Psoriatic Arthritis
Clinical Features and
Epidemiology
Dafna D. Gladman MD, FRCPC
Director, Psoriatic Arthritis Program,
University Health Network
Centre for Prognosis Studies in the Rheumatic Diseases
Toronto Western Hospital
Toronto Western Hospital
Psoriatic Arthritis
Definition
 An
inflammatory arthritis
 Associated with psoriasis
 Usually seronegative for
rheumatoid factor
Psoriatic Arthritis Clinical Patterns
 Distal
predominant (Distal interphalangeal joints of fingers and toes).
 Oligo-articular (<5 joints) often in an
asymmetric distribution.
 Poly-articular (5 joints), rheumatoid
arthritis-like.
 Spinal Involvement.
 ‘Arthritis Mutilans’.
Moll & Wright, Seminars Arthritis Rheum 1973;32:181
Psoriatic Arthritis Patterns


Oligoarthritis
Distal Arthritis
Psoriatic Arthritis Patterns
Polyarticular Pattern
Psoriatic Arthritis Patterns
Arthritis Mutilans
Psoriatic Arthritis Patterns
Arthritis Mutilans
Telescoping
Psoriatic Spondyloarthropathy

Psoriatic Spondyloarthropathy


Dactylitis in PsA
Edema in PsA
Heel Lesions in PsA
Achilles Tendon Spur
Achilles Tendon Insertion Erosion
Plantar Spur
Other Radiological Features of PsA
Periostitis
Tuft resorption
Hidden Psoriasis
PsA Reported Series*
Feature
Year
Site
No.
M/F
Age
J<S
SI
Asymm
Sym.
Distal
Back
Mutilans
Roberts Kammer Gladman
1976
Leeds
168
67/101
40
?
NA
?
78
17
?
5
1979
Boston
100
45/55
39
30
11
53
28
10
2
7
1987
Toronto
220
104/116
37
17
26
21
48
12
3
16
*Includes only series with > 100 Patients
TorreAlonso
1991
Spain
180
99/81
39
15
20
45
42
1
7
5
Veale
Jones
1994
Leeds
100
59/52
34
?
14
43
33
16
4
2
1994
Bath
100
43/57
38
18
16
26
63
1
6
4
Psoriatic arthritis: A distinct entity ?
 Dutch
study found no association
between psoriasis and polyarthritis.
 No association between HLA antigens and
seronegative polyarthritis with psoriasis.
 No radiological features in seronegative
polyarthritis with psoriasis.
– van Romunde LKJ, et al.Rheumatology
International 1984;4:55-73.
?
fortuitous association
– Cats A. Cutis 1990;46:323-329.
Psoriatic arthritis
Epidemiological Evidence
 Prevalence
of psoriasis in the
general population: 0.1-2.8%.
 Prevalence of psoriasis in arthritis
patients: 2.6-7.0%.
 Prevalence of arthritis in the general
population: 2-3%.
 Prevalence of arthritis in psoriatic
patients: 6-42%.
Psoriatic arthritis: A distinct entity !
 Previous
population studies.
 Epidemiological studies.
 Dutch study found DIP joints disease
more common in patients with
seronegative polyarthritis and
psoriasis.
 A distinct form of arthritis, with
different patterns, associated with
psoriasis.
A comparison between
Psoriatic Arthritis and Rheumatoid Arthritis
DIP Involvement
Symmetry
Erythema of joint
Back Involvement
Skin Lesions
Nail Lesions
Dactylitis
Enthesitis
Rheumatoid nodules
Rheumatoid Factor
HLA-B*27
Psoriatic
Arthritis
Rheumatoid
Arthritis
Common
Less Common
Common
Common
Always
Common
Common
Common
Never
Uncommon
40-50%
Uncommon
Common
Uncommon
Uncommon
Uncommon
Uncommon
Uncommon
Uncommon
Common
Common
4-8%
Assessment of Tenderness
Psoriatic Arthritis Vs. Rheumatoid Arthritis
RA
PsA
N=51 N=50
Test
P Value
 2=9.99 0.0016
t=5.23 <0.0001
Fibromyalgia (N)
29
12
Dolorimeter (Kg)
Tender Points
4.77
6.60
Dolorimeter (Kg)
Control Points
5.99
7.58
t=5.18
Dolorimeter (Kg)
Active Joints
4.19
6.78
t=10.18 <0.0001
Buskila D, et al. J Rheumatol 1992;19:1115-9.
<0.0001
Psoriatic Arthritis
Classification
Classified with the Seronegative
Spondyloarthropathies:
– It is usually seronegative for
rheumatoid factor.
– It may be associated with a
spondyloarthropathy.
– It is associated with HLA-B27.
Differentiating PsA from other SpA
Feature
PsA
AS
M:F
Age onset
Peripheral
Distribution
1:1
35-45
96%
Any
9:1
20
25%
Axial
40%
~50%
100%
>90%
Dactylitis
Enthesitis
Sacroiliitis
HLA-B*27
ReA
IBD
8:1
1:1
20
Any
90%
Common
Lower
Lower
Lower limbs
limbs
limbs
35%
Uncommon Common Uncommon
Common Common Common Unommon
80%
80%
20%
40%
Psoriatic Arthritis
Prevalence
 Exact
prevalence unknown.
 Estimated figures vary from 0.1% in
Rochester Minnesota to 1.4% in the Faroe
Islands.
 Recent Survey by National Psoriasis
Foundation suggests prevalence of 1.4%
of general population in the US.
 Recent study from Toronto suggests a
prevalence of 2.5%.
Psoriatic Arthritis
Prevalence among people with psoriasis
Author (yr)
Centre
No. Ps. Pts.
% PsA
Leczinsky (1948)
Sweden
534
7
Vilanova (1951)
Barcelona
214
25
Little (1975)
Toronto
100
32
Scarpa (1984)
Napoli
180
34
Stern (1985)
Boston
1285
20
Zaneli (1992)
Winston-Salem
459
17
Barisic-Drusko (1994)
Osijek region
553
10
Salvarani (1995)
Regio Emilia
205
36
Shbeeb (2000)
Mayo Clinic
1056
6.25
Brockbank (2001)
Toronto
126
31
NPF (2002)
US
4.4 m
23
Psoriatic arthritis
Clinical Outcome
PsA is much more serious than previously
recognized.
20% of patients with PsA develop clinical
deformities and damage, resulting in
functional disability.
5 deformities were detected in 55% of
patients after 10 years of follow-up.
Gladman DD et al. Quart J Med 1987;62:127.
Torre Alonso et al. Brit J Rheumatol 1991;30:245.
The University of Toronto
Psoriatic Arthritis Program
Development of Deformities during follow-up
Duration
Visit
<1 yr
1-5 yr
6-10 yr
>10 yr
1st Last 1st Last 1st Last 1st Last
No Deformities 53% 51% 70% 50% 64% 35% 59% 22%
< 5 deformities 28% 30% 20% 28% 17% 28% 26% 23%
5 deformities
19% 19% 10% 22% 19% 37% 15% 55%
Gladman DD. Baillière’s Clinical Rheumatology1994;8:379.
Prognostic Indicators in PsA
Clinical Indicators of Progression
 Progression of damage defined by a
change in damage state:
– State 1 = 0 damaged joints
– State 2 = 1-4 damaged joints
– State 3 = 5-9 damaged joints
– State 4 =  10 damaged joints
 Analysis
by model for rate of
transition between damage states.
Gladman DD et al. J Rheumatology 1995;22:675.
Prognostic Indicators in PsA
Multivariate model for Clinical Indicators
of Clinical Progression*
Variable
> 4 Effusions
ESR < 15
Rx
Steroids
Relative Risk
1 to 2 2 to 3 3 to 4
1.6
0.61
1.78
1.55
1.6
0.61
1.78
1.55
1.6
1.78
1.55
*Based on clinical features at presentation
Gladman DD et al. J Rheumatology 1995;22:675.
2
P value
5.7
6.68
7.8
5.46
0.017
0.01
0.005
0.019
Prognostic Indicators in PsA
Multivariate Model for Clinical Damage
Variable
B22
B27
B27xDR7
Relative Risk
1 to 2 2 to 3 3 to 4
0.19
0.19
0.19
1.06
1.06
1.06
2.47
2.47
2.47
X2
P value
0.06
5.39
0.002
0.81
0.02
B39
DR7
DQw3
7.05
0.83
1.63
0.83
0.63
0.83
1.63
16.40
0.63
6.86
<0.001
0.43
<0.001
DQw3xDR7
> 4 Efusions
ESR < 15
High Past Rx
Steroids
0.54
1.27
0.83
2.25
1.58
0.54
1.27
0.83
2.25
1.58
0.54
1.27
0.83
2.25
1.58
3.09
1.18
1.91
8.10
6.73
0.08
0.28
0.17
0.004
0.0001
Gladman DD & Farewell VT. Arthritis Rheum 1995;38:845.
Gladman DD, et al. J Rheumatol 1998;25:730.
Prognostic Indicators in Psoriatic Arthritis
Final Multivariate Model for Time Varying Clinical Indicators
Factor
No. AJ
 FC
Male gender
Current Damage
Initial ESR
Pre Clinic Rx
Relative
Damage Rate
1.04
1.86
0.65
3.95
0.61
1.83
95% CI
P value
1.02,1.07 <0.001
1.05,2.16 0.027
0.47,0.92 0.013
2.52,6.20 <0.001
0.42,0.90 0.013
1.20,2.79 0.005
Gladman DD, Farewell VT. J Rheumatol 1999;26:2409
Outcome in Psoriatic arthritis
Mortality Studies


PsA patients are at an increased risk of
death.
Overall risk is 1.62 that of Ontario
Residents.
» 1.66 for women, 1.59 for men


Causes of Death are similar to general
population.
Risk of death is related to previously
active and severe disease.
Wong K, et al. Arthritis Rheum 1997;40:1868-7.
Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.
Mortality in Psoriatic Arthritis
Primary causes of death in 53 patients
Primary Cause
N (%)
Circulatory system
Myocardial Infarction
17 (36.2)
13 (27.6)
Cerebrovascular accident
CHF/arteriosclerosis
Respiratory system
Pneumonia
2 ( 4.3)
2 ( 4.3)
10 (21.3)
7 (14.9)
COPD
Digestive system (liver)
3 ( 6.4)
4 ( 8.5)
Malignant neoplasms
8 (17.0)
Injuries/poisoning
7 (14.9)
Other
1 ( 2.1)
Total known cause
47 ( 100)
0.9
0.8
0.6
0.7
All patients
0.5
Survival Probability
1.0
Survival in Psoriatic Arthritis
0
5
10
15
Time Since Clinic Entry (Years)
20
Mortality in Psoriatic Arthritis
Prognostic Factors: Final Multivariate Model
Factor
Relative Confidence
P
risk
interval
value
Prior Medication
1.83
0.93, 3.60
Radiological damage
3.88
1.32,11.35 0.014
ESR > 15
3.77
1.31,10.83 0.013
Nail changes
0.33
0.14, 0.76
Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.
0.079
0.009
Remission in Psoriatic Arthritis




Summary
Remission occurred in 17.6% of our PsA
patients.
Male gender and less active and severe
arthritis at presentation to Clinic were
associated with remission.
Only 6 (8.7%) of the PsA patients
sustained “true remission”,
35 (52%) had subsequent flares.
Gladman DD et al. J Rheumatol 2001;28:1045-8.
Psoriatic Arthritis
Prognostic Factors

Progression of Damage:
 High effusion count at presentation
 High joint count at each visit
 High medication level at presentation
 Low ESR is “protective”

Death:
 Elevated ESR
 High prior medication level
 Radiological Damage

Remission
 Male Gender
 Low joint count at presentation
Psoriatic Arthritis
Not just skin and joints!
An inflammatory arthritis associated with
psoriasis.
 More common than previously thought.
 About one fifth of the patients have a
severe debilitating disease, although
some patients achieve remission.
 Earlier studies suggesting that PsA was a
mild disease included patients with early
disease.

Psoriatic Arthritis Program
Dr. Dafna Gladman - Director
Cathy Schentag MsC
Research Associate
CPSRD, TWH
Nicole Anderson, BSc
Research Assistant
CPSRD, TWH
Fawnda Pellett, BSC
Research Technologist
CPSRD, TWH
Vern Farewell, PhD
Biostatistician
MRC, Cambridge, UK
Janice Husted, PhD
Epidemiologist
Waterloo, Ontario
Richard Cook, PhD
Biostatistician
Waterloo, Ontario
Research Fellows, Rheumatology Residents, Students,Patients
Psoriatic Arthritis Program - Support
 Ontario
Ministry of Health
 Medical Research Council / Canadian
Institutes of Health Research
 The Arthritis Society
 Centre for Prognosis Studies in The
Rheumatic Diseases
 University of Toronto / University Health
Network Arthritis Centre of Excellence
 Krembil Foundation
 PsA Patients