Psoriatic Arthritis • 50% spondylitis
(source: Harrisons pp1998-1999)
Chronic, inflammatory arthritis affecting 5-42% of
people with psoriasis.
Etiology and Pathogenesis
FACTORS:
• Infections (strep, HIV-fulminant)
• Trauma
• Increased cellular and humoral immunity
• Cytokines
• Adhesion molecules
• Abnormal fibroblasts, PMNs, dendritic
cells, and keratinocytes
• Genetics:
o Psoriatic Spondylitis: HLA-17,
CW6, and/or HLA-B27
o Peripheral Arthritis: HLA-B27,
B38, B39, and DR7
Clinical Manifestations
Three Major Types of PsA
1. Asymmetric Inflammatory Arthritis (47%)
• Psoriasis precedes arthritis
• M=F
• Morning stiffness
• PIP and DIP involvement
• Dactylitis “sausage-shaped digits”
• Onychodystrophy: lysis, ridging,
and pitting of nails
• Good prognosis
• 25% develop progressive
destructive disease
• 33% devop ocular Sxs:
conjunctivitis, iritis, episcleritis
2. Symmetric Arthritis (25%)
• Psoriasis and inflammatory arthritis
occur simultaneously
• M(1)=F(2)
• Similar to RA, but with
onychodystrophy, and no sub-q
nodules
• Morning stiffness
• DIP, PIP, MCP,MTP,
sternoclavicular, and large
peripheral joints
• >50% develop destructive arthritis
(i.e. arthritis mutilans)
• Eye complications are uncommon
• 25% have increased RF
3. Psoriatic Spondylitis (23%)
• Psoriasis precedes arthritis
• M>F
• With or without peripheral joint
involvement
• 50% sacroiliitis
• Progresses more slowly and less
destructive compared to ankylosing
spondylitis
• Morning stiffness with low back pain
• Enthesopathy (i.e. Achilles tendon,
plantar fascia): characteristic
• Onychodystrophy
• Ocular Cxs are rare
• 30% GIT inflammation
Additional Subsets of PsA
1. Predominant DIP involvement
2. Arthritis mutilans
3. Peripheral Enthesitis
4. Juvenile PsA
5. SAPHO (synovitis, acne, pustulosis,
hyperostosis, osteomyelitis)
Pathology
• Synoviocytic hyperplasia
• Early PMN infiltration and later
mononuclear infiltration
• Cartilage erosion
• Pannus formation
• Synovium is more vascular vs. RA
• Less macrophages and ELAM-1
Laboratory Findings
• Elevated:
o ESR, CRP, and complement
o RF (in symmetric PsA)
o IgA against cytokelratins and
antienterobacteria)
o Urate
• Radiologic findings
o Soft tissue swelling
o Erosions at DIP joints
o Bone ankylosis of fingers
o Subluxations
o Subchondral cysts
o Expansion at the base of the
terminal phalanx
o Tapering of the proximal
phalanx
o “ Pencil-in-a-cup”: cuplike
erosions and bony proliferation
of terminal phalanx
o Proliferation of bone near
osseous erosions
o Terminal phalangeal osteolysis
o Bony proliferation and
periostitis
o “Opera-glass deformity”:
telescoping of a bone into an
adjacent bone
o Asymmetric or unilateral
sacroiliitis
 o Asymptomatic paravertebral
ossification
o Large asymmetric
syndesmophytes
o Echocardio: similar to
ankylosing Spondylitis
Diagnosis
• Check psoriatic lesions in areas such as
the scalp, umbilicus, and gluteal folds
• PsA nails have pitting and onyhcolysis
vs. nail infection
• Dactylitis: similar feature with Reiter’s
syndrome
• PsA (no intra-articular crystals) vs. Gout
• Vs. Rheaumatoid Arthritis
o Usually asymmetric
o Dactylitis
o Iritis
o Enthesopathy
o Onychodystrophy
o High frequency of HLA-B27

Treatment
• Education, physical and occupational
therapy
• Orthotics
• NSAIDs (mainstay)
• If unresponsive:
• MTX + Folate (monitor CBC, UA,
& LFTs)
• Sulfasalazine (monitor CBC)
• Gold (monitor CBC, UA)
• Hydroxychloroquine (monitor
eyes)