Skip to main content
SpringerLink
Log in

Diagnosis and Management of Psoriatic Arthritis

  • Therapy In Practice
  • Published:
Drugs Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Table I
Table II

Similar content being viewed by others

References

  1. Zias J, Mitchell P. Psoriatic arthritis in a fifth-century Judean desert monastery. Am J Phys Anthropol 1996; 101: 491–502

    Article  PubMed  CAS  Google Scholar 

  2. Bazin P. Leçons théorétique et Cliniques sur les Affections Cutanées de Nature arthritique et Arthreux. Paris: Delahaye, 1860

    Google Scholar 

  3. Hench PS. Arthropathia psoriatiaca: presentation of a case. Proc Staff Meet Mayo Clin 1927; 2: 80

    Google Scholar 

  4. O’Neill TO, Silman AJ. Psoriatic arthritis: historical background and epidemiology. Baillieres Clin Rheumatol 1994; 8: 245–61

    Article  PubMed  Google Scholar 

  5. Leczinsky CG. The incidence of of arthropathy in a 10 year series of psoriatic cases. Acta Derm Venereol 1948; 28: 483–7

    PubMed  CAS  Google Scholar 

  6. Wright V. Rheumatism and psoriasis: a re-evaluation. Am J Med 1959; 27: 454–62

    Article  PubMed  CAS  Google Scholar 

  7. Wright V. Psoriasis and arthritis. Ann Rheum Dis 1956; 15: 348–56

    Article  PubMed  CAS  Google Scholar 

  8. Moll JMH, Wright V. Psoriatic arthritis. Semin Arthritis Rheum 1973; 3: 55–78

    Article  PubMed  CAS  Google Scholar 

  9. Vasey FB, Espinoza LR. Psoriatic arthropathy. In: Calin A, editor. Spondyloarthropathies. New York: Grune & Stratton, 1984: 151–85

    Google Scholar 

  10. Helliwell P, Marchesoni A, Peters M, et al. A re-evaluation of the osteoarticular manifestations of psoriasis. Br J Rheumatol 1991; 30: 339–45

    Article  PubMed  CAS  Google Scholar 

  11. Fournie B, Crognier L, Arnaud C, et al. Proposed classification criteria of psoriatic arthritis. Rev Rheum Engl Ed 1999; 66: 446–56

    CAS  Google Scholar 

  12. Roberts MET, Wright V, Hill AGS, et al. Psoriatic arthritis: follow-up study. Ann Rheum Dis 1976; 35: 206–12

    Article  PubMed  CAS  Google Scholar 

  13. Gladman DD. Natural history of psoriatic arthritis. Baillieres Clin Rheumatol 1994; 8: 379–94

    Article  PubMed  CAS  Google Scholar 

  14. Jones SM, Armas JB, Cohen MG, et al. Psoriatic arthritis: outcome of disease subsets and relationship of joint disease to nail and skin disease. Br J Rheumatol 1994; 33: 834–9

    Article  PubMed  CAS  Google Scholar 

  15. Gladman DD, Farewell VT, Nadeau C. Clinical indicators of progression of psoriatic arthritis: multivariate relative risk model. J Rheumatol 1995; 22: 675–9

    PubMed  CAS  Google Scholar 

  16. Gladman DD, Farewell VT. Progression in psoriatic arthritis: role of time varying clinical indicators. J Rheumatol 1999; 26: 2409–13

    PubMed  CAS  Google Scholar 

  17. Gladman DD, Shuckett R, Russell ML, et al. Psoriatic arthritis: clinical and laboratory analysis of 220 patients. Quart J Med 1987; 62: 127–41

    PubMed  CAS  Google Scholar 

  18. Oriente P, Biondi Orienet C, Scarpa R. Clinical manifestations. Baillieres Clin Rheumatol 1994; 8: 277–94

    Article  PubMed  CAS  Google Scholar 

  19. Buskila D, Langevitz P, Gladman DD, et al. Patients with rheumatoid arthritis are more tender than those with psoriatic arthritis. J Rheumatol 1992; 19: 1115–9

    PubMed  CAS  Google Scholar 

  20. Battistone MJ, Manaster BJ, Reda DJ, et al. The prevalence of sacroiliitis in psoriatic arthritis: new perspectives from a large, multi-centre cohort. Skeletal Radiol 1999; 28: 196–201

    Article  PubMed  CAS  Google Scholar 

  21. Avila R, Pugh DG, Slocum CH, et al. Psoriatic arthritis: a roentgenologic study. Radiology 1960; 75: 691–702

    PubMed  CAS  Google Scholar 

  22. Gladman DD, Brubacher B, Buskila D, et al. Differences in the expression of spondyloarthropathy: a comparison between ankylosing spondylitis and psoriatic arthritis. Clin Invest Med 1993; 16: 1–7

    PubMed  CAS  Google Scholar 

  23. Helliwell PS, Hickling P, Wright V. Do the radiological changes of classic ankylosing spondylitis differ from the changes found in the spondylitis associated with inflammatory bowel disease, psoriasis and reactive arthritis? Ann Rheum Dis 1998; 57: 135–40

    Article  PubMed  CAS  Google Scholar 

  24. McGonagle D, Conaghan PG, Emery P. Psoriatic arthritis: a unified concept twenty years on. Arthritis Rheum 1999; 42: 1080–6

    Article  PubMed  CAS  Google Scholar 

  25. Dougados M, Linden S, Juhlin R, et al. The European Spondylarthropathy Study Group preliminary criteria for the classificiation of spondylarthropathy. Arthritis Rheum 1991; 34: 1218–27

    Article  PubMed  CAS  Google Scholar 

  26. Salvarani C, Cantini F, Olivieri I, et al. Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis. J Rheumatol 1997; 24: 1106–10

    PubMed  CAS  Google Scholar 

  27. Troughton PR, Morgan WA. Laboratory findings and pathology of psoriatic arthritis. Baillieres Clin Rheum 1994; 8: 439–63

    Article  CAS  Google Scholar 

  28. Gladman DD, Farewell VT, Husted J, et al. Mortality studies in psoriatic arthritis: results from a single centre. II. prognostic indicators for mortality. Arthritis Rheum 1998; 41: 1103–10

    Article  CAS  Google Scholar 

  29. Baeten D, Demetter P, Cuvelier C, et al. Comparative study of the synovial histology in rheumatoid arthritis, spondyloarthropathy and osteoarthritis: influence of disease duration and activity. Ann Rheum Dis 2000; 59: 945–53

    Article  PubMed  CAS  Google Scholar 

  30. Veale D, Yanni G, Rogers S, et al. Reduced synovial membrane macrophage numbers, ELAM1 expression, and lining layer hyperplasia in psoriatic arthritis as compared with rheumatoid arthritis. Arthritis Rheum 1993; 36: 893–900

    Article  PubMed  CAS  Google Scholar 

  31. Ritchlin C, Haas-Smith SA, Hicks D, et al. Patterns of cytokine production in psoriatic synovium. J Rheumatol 1998; 25: 1544–52

    PubMed  CAS  Google Scholar 

  32. Partsch G, Steiner G, Leeb BF, et al. Highly increased levels of tumor necrosis factor-α and other pro-inflammatory cytokines in psoriatic arthritis synovial fluid. J Rheumatol 1997; 24: 518–23

    PubMed  CAS  Google Scholar 

  33. Wong K, Gladman DD, Husted J, et al. Mortality studies in psoriatic arthritis: results from a single outpatient clinic: I. causes and risk of death. Arthritis Rheum 1997; 40: 1868–7

    Article  CAS  Google Scholar 

  34. Jones G, Crotty M, Brooks P, et al. Psoriatic arthritis: a quantitative overview of therapeutic options. Br J Rheumatol 1997; 36: 95–9

    Article  PubMed  CAS  Google Scholar 

  35. Clegg DO, Reda DJ, Mejias E, et al. Comparison of sulfasalazine and placebo in the treatment of psoriatic arthritis: a department of veterans affairs cooperative study. Arthritis Rheum 1996; 39: 2013–20

    Article  PubMed  CAS  Google Scholar 

  36. Mease PJ, Goffe BS, Metz J, et al. Etanercept in the treatment of psoriatic arthritis and psoriasis: a randomised trial. Lancet 2000; 356: 385–90

    Article  PubMed  CAS  Google Scholar 

  37. Black RL, O’Brien WM, Van Scott EJ, et al. Methotrexate therapy in psoriatic arthritis: double blind study on 21 patients. JAMA 1964; 189: 743–7

    Article  PubMed  CAS  Google Scholar 

  38. Wilkens RF, Williams J, Ward JR, et al. Randomized double blind, placebo-controlled trial of low-dose pulse methotrexate in psoriatic arthritis. Arthritis Rheum 1984; 27: 376–81

    Article  Google Scholar 

  39. Zacharias H, Zacharias E. Methotrexate treatment of psoriatic arthritis. Acta Dermatol Venereol 1987; 67: 270–3

    Google Scholar 

  40. Espinoza LR, Zakraoni L, Espinoza CG, et al. Psoriatic arthritis: clinical response and side effects of methotrexate therapy. J Rheumatol 1992; 19: 872–7

    PubMed  CAS  Google Scholar 

  41. Abu-Shakra M, Gladman DD, Thorne JC, et al. Long-term methotrexate therapy in psoriatic arthritis: clinical and radiologic outcome. J Rheumatol 1995; 22: 241–5

    PubMed  CAS  Google Scholar 

  42. Poikolanen K, Karvonen J, Pukkala E. Excess mortality related to alcohol and smoking amongst hospital-treated patients with psoriasis. Arch Dermatol 1999; 13: 1490–3

    Article  Google Scholar 

  43. Combe B, Goupille P, Kuntz JL, et al. Sulphasalzine in psoriatic arthritis: a randomized, multicentre placebo-controlled study. Br J Rheumatol 1996: 35; 664–8

    Article  PubMed  CAS  Google Scholar 

  44. Farr M, Kitas GD, Waterhouse L, et al. Sulphasalazine in psoriatic arthritis: a double-blind placebo-controlled study. Br J Rheumatol 1990; 29: 46–9

    Article  PubMed  CAS  Google Scholar 

  45. Fraser SM, Hopkins R, Hunter JA, et al. Sulphasalzine in the management of psoriatic arthritis. B J Rheum 1992; 32: 923–5

    Article  Google Scholar 

  46. Rahman P, Gladman DD, Zhou Y, et al. The use of sulfasalazine in psoriatic arthritis: a clinic experience. J Rheumatol 1998; 25: 1957–61

    PubMed  CAS  Google Scholar 

  47. Meinardi MM, de Rie MA, Bos JD. Oral cyclosporin A in the treatment of psoriasis: an overview of studies performed in the Netherlands. Br J Dermatol 1990; 122 Suppl. 36: 27–31

    Article  PubMed  Google Scholar 

  48. Mahrle G, Schulze HJ, Brautigam M. Anti-inflammatory efficacy of low-dose cyclosporin A in psoriatic arthritis: a prospective multicentre study. Br J Dermatol 1996; 135: 752–7

    Article  PubMed  CAS  Google Scholar 

  49. Gupta AK, Matteson EL, Ellis CN, et al. Cyclosporine in the treatment of psoriatic arthritis. Arch Dermatol 1989; 125: 507–10

    Article  PubMed  CAS  Google Scholar 

  50. Spadarao A, Riccieri V, Sili-Scavalli A, et al. Comparison of cyclosporin A and Methotrexate in the treatment of psoriatic arthritis: a one-year prospective study. Clin Exp Rheumatol 1995; 13: 589–93

    Google Scholar 

  51. Palit J, Hill J, Capell HA, et al. A multi-centre double-blind comparison of auranofin, intra-muscular gold thiomalate and placebo in patients with psoriatic arthritis. Br J Rheumatol 1990; 29: 280–3

    Article  PubMed  CAS  Google Scholar 

  52. Carette S, Calin A, McCafferty JP, et al. A double-blind placebo-controlled study of auranofin in patients with psoriatic arthritis. Arthritis Rheum 1989; 32: 158–65

    Article  PubMed  CAS  Google Scholar 

  53. Levy J, Paulus HE, Barnett EV, et al. A double blind evaluation of azathioprine treatment in rheumatoid arthritis and psoriatic arthritis [abstract]. Arthritis Rheum 1972; 15: S116

    Google Scholar 

  54. Lee JCT, Gladman DD, Schentag CT, et al. The long-term use of azathioprine in patients with psoriatic arthritis. J Clin Rheumatol 2001; 7: 160–5

    Article  PubMed  CAS  Google Scholar 

  55. Gladman DD, Blake R, Brubacher B, et al. Chloroquine therapy in psoriatic arthritis. J Rheumatol 1992; 19: 1724–6

    PubMed  CAS  Google Scholar 

  56. Maksymowych W, Lambert R, Jhangri GS, et al. Clinical and radiologcial amelioration of refractory peripheral spondyloarthropathies by pulse intravenous pamidronate therapy. J Rheumatol 2001; 28: 144–55

    PubMed  CAS  Google Scholar 

  57. Breedveld FC, Dayer J-M. Leflunomide Mode of action in the treatment of rheumatoid arthritis. Ann Rheum Dis 2000; 59: 841–9

    Article  PubMed  CAS  Google Scholar 

  58. Sharp JT, Strand V, Leung H, et al. Treatment with leflunomide slows radiographic progression of rheumatoid arthritis: results from three randomized controlled trials of leflunomide in patients with active rheumatoid arthritis. Leflunomide Rheumatoid Investigators Group. Arthritis Rheum 2000; 43: 495–505

    Article  CAS  Google Scholar 

  59. Grundmann-Kollmann M, Mooser G, Schraeder P, et al. Treatment of chronic plaque-stage psoriasis and psoriatic arthritis with mycophenolate mofetil. J Am Acad Dermatol 2000; 42: 835–7

    Article  PubMed  CAS  Google Scholar 

  60. Bathon JM, Martin RW, Fleischmann RM, et al. A comparison of etanercept and methotrexate in patients with early rheumatoid arthritis. N Engl J Med 2000; 343: 1586–93

    Article  PubMed  CAS  Google Scholar 

  61. Lipsky PE, van der Heijde DMFM, St. Clair W, et al. Infliximab and methotrexate in the treatment of rheumatoid arthritis. N Engl J Med 2000; 343: 1594–602

    Article  PubMed  CAS  Google Scholar 

  62. Mease P, Goffe BS, Metz J, et al. Enbrel (etanercept) in patients with psoriatic arthritis and psoriasis. Arthritis Rheum 2000; 43 Suppl. 9: S403

    Google Scholar 

  63. Van den Bosch F, Kruithof E, Baeten D. Effects of a loading dose regimen of three infusions of chimeric monoclonal antibody to tumour necrosis factor alpha (infliximab) in spondyloarthropathy: an open pilot study. Ann Rheum Dis 2000; 59: 428–33

    Article  PubMed  Google Scholar 

  64. Dechant C, Antoni C, Wendler J, et al. One year outcome of patients with severe psoriatic arthritis treated with infliximab [abstract]. Arthritis Rheum 2000; 43 Suppl. 9: S212

    Google Scholar 

  65. Brockbank JE, Lapp V, Gladman DD. Infliximab therapy in 15 patients with Psoriatic Arthritis (PsA) [abstract 092]. J Rheumatol 2001; 28 Suppl. 63: 62

    Google Scholar 

  66. Gottlieb A, Kreuger JG, Bright R, et al. Effects of administration of a single dose of humanised monoclonal antobody to CD11a on the immunobiology and clinical activity of psoriasis. J Am Acad Dermatol 2000; 42: 428–33

    Article  PubMed  CAS  Google Scholar 

  67. Abrams JR, Lebwohl MG, Guzzo CA, et al. CTLA4Ig-mediated blockade of T-cell co-stimulation in patients with psoriasis vulgaris. J Clin Invest 1999; 9: 1243–52

    Article  Google Scholar 

  68. Cohen MR, Reda DJ, Clegg DO. Baseline relationships between psoriasis and psoriatic arthritis: analysis of 221 patients with active psoriatic arthritis. J Rheumatol 1999; 26: 1752–6

    PubMed  CAS  Google Scholar 

  69. Elkayam O, Ophir J, Yaron M, et al. Psoriatic arthritis: interrelationships between skin and joint manifestations related to onset, course and distribution. Clin Rheumatol 2000; 19: 301–5

    Article  PubMed  CAS  Google Scholar 

  70. Klinkhoff AV, Gertner E, Chalmers A, et al. Pilot study of etretinate in psoriatic arthritis. J Rheumatol 1989; 16: 789–91

    PubMed  CAS  Google Scholar 

  71. Perlman SG, Gerber LH, Roberts M, et al. Photochemotherapy and psoriatic arthritis: a prospective study. Ann Intern Med 1979; 91: 717–22

    PubMed  CAS  Google Scholar 

  72. Snellman E, Lauharanta J, Reunanen A, et al. Effect of heliotherapy on skin and joint symptoms in psoriasis: a 6 month follow-up study. Br J Dermatol 1993; 128: 172–7

    Article  PubMed  CAS  Google Scholar 

  73. Sukenik S, Giryes H, Halevy S, et al. Treatment of psoriatic arthritis at the Dead Sea. J Rheumatol 1994; 21: 1305–9

    PubMed  CAS  Google Scholar 

  74. Chaudhari U, Romano P, Mulcahy LD, et al. Efficacy and safety of infliximab monotherapy for plaque-type psoriasis: a randomised trial. Lancet 2001; 357: 1842–8

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgements

This work was supported by grants from the Canadian Institute for Health Research and The Arthritis Society. Dr Brockbank was supported by a grant from the University of Toronto/University Health Network Arthritis Centre of Excellence.

Author information

Authors and Affiliations

  1. Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, 399 Bathurst Street, ECW 5-034B, Toronto, Ontario, M5T 2S8, Canada

    John Brockbank &  Dafna Gladman

Authors
  1. John Brockbank
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dafna Gladman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dafna Gladman.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Brockbank, J., Gladman, D. Diagnosis and Management of Psoriatic Arthritis. Drugs 62, 2447–2457 (2002). https://doi.org/10.2165/00003495-200262170-00004

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00003495-200262170-00004

Keywords

Search

Navigation