inflammatory arthritis associated with the skin disease, psoriasis. It is a highly heterogeneous disorder, not only in the musculoskeletal phenotype but also in its cutaneous manifestations. Enthesitis, dactylitis, and nail changes are the hallmark of the disease, and experts in the field believe that the initiating process of PsA is a deep Koebner phenomenon which triggers enthesitis and the subsequent disease process and progression. We aim to discuss the most recent advances in the treatment of enthesitis, dactylitis, and nail changes in psoriatic arthritis.
Various treatment regimens have been used to control the above manifestations of PsA, including conventional synthetic disease-modifying agents (csDMARDs), biologic disease-modifying agents (bDMARDs), and newer therapies which include interleukin (IL)-12/23 antagonist (ustekinumab), IL-17 antagonists (secukinumab and ixekizumab), as well as small molecules including the Janus kinase (JAK) inhibitors and phosphodiesterase-4 inhibitor (apremilast). The csDMARDs include methotrexate, sulphasalazine, leflunomide, as well as cyclosporine.
These modalities of treatment are further discussed in this review. Rapid escalation of therapy in patients who have an inadequate response to conventional therapy results in better outcomes. Future research includes specific antibodies against the p19 subunit of IL-23.
KeywordsPsoriasis Psoriatic arthritis Methotrexate Biologics Secukinumab
Compliance with Ethical Standards
Conflict of Interest
Ajesh B Maharaj, MB.BS, H. Dip.Int. Med, FCP, Cert in Rheumatology and Faranah Paruk, MBChB, FCP, Cert in Rheumatology, Ph.D. declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal studies performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 5.• Williamson L, Dalbeth N, Dockerty JL, et al. Extended report: nail disease in psoriatic arthritis—clinically important, potentially treatable and often overlooked. Rheumatology. 2004;43:790–4. This report outlines the importance of nail disease assessment and treatment in PSA.CrossRefPubMedGoogle Scholar
- 9.• Chandran V, Gottlieb A, Cook RJ, et al. International multicenter psoriasis and psoriatic arthritis reliability trial for the assessment of skin, joints, nails, and dactylitis. Arthritis Rheum. 2009;61:1235–42. This paper discusses the assessment of the various components of PsA.CrossRefPubMedGoogle Scholar
- 14.Ibrahim G, Groves C, Chandramohan M, et al. Clinical and ultrasound examination of the Leeds enthesitis index in psoriatic arthritis and rheumatoid arthritis. Rheumatology(Oxford). 2011;2011:731917.Google Scholar
- 26.•• Orbai AM, Weitz J, Siegel EL, GRAPPA Enthesitis Working Group, et al. A systematic review of treatment effectiveness and outcome measures for enthesitis in psoriatic arthritis. J Rheumatol. 2014;41:2290–4. Important and insightful review and recommendations by GRAPPA working groups.CrossRefPubMedGoogle Scholar
- 33.Fox RI. Mechanism of action of leflunomide in rheumatoid arthritis. J Rheumatol. 1998;53:20–6.Google Scholar
- 34.Scarpa R, Manguso F, Oriente P, et al. Leflunomide in psoriatic polyarthritis: an Italian pilot study. Arthritis Rheum. 2001;44:S92.Google Scholar
- 38.• Antoni CE, Kavanaugh A, Kirkham B, et al. Sustained benefits of infliximab therapy for dermatologic and articular manifestations of psoriatic arthritis: Results from the infliximab multinational psoriatic arthritis controlled trial (IMPACT). Arthritis Rheum. 2005;52:1227–36.Shows data on the response of infliximab on PsA domains.CrossRefPubMedGoogle Scholar
- 41.Kavanaugh A, McInnes IB, Philip Mease P, et al. Clinical efficacy, radiographic and safety findings through 5 years of subcutaneous golimumab treatment in patients with active psoriatic arthritis: results from a long-term extension of a randomised, placebo-controlled trial, the GO-REVEAL study. Ann Rheum Dis. 2014;0:1–6. https://doi.org/10.1136/annrheumdis-2013-204,902.Google Scholar
- 43.Ritchlin C, Rahman P, Kavanaugh A, PSUMMIT 2 Study Group, et al. Efficacy and safety of the anti-IL-12/23 p40 monoclonal antibody, ustekinumab, in patients with active psoriatic arthritis despite conventional non-biological and biological anti-tumour necrosis factor therapy: 6-month and 1-year results of the phase 3, multicentre, double-blind, placebo-controlled, randomised PSUMMIT 2 trial. Ann Rheum Dis. 2014;73:990–9.CrossRefPubMedPubMedCentralGoogle Scholar
- 44.Kavanaugh A, Puig L, Gottlieb AB, et al. Efficacy and safety of ustekinumab in psoriatic arthritis patients with peripheral arthritis and physician-reported spondylitis: post-hoc analyses from two phase III, multicentre, double-blind, placebo-controlled studies (PSUMMIT-1/PSUMMIT-2). Ann Rheum Dis. 2016.Google Scholar
- 52.Mease PJ, van der Heijde D, Ritchlin CT, SPIRIT-P1 Study Group, et al. Ixekizumab, an interleukin-17A specific monoclonal antibody, for the treatment of biologic-naïve patients with active psoriatic arthritis: results from the 24-week randomised, double-blind, placebo-controlled and active (adalimumab)-controlled period of the phase III trial SPIRIT-P1. Ann Rheum Dis. 2016.Google Scholar
- 54.Mease P, Gottlieb AB, Berman A, et al. The efficacy and safety of clazakizumab, an anti-interleukin-6 monoclonal antibody, in a phase 2b study of adults with active psoriatic arthritis. Arthritis Rheum. 2016;Google Scholar
- 61.O’Shea JJ. Jaks, STATs, cytokine signal transduction, and immunoregulation: are we there yet? Immunity. 1997;7:11–3.Google Scholar
- 63.•• Gossec L, Smolen JS, Ramiro S, et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. 2016;75:499–510. This is an important consensus document by EULAR on the management and recommendations of PsA.CrossRefPubMedGoogle Scholar
- 64.•• Ogdie A, Schwartzman S, Eder L, et al. Comprehensive treatment of psoriatic arthritis: managing comorbidities and extraarticular manifestations. J Rheumatol. 2014;41:2315–22. This is an important paper the deals comprehensively with extraarticular manifestations, the importance in management of PsA in totality.CrossRefPubMedGoogle Scholar
- 65.•• Coates LC, Kavanaugh A, Ritchlin CT. GRAPPA Treatment Guideline Committee: Systematic review of treatments for psoriatic arthritis: 2014 update for the GRAPPA. J Rheumatol. 2014;41:2273–6. Important review on the guidelines and recommendations of treatment of PsA by GRAPPA.CrossRefPubMedGoogle Scholar
- 66.•• Coates LC, Kavanaugh A, Mease PJ. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68:1060–71. Important update of the previous recommendations of GRAPPA to include new agents.PubMedGoogle Scholar