A New Plan for Collaborating Against Psoriatic Arthritis

April 8, 2014

How can two specialties be alert for psoriasis evolving into psoriatic arthritis? An expert panel offers a plan for rheumatologists and dermatologists.

Cañete JD, Daudén E, Queiro R. Recommendations for the Coordinated Management of Psoriatic Arthritis by Rheumatologists and Dermatologists: A Delphi Study. Actas Dermo-Sifiliográficas. March 2014;105(02): 0-212  (IN PRESS, English)

Managing psoriatic arthritis (PsA) and psoriasis calls for a team approach – close collaboration between rheumatologists and dermatologists – to treat patients’ joint and skin problems effectively, an expert panel from Spain concludes.

In its recommendations, the 12-member panel included a simplified version of the widely-used CLASsification criteria for Psoriatic Arthritis (CASPAR) designed for easier use in the clinic.

It states that PsA should be suspected in patients who have any of these signs or symptoms:

•   Inflammatory pain or swelling in peripheral joints
•   Inflammatory or nocturnal pain the axial skeleton
•   Enthesitis (especially of the Achilles tendon or the plantar fascia)
•   Dactylitis

To apply the simplified CASPAR criteria, the panel drafted separate screening recommendations for dermatologists and rheumatologists.

Dermatologists should regularly screen patients with psoriasis for PsA (once a year for those on topical treatments, every 6 months for those treated systemically), paying special attention to certain risk factors, signs and symptoms:

•  Onychopathy (nail disease)
•  Obesity
•  More than 3 areas affected by psoriasis
•  Psoriasis in high risk sites including the scalp and intergluteal (buttocks) fold 
•  Inflammatory pain or swelling in peripheral joints especially the knees, ankles, and small joints of the hand)
•  Inflammatory or nocturnal pain in the axial skeleton
•  Evidence of enthesitis (especially in the Achilles tenon of plantar fascia).
•   Dactylitis (or a prior diagnosis by a rheumatologist).

If PsA is suspected, the patient should be referred to a rheumatologist with a full report. If a PsA patient is referred by a rheumatologist, assess for psoriasis and report back. Both clinicians should devise a joint treatment and monitoring plan.

As for rheumatologists, they should look for skin lesions in PsA patients or those with being assessed for PsA.

•   Pay special attention to skin lesions indicative of palmoplantar pustulosis in patients with musculoskeletal pain.
•   If such lesions are found, include SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) as a differential diagnosis.

To meet the CASPAR criteria, patients must score at least 3 points:

•   Current psoriasis (2 points)
•   A history of psoriasis but no current psoriasis (1 point)
•   New-bone formation near a joint, juxta-articular bone growth (1 point)
•   Rheumatoid factor (RF) negativity (1 point)
•   Abnormal, shape, texture, thickness of finger or toenails, nail dystrophy (1 point)

The new recommendations include detailed algorithms for screening, diagnosis, monitoring of disease activity, treatment regimens and goals, as well as planning for coordinated patient management.

The panel, comprised of six rheumatologists and six dermatologists aided by a duo of epidemiologists, used round-robin voting (a version of the Delphi method) to approve each item with a 70% consensus to ensure the strength of the final PsA/psoriasis recommendations.


The full recommendations can be found at:
http://www.actasdermo.org/en/pdf/S1578-2190(14)00074-2/S100/