The classification of psoriatic arthritis: what will happen in the future?

Some patients with psoriasis have articular involvement that falls within the spectrum of seronegative spondyloarthropathies. This form of arthritis has been classified by Moll and Wright into five clinical subsets. Recently this classification has been contested. We review the historical evolution of the concept of psoriatic arthritis and discuss its clinical spectrum.

Prevalence and clinical features of juvenile psoriatic arthritis in 425 psoriatic patients.

The aim of this study was to define the prevalence and clinical features of Juvenile Psoriatic Arthritis (JPsA). According to the definition by Ansell and Bywaters, we identified the population at risk of JPsA in 425 patients with psoriasis with onset occurring before the age of 31. Among these, 85 were younger than 16 years. Five patients with JPsA were found (prevalence 1.0%). All had a family history of psoriasis and onset of skin disease in the age range 10 to 20 years. Arthritis preceded psoriasis in two cases, while in the remainder the converse occurred. The interval between the onset of cutaneous and articular involvement never exceeded 8 years. Previous studies reported the low frequency of JPsA among juvenile arthritides. Our data appear to underline the rarity of the arthritic form.

[Erythema nodosum: epidemiology, etiology, pathogenesis, clinical picture and therapy]. / L'eritema nodoso: epidemiologia, etiologia, patogenesi, quadro clinico e terapia.

Erythema Nodosum (EN) is a painful nodular syndrome, most likely of immunologic origin, which involves dermis and subcutaneous tissue. Pathologic process is that of vasculitis of the small veins with inflammation of the septa of the fat lobules (septal panniculitis). It is generally agreed that EN represents a hypersensitive reaction to a variety of antigenic stimuli and thus may be observed in the course of several diseases (infections, immunopathies, malignancies) as well as during drug therapy (with halides, sulfonamides, oral contraceptives). In approximately 50 per cent of the cases an underlying etiology is not apparent (idiopathic form). The clinical picture is always that of a nonspecific systemic illness with low-grade fever (in 60%), malaise (in 67%), arthralgias (in 64%) and arthritis (in 31%), while when there is an associated illness, this may dominate the presentation. Laboratory tests show no specific abnormalities except for those related to an underlying disease. Treatment of idiopathic form includes nonsteroidal antiinflammatory agents which usually ease the discomfort. Steroids, although highly effective, are not recommended because of the benign nature of EN and the danger of disseminating an underlying disease.

Psoriasis and psoriatic arthritis. Dermatological and rheumatological co-operative clinical report.

Six hundred and forty-seven patients with psoriasis were studied in order to define prevalence and clinical features of psoriasis and psoriatic arthritis. After medical history review all patients were observed by a dermatologist and a rheumatologist. Successive laboratory tests and radiological and scintiscan examinations of joints were also performed. Diagnosis of arthritis was made according to Wright and Moll. In our district, the prevalence of psoriasis in respect to other dermatological diseases was 1.86%. Vulgaris pattern occurred in 85% of the total cases while eruptive was found in 10.5%. Erythrodermic and pustular forms were uncommon, occurring in 2.47% and in 1.23%, respectively. In 84.8% of the total cases, psoriasis onset was clinically evident while in 10.8% it affected non-evident cutaneous sites. Onycopathic onset occurred in 4.3%. Altogether 138 psoriatic patients exhibited arthritis and spondylitic and polyarticular patterns were very common (occurring in 42.7% and 33.3%, respectively). Psoriasis antedated arthritis in 68.4% of the cases but followed it in 21%. Synchronous onset occurred in 10.8%. The data obtained strengthen those of our previous reports. In particular, the marked articular involvement of psoriatic patients is confirmed. Moreover, our results, when compared with data of other authors, show a different distribution among the arthritic subtypes.

The management of 138 psoriatic arthritic patients.

Clinical experience obtained in the management of 138 patients of psoriatic arthritis is reported. The correct recognition of arthritic subtype (according to Moll and Wright classification) always resulted essentially in the choice of the therapy. Our programme included rehabilitative, pharmacologic and surgical approaches. Our data suggest that psoriatic arthritis is a mild articular disease when compared to other affections such as rheumatoid arthritis or ankylosing spondylitis. Notwithstanding an accurate therapeutical programme, it is necessary to control atypical cases which not infrequently can occur.

The clinical spectrum of psoriatic spondylitis.

Forty-three psoriatic patients with spondylitic involvement (19 women and 24 men, mean age 41 years) have been reviewed. Three different subsets were recognized. The first (PS1), with predominant involvement of the axial skeleton, occurred in 22 (seven women and 15 men, mean age 39). The second (PS2) and the third (PS3) showed an overlap of spondylitis and peripheral articular disease. In PS2 this consisted of distal interphalangeal (DIP) arthritis (five women and three men, mean age 41), while in PS3 there was symmetrical polyarthritis (seven women and six men, mean age 42). Spinal involvement, present in every case, was characterized by unilateral and asymmetrical syndesmophytes, often nonmarginal and randomly affecting the vertebral column. Sacroiliitis, absent in the PS2 subset, was present in 15 of the PS1 and in two of the PS3 subgroup and was bilateral in six and unilateral in 11. The HLA-B27 antigen, absent in the PS2 subgroup, was found in 12 of the PS1 and in two of the PS3 subset. It was associated with sacroiliitis in 13 cases and with spondylitis without sacroiliitis in only one case. Nail changes were recorded in 30% of the total cases and showed a strict relationship with the PS2 subset (40%). Extra-articular symptoms, consisting almost exclusively of ocular involvement, occurred in three patients only (two cases of conjunctivitis and one of acute anterior uveitis). The clinical course of psoriatic spondylitis appeared less disabling than that of the idiopathic form.

Psoriatic arthritis in psoriatic patients.

One hundred and eighty patients with psoriasis have been studied in the Neapolitan area to find the prevalence of arthritis in psoriasis. Wright and Moll's criteria for the diagnosis of arthritis were applied. Of 180 psoriatic patients, 62 exhibited arthritis (34.4% of total cases) According to Moll and Wright's five broad clinical forms of arthritis, the following distribution was found: polyarticular in 38.7% of arthritic patients, mono-oligoarticular in 16.1%, distal interphalangeal in 7.5%, deforming or mutilans in 2.3% and spondylitic and/or sacro-iliitic in 20.9%. In 14.5% of arthritic patients an overlap of the spondylitic form and peripheral involvement was also found. Stratification by age of patient populations shows that cutaneous pathology has a homogeneous distribution in the various age decades, while joint symptoms are seen maximally in the sixth decade and are absent in the first two decades. The relationship between the onset of skin lesions and joint pathology demonstrates that skin lesions preceded arthritis in 64.5% of the cases, whilst arthritis antedated psoriasis in only 19.35%. In 16.1% of cases psoriasis and arthritis began almost simultaneously. Nail changes were present in 63% of arthritic patients and in 37% of psoriatic subjects without arthritis. Furthermore, in 88% of arthritic patients in whom arthritis preceded skin lesions, nail changes antedated the onset of clinically apparent psoriasis. Extra-articular features were not found. This absence might be associated with the usual seronegativity for rheumatoid factor in psoriatic arthritis, also confirmed in this survey.

Supportive laboratory findings in psoriatic arthritis.

Serum copper, iron and ceruloplasmin concentrations were determined in 45 subjects (22 males and 23 females, medium age 50.3, range 25-76) diagnosed as psoriatic arthritic patients (20 with poliarticular, 12 with mono-oligoarticular and 13 with spondyloarticular form), in 63 patients (30 males and 33 females, medium age 32.4, range 10-78) with psoriasis, and in 60 blood donors (32 women and 28 men) as reference group. Mean serum copper, iron and ceruloplasmin was significantly increased (p less than .001) in psoriatic arthritis as compared with controls or subjects with psoriasis alone. The number of synovial joints affected was significantly correlated to changes in these serum parameters. Indeed, serum copper, iron and ceruloplasmin were found to be significantly different from that of normals in the polyarticular subgroup (p less than .001), while only copper and ceruloplasmin were different in the mono-oligoarticular form (p less than .001 and p less than .01 respectively). No significant changes were found in a spondyloarticular subgroup. In the polyarticular subgroup a direct correlation was found between another disease activity marker (e.g. ESR) and serum changes in iron, ceruloplasmin and copper (p less than .001). Our data indicate that psoriatic arthritis is a multifaceted disease: the polyarticular form behaves like seronegative rheumatoid arthritis, while the monoarticular forms shows a lesser involvement of serum iron; spondylitic arthritis does not show any significant change in serum copper, ceruloplasmin and iron concentrations.