Explore PsA clinical manifestations in the hall of statues
LECTURE SERIES WITH DR. SAAKSHI KHATTRI
Get insights on the clinical manifestations of PsA
Learn how to recognize PsA clinical manifestations as Dr. Khattri delves deep into the features of psoriasis, nail psoriasis, axial involvement, dactylitis, and more.
Get to know the clinical manifestations of PsA
- Sacroiliitis and spondylitis
- Extra-musculoskeletal
- Peripheral articular manifestations
- Associated conditions
Sacroiliitis and spondylitis
Sacroiliitis and spondylitis
Prevalence: 25%–70%1,*
Sacroiliitis is an inflammation of one or both sacroiliac joints.1 In PsA, sacroiliitis is usually asymmetrical with non-marginal syndesmophytes and paravertebral ossification occurring more in the cervical spine, whereas sacroiliitis in axSpA is symmetrical with marginal syndesmophytes having more involvement in the lumbar joint.1
Spondylitis is inflammation in the insertion of tendons and ligaments into bone with contiguous inflammation of the substance of bone. Spondylitis affects 7%–32% of patients with PsA and is typically less severe than axSpA.1-3
*Prevalence of axial involvement in PsA.
Image copyright: Case courtesy of Dr Lýdia Priskin, Radiopaedia.org. From the case rID: 36996 Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org. From the case rID: 9152
Extra-musculoskeletal
Psoriasis
Prevalence: 90%2
An auto-immune skin disease that features red, itchy, scaly skin on the5,6:
- Knees
- Elbows
- Trunk
- Scalp
Extra-musculoskeletal
Nail psoriasis
Prevalence: Up to 80%4
An auto-immune skin condition that includes a spectrum of nail dystrophies and can be associated with the activity and progression of PsA, with symptoms ranging from4:
- Nail pitting
- Onycholysis
- Nail discoloration
- Subungual hyperkeratosis
- Splinter hemorrhage
Peripheral articular
Peripheral arthritis
Prevalence: Up to 100%12
Arthritis of the peripheral joints associated with13:
- Synovial inflammation
- Bony erosion
- Pathologic new bone formation
This arthritis can be symmetrical or asymmetrical and oligo- or polyarticular and involves the larger joints of the arms and hands.12 Compared with axSpA, patients with PsA have more peripheral joint involvement and a lower prevalence of HLA-B27.14
Peripheral articular
Enthesitis
Prevalence: 35%–50%10
The inflammation of the insertion of ligaments, tendons, or joint capsules into bone, which can be painful.10 This condition is an important manifestation of PsA and typically precedes the development of the skeletal manifestations in these patients.11
Image copyright: https://www.researchgate.net/figure/enthesitis-of-the-Achilles-tendon-Note_arrows-indicate-severe-inflamation-of-the_fig3_305322505
Peripheral articular
Dactylitis
Prevalence: 16%–49%7
Dactylitis is the uniform and extensive swelling of soft tissues surrounding the phalangeal joint, and often occurs early in the PsA disease course.7,8 Dactylitis in PsA is usually asymmetrical and involves the feet more than the hands.7,8 Also, there is a high prevalence of dactylitis in patients with PsA compared with patients with axSpA.9
Image copyright: https://www.the-rheumatologist.org/article/case-report-a-psoriasis-arthritis-patient-with-dactylitis-enthesits/?singlepage=1
Associated conditions
Uveitis
Prevalence: 7%–20%15
An inflammation of the uveal tract that features15,16:
- Dry eyes
- Redness
- Pain
- Floaters
- Photophobia
- Blurry vision
The risk of developing uveitis is generally lower in PsA compared with axSpA. Anterior uveitis is more common in patients with PsA compared with posterior uveitis and pan-uveitis and is usually insidious in onset as well as continuous, prolonged, and bilateral.15,17,18
Associated conditions
IBD
Prevalence: 4%19
Chronic inflammation of the gastrointestinal tract.18
Symptoms18:
- Persistent diarrhea
- Abdominal pain
- Rectal bleeding
- Weight loss
- Fatigue
There is a 1-4-fold increased risk of IBD in PsA compared with the general population, and it is more common in patients with axial PsA than in those with peripheral PsA.18
Important distinctions are emerging about which cytokines contribute to various clinical manifestations
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Clinical features
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- Poddubnyy D, Jadon DR, Van den Bosch F, et al. Axial involvement in psoriatic arthritis: An update for rheumatologists. Semin Arthritis Rheum. 2021;51(4):880-887. doi:10.1016/j.semarthrit.2021.06.006
- Mease PJ, Armstrong AW. Managing patients with psoriatic disease: the diagnosis and pharmacologic treatment of psoriatic arthritis in patients with psoriasis. Drugs. 2014;74(4):423-441. doi:10.1007/s40265-014-0191-y
- Ogdie A, Weiss P. The epidemiology of psoriatic arthritis. Rheum Dis Clin North Am. 2015;41(4):545-568. doi:10.1016/j.rdc.2015.07.001
- Sobolewski P, Walecka I, Dopytalska K. Nail involvement in psoriatic arthritis. Rheumatologia. 2017;55(3):131-135. doi:10.5114/reum.2017.68912
- Prignano F, Ricceri F, Pescitelli L, et al. Itch in psoriasis: epidemiology, clinical aspects and treatment options. Clin Cosmet Investig Dermatol. 2009;2:9-13.doi: 10.2147/ccid.s4465
- Centers for Disease Control and Prevention. Psoriasis. https://www.cdc.gov/psoriasis/index.htm. Published August 18, 2020. Accessed March 21, 2022
- Kaeley GS, Eder L, Aydin SZ, et al. Dactylitis: A hallmark of psoriatic arthritis. Semin Arthritis Rheum. 2018;48(1):263-273.
- Helliwell PS, Firth J, Ibrahim GH, et al. Development of an assessment tool for dactylitis in patients with psoriatic arthritis. J Rheumatol. 2005;32(9):1745-1750.
- Lopez-Medina C, Molto A, Sieper J, et al. Prevalence and distribution of peripheral musculoskeletal manifestations in spondyloarthritis including psoriatic arthritis: results of the worldwide, cross-sectional ASAS-PerSpA study. RMD Open. 2021;7:e001450. Doi:10.1136/rmdopen-2020-001450.
- Kaeley GS, Eder L, Aydin SZ, Gutierrez M, et al. Enthesitis: A hallmark of psoriatic arthritis. Semin Arthritis Rheum. 2018;48(1):35-43. doi:10.1016/j.semarthrit.2017.12.008
- Belasco J, Wei N. Psoriatic arthritis: what is happening at the joint?. Rheumatol Ther. 2019;6(3):305-315. doi:10.1007/s40744-019-0159-1
- Felquer Acosta ML, FitzGerald O. Peripheral joint involvement in psoriatic arthritis patients. Clin Exp Rheumatol. 2015;33:S26-S30
- Mortezavi M, Thiele R, Ritchlin C. The joint in psoriatic arthritis. Clin Exp Rheumatol. 2015;33(5 Suppl 93):S20-S25
- Benavent D, Plasencia-Rodríguez C, Franco-Gómez K, et al. Axial spondyloarthritis and axial psoriatic arthritis: similar or different disease spectrum?. Ther Adv Musculoskelet Dis. 2020;12:1759720X20971889. Published 2020. doi:10.1177/1759720X20971889
- Fotiadou C, Lazaridou E. Psoriasis and uveitis: links and risks. Psoriasis (Auckl). 2019;9:91-96. Published 2019 Aug 28. doi:10.2147/PTT.S179182
- Guly CM, Forrester JV. Investigation and management of uveitis. BMJ. 2010;341:c4976. Published 2010. doi:10.1136/bmj.c4976
- Fraga NA, Oliveira Mde F, Follador I, et al. Psoriasis and uveitis: a literature review. An Bras Dermatol. 2012;87(6):877-883. doi:10.1590/s0365-05962012000600009
- Chia AYT, Ang GWX, Chan ASY, et al. Managing psoriatic arthritis with inflammatory bowel disease and/or uveitis. Front Med (Lausanne). 2021;8:737256. Published 2021. doi:10.3389/fmed.2021.737256
- Bergman JM, Zuegar P, Song J, et al. Inflammatory bowel disease is associated with a substantial economic burden in patients with psoriatic arthritis and in patients with ankylosing spondylitis (Abstract 285). 2018; ACR/ARHP Annual Meeting. https://acrabstracts.org/abstract