Psoriatic arthritis in practice : How to detect? How to diagnose? Pascal RICHETTE Hôpital Lariboisière, Paris. Copyright

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1 Psoriatic arthritis in practice : How to detect? How to diagnose? Pascal RICHETTE Hôpital Lariboisière, Paris

2 The patient: a 57 year-old man, with a history of psoriatic nail dystrophy for 10 years Past history: - Dyslipidemia - Hyperuricemia (urate levels: 7 mg/dl) Current oral medications - Atorvastatin (20mg/d) - Acetaminophen (up to 4g/d): acute painful knee

3 C op yr ig ht Physical examination - Overweight (BMI 27 kg/m2) - Blood pressure: normal - Swollen knees (left > right) Is this a Psoriatic Arthritis?

4 op C ig ht yr

5 Why should dermatologists know everything on PsA? Time Earlier diagnosis: better outcomes

6 ACR, 2009 The psoriasis incidence cohort comprised 1,633 subjects. C op yr ig ht (psoriasis diagnosed between January 1, 1970 and December 31, 1999)

7 The cumulative incidence of PsA at 5, 10, and 20 years following psoriasis was 1.7% (95% CI %), 3.1% (95% CI %) 5.1% (95% CI %) the estimated prevalence was 13.8%

8 Tip 1: to know classification criterias for PsA Example: Caspar criteria To meet the criteria of the Classification of Psoriatic Arthritis (CASPAR) Study Group, a patient must have inflammatory articular disease (joint, spine, or enthesial) with 3 points from 5 categories.

9 Semin Arthritis Rheum 2004 Criteria of Fournie Vasey and Espinoza McGonagle Gladman Moll and Wright Bennett ESSG Classification criteria rather than diagnostic criteria +++

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11 C op SF analysis 2000 cells/mm3 No strains (no septic arthritis) No crystals (no gout) yr ig ht Meaning of SYNOVIAL FLUID ANALYSIS: THE Inflammatory arthritis? KEY FOR NOSOLOGIC CLASSIFICATION OF ARTHRITIS

12 Tip 2: clinical examination Peripheral arthritis: dactylitis +++. Examine the feet. Take off the shoes/socks: it might be worthwhile. Enthesitis: ask for the presence of talalgia (pain under the heel) Spinal involvement (5-25%): inflammatory low back pain (Calin/Berlin criteria) Sensibility to NSAIDs +++

13 1) MONO/OLIGO/POLYARTHRITIS C op yr ig ht Peripheral arthritis - mono-/oligoarthritis, DIP joint involvement, dactylitis 2 diag Helliwell et al; JR 2009

14 2) ENTHESITIS Enthesis Frequent involvement of calcaneum: talalgia But also the knees (supra/infra patellaire tendon) Ultrasound and PsA +++

15 Tip 3: Imaging (X-Rays +/- MRI)

16 Screening questionnaires Ideally every psoriasis patient with musculoskeletal pain should be evaluated by a rheumatologist, but this is not practical. Screening questionnaires have been developed as referral tools to help dermatologists identify suitable individuals for referral to rheumatologists. 1. Psoriatic Arthritis Screening and Evaluation (PASE) 2. Psoriasis Epidemiology Screening Tool (PEST) 3. Toronto Psoriatic Arthritis Screening (ToPAS). AIM: to identify individuals that might be at high risk for the development of PsA

17 Fulfilled by the patients Gladman DD et al. Development and initial validation of a screening questionnaire for psoriatic arthritis: The Toronto Psoriatic Arthritis Screen (ToPAS). Ann Rheum Dis 2009;68:

18 Husni ME et al. The PASE questionnaire: pilot testing a psoriatic arthritis screening and evaluation tool. J Am Acad Dermatol 2007 Oct;57(4):581 7; Dominguez PL et al. Validity, reliability, and sensitivity to change properties of the psoriatic arthritis screening and evaluation questionnaire. Arch Dermatol Res 2009 Sep;301(8):573 9.

19 Ann Rheum Dis 2012;0 To compare the performance and utility of the three PsA questionnaires (PASE, PEST, and the ToPAS) versus a full rheumatological evaluation (CASPAR criteria) in psoriasis patients attending dermatology clinics. The assessment of PsA was carried out in two steps. - The first step involved completing the questionnaires (PEST, PASE, ToPAS). - Patients received a full rheumatological evaluation (CASPAR)

20 è Poor sensitivity performance of the three available screening tools

21 Many screening questionnaires to detect PsA not used by dermatologists in everyday practice because of their complexity.

22 The sensitivity and specificity were 91% and 85%, respectively, for the cut-off value of 3. «The EARP is fast and easy for dermatologists to use to identify early symptoms of PsA.»

23 In practice, Have you ever experience pain in knees, wrists, hands or feet? If yes, - were these joints swollen? - Painful during night - Stiffned on the morning If yes: refer the patient to a rheumatologist Some questions you should ask to patients with Psoriasis Have you ever experience back pain? If yes, Morning stiffness >30 minutes Improvement in back pain with exercise but not with rest Awakening in the second half of the night because of back pain Alternating buttock pain. If yes: refer the patient to a rheumatologist

24 CONCLUSIONS. Role of dermatologists: corner stone Diagnostic of PsA can be uneasy Refer the patient to a rheumatologist Avoid overestimation of PsA