Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Psoriatic Arthritis



- See: Spondyloarthropathies

- Discussion:
    - psoriasis affects 1-2 % of U.S. population & typically presents w/ well-defined erythematous scaly plaques;
    - only a minority of pts with psoriasis develop arthritis;
    - when arthritis develops, it most often is an asymmetrical oligoarthritis, which at times may be quite destructive;
    - some patients may develop spondylitis (usually will have HLA-B27 antigen);
    - incidence of MV prolapse is high ( > 50%);


- Clinical Presentation:
    - clinical course of psoriasis is long-term, w/ characteristic relapses & remissions;
    - age: presents in 3rd-4th decade;
    - gender: men and women are affected in equal numbers;
         - skin:
                 - circumscribed erythrematous maculopapules or silver scaling;
                 - activity of skin lesions may or may not correlate w/ of peripheral arthritis;
                 - skin lesions may appear similar to Reiter's Syndrome;
                 - subcutaneous nodules are absent;
                 - nail deformities: 80% of patients will have nail lesions, including nail pits and onycholysis;
         - joints:
                 - involves the small joints of feet and hands more than any other joint;
                 - dactylitis may involve degree of tenosynovitis as well;
                 - severe cases may progress to arthritis mutilans, w/ widespread destruction;
         - foot:
                 - calcaneal spurs, sclerosis, & periarticular erosions of MP joints;
                 - spontaneous fusions do not occur;
         - hand & wrist:
                 - may have fusiform swelling of digits & nail changes;
                 - asymmetric joint involvement which affects terminal IP joints;
                 - DIP joint involvement.
                 - marked tendency for hand joints to becomes stiff;
                 - MP joints:  become stiff in extension, rather than stiff in flexion as in RA;


- Radiographic Features:
    - cartilage loss & erosions resemble changes seen in RA;
    - IP Joints:
         - symmetrical bony involvement with a predilection for DIP joints;
         - erosive damage in the IP joints (presence of pencil-in-cup change);
         - jonit destruction, widened joint spaces, & well defined adjacent bony surfaces;
         - advanced cases reveal a "pencil in cup" deformity, tuft resorption, and eventual ankylosis;
         - interphalangeal joint of the great toe is often involved;
         - there is generally a lack of juxta-articular osteopenia;
         - erosions are often para-marginal (where as in RA erosions are marginal);
    - Spine & SI Joint:
         - beaklike nonmarginal syndesmophytes are found (also seen in Reiter's);
         - bilateral sacroilitis occurs in 10-30% of pts;
         - paraspinal ligamentous calcification or ossification may occur similar to AS;


- Labs:
    - RF & antinuclear AB test (ANA) are neg;


- Treatment:
    - non-steroidals and occasionally methotrexate or oral colchicine;
    - sulfasalazine 1-2 gm per day has excellent efficacy;
    - systemic steroids should be used with caution since these may cause skin lesions to become pustular;
    - topical treatments:
           - anthralin, corticosteroids, keratolytic agents;
    - DIP joints are frequently spontaneously fused;
    - nail deformity:
           - w/ pitting, longitudinal ridging, consider intralesional corticosteroids;
           - triamcinolone acetonide 5 mg/ml injected into nail fold q3-4 weeks;
    - postoperative infection rates are higher than seen w/ RA



Total knee arthroplasty in patients with psoriasis.

Psoriatic arthritis in the hand.

The psoriatic hand

Sulphasalazine in the management of psoriatic arthritis.     

Comparison of sulfasalazine and placebo in the treatment of psoriatic arthritis. A Department of Veterans Affairs Cooperative Study.

Psoriatic arthritis: a quantitative overview of therapeutic options. The Psoriatic Arthritis Meta-Analysis Study Group.

Sulphasalazine in psoriatic arthritis: a randomized, multicentre, placebo controled study.     



Alternatives to Total Knee Replacement: Autologous Hamstring Resurfacing Arthroplasty



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, August 21, 2012 4:41 pm

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