Demographics, clinical disease characteristics, and quality of life in a large cohort of psoriasis patients with and without psoriatic arthritis.

INNOVATION: What is already known about the topic: psoriasis (PsO) is a common skin disease with major impact on quality of life (QoL). Patient-reported data on QoL from large number of PsO patients with and without psoriatic arthritis (PsA) are limited. WHAT THIS STUDY ADDS: In a large cohort referred to a university psoriasis center, patients with PsO and concomitant PsA (~30% in this group) had greater degrees of skin and nail involvement and experienced greater negative impacts on QoL. Despite large numbers of patients with moderate-to-severe disease, use of systemic therapy by community practitioners was uncommon. BACKGROUND: PsO and PsA are common diseases that have marked adverse impacts on QoL. The disease features and patient-reported QoL data comparing PsO and PsA patients are limited. OBJECTIVE: To identify and compare demographics, clinical disease characteristics, and QoL scores in a large cohort of PsO patients with and without PsA. METHODS: All PsO patients seen in a psoriasis specialty clinic, named the Center of Excellence for Psoriasis and Psoriatic Arthritis, were enrolled in an observational cohort. Demographic, QoL, and clinical data were collected from patient-reported questionnaires and from physical examinations performed by Center of Excellence for Psoriasis and Psoriatic Arthritis dermatologists and a rheumatologists. Cross sectional descriptive data were collected and comparisons between patients with PsO alone and those with concomitant PsA are presented. RESULTS: A total of 568 patients were enrolled in the database. Mean age of PsO onset was 28 years and mean disease duration was 18 years. Those with family history had an earlier onset of PsO by ~7 years. Mean body surface area involvement with PsO was 14%. Mean body mass index was 30.7. Prevalence of PsA was 29.8%. PsA patients had a higher mean body surface area compared to patients with PsO alone (16.7% vs 13.4%, P<0.05), higher prevalence of psoriatic nail changes (54.4% vs 36%, P<0.0002), and worse QoL scores as assessed by the Short Form-12 (67 vs 52, P<0.00001), Psoriasis Quality of Life-12 questionnaire (62 vs 71, P<0.01), and Routine Assessment of Patient Index Data 3 (2.3 vs 4.7, P<0.01). Strikingly, 49% of patients with PsO had never received any systemic therapy. CONCLUSION: These data highlight that PsO has marked negative impacts on QoL, while those patients with concomitant PsA are affected to a much greater degree. Despite large numbers of patients presenting with moderate-to-severe disease, use of systemic therapy for both PsO and PsA was uncommon.

A novel, short, and simple screening questionnaire can suggest presence of psoriatic arthritis in psoriasis patients in a dermatology clinic.

Delaying diagnosis of psoriatic arthritis (PsA) can lead to poor quality of life and disability. The purpose of this study is to identify simple questions for dermatologists to screen psoriasis patients for psoriatic arthritis. Data regarding psoriasis and arthritis were prospectively collected by a questionnaire from all psoriasis patients. Patients with joint-related symptoms were assessed by a rheumatologist for the presence of PsA. Retrospectively, the sensitivity and specificity, positive and negative predictive values, likelihood ratios, and posttest probabilities of various screening questions were calculated to identify the best combination of parameters. Of 517 patients seen in dermatology clinic, 117 (22.63 %) were found to have PsA. Four screening questions ("Do you have a history of joint pain or swelling?" "Do you have stiffness in the morning?" "Have you had X-rays taken of your joints?" "Do you have PsA?") with psoriatic nail changes demonstrated high sensitivity and specificity for predicting PsA. A cutoff of three out of these five parameters correctly classified patients with and without PsA with 86.9 % sensitivity, 71.3 % specificity, 53 % positive predictive value (PPV), 93.6 % negative predictive value (NPV), and area under the curve (AUC) of 0.87. Likelihood ratios for individual parameters varied between1.6 and 3.7, and with a combination of certain parameters, the posttest probability of PsA was 76 %. This is a preliminary data on a potential screening questionnaire which can help dermatologists quickly screen for PsA. All patients not having evaluated by a rheumatologist could have led to underdiagnosis of PsA and potential misclassification. Psoriasis patients seen at a specialty clinic may introduce a referral bias.

CD28/B7 interactions deliver a unique signal to naive T cells that regulates cell survival but not early proliferation.

CD28/B7 ligation provides costimulatory signals important for the development of T cell responses. In the present study, we examined whether CD28/B7 interactions have a specialized role in the regulation of cell cycle progression and sustained T cell proliferative responses in naive T cell populations using TCR transgenic mice. CD28-mediated signaling was shown to be uniquely capable of regulating cell survival compared with TCR-mediated signaling. Increasing the strength of the TCR-mediated signal 1 increased early proliferative responses, but had no effect on sustained cell survival. In contrast, CD28 ligation, signal 2, was not required for early proliferative responses, but dramatically influenced long term T cell survival. The increased cell survival after CD28 ligation was not due to increased IL-2 production, but was linked to up-regulation of Bcl-xL. The Bcl-xL protein could not be induced following increased TCR cross-linking in the absence of CD28 signaling. In addition, survival of T cells from Bcl-xL transgenic mice was not inhibited by blocking CD28 ligation, suggesting that CD28-induced T cell survival is regulated by Bcl-xL expression. Together, these results suggest that the unique role of CD28 signaling is not to costimulate the initial activation of naive T cells, but is, in fact, to sustain the late proliferative response and enhance long term cell survival.