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Psoriatic arthritis



PsA is a chronic, systemic inflammatory disorder that occurs in patients with psoriasis and is associated with multiple musculoskeletal manifestations.
The pathogenesis of PsA is multifactorial and involves polygenic inheritance, environmental factors, and patient-specific risk factors, including obesity. These various factors initiate an auto-inflammatory loop with amplification of the IL-23/IL-17 pathway that leads to a diverse array of associated pathologies at distant body sites.
In the US, the prevalence of PsA is estimated at 50-250 persons per 100,000 population. PsA is prevalent in 6-41% of patients with psoriasis.
Disease course
Key clinical manifestations include arthritis, enthesitis, spondylitis, nail disease, dactylitis, and uveitis. Five disease phenotypes have been described. The oligoarticular subtype affects ≤ 4 joints, and typically occurs in an asymmetric distribution. The polyarticular subtype affects ≥ 5 joints; the involvement may be symmetric and resemble rheumatoid arthritis. The distal subtype affects distal interphalangeal joints of the hands, feet, or both. The axial or spondyloarthritis subtype primarily involves the spine and sacroiliac joints. Finally, a subtype known as arthritis mutilans is characterized by deforming and destructive arthritis that involves marked bone resorption or osteolysis, with telescoping and flail digits.
Prognosis and risk of recurrence
Articular damage develops in a large number of patients with PsA, with up to 47% of patients developing bony erosions within 2 years of diagnosis, despite the use of disease-modifying medications. Spontaneous remission is extremely rare. Treatment with biologics leads to partial remission in over 50% of patients.


Key sources

The following summarized guidelines for the evaluation and management of psoriatic arthritis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023), the Assessment of SpondyloArthritis international Society (ASAS/EULAR 2022), the British Society for Rheumatology (BSR 2022), the European League Against Rheumatism (EULAR 2022,2020), the American College of Radiology (ACR 2021,2017), the British ...
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Screening and diagnosis

Indications for screening: as per BAD 2020 guidelines, screen for PsA in patients without this diagnosis using a validated tool, such as the PEST, and recognize that the PEST May not detect axial arthritis/inflammatory back pain.
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Classification and risk stratification

Severity assessment: as per BHPR/BSR 2017 guidelines, measure BASDAI on 2 occasions at least 4 weeks apart.
define the disease as active if BASDAI and spinal pain VAS score is ≥ 4 despite standard therapy.

Diagnostic investigations

Diagnostic imaging: as per ACR 2021 guidelines, obtain radiography of sacroiliac joints or sacroiliac joints and spine area of interest as the initial imaging of suspected axial spondyloarthritis.
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  • Pretreatment evaluation

Medical management

Goals of treatment: as per ASAS/EULAR 2022 guidelines, individualize treatment of patients with axial spondyloarthritis according to the current signs and symptoms of the disease (axial, peripheral, extra-musculoskeletal manifestations) and the patient characteristics including comorbidities and psychosocial factors. Guide treatment according to a predefined treatment target.

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  • NSAIDs

  • DMARDs

  • Systemic corticosteroids

  • Biologic agents (patients with peripheral arthritis)

  • Biologic agents (patients with active enthesitis and/or dactylitis)

  • Biologic agents (patients with predominantly axial disease)

Nonpharmacologic interventions

Lifestyle modifications: as per ASAS/EULAR 2022 guidelines, advise smoking cessation in patients with axial spondyloarthritis.

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  • Physical therapy

Therapeutic procedures

Local corticosteroid injections: as per ASAS/EULAR 2022 guidelines, consider administering corticosteroid injections directed to the local site of musculoskeletal inflammation.

Surgical interventions

Spinal osteotomy: as per ASAS/EULAR 2022 guidelines, consider performing spinal corrective osteotomy in patients with severe disabling deformity in specialized centers.

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  • Total hip replacement

Specific circumstances

Patients with extra-articular manifestations, general principles: as per ASAS/EULAR 2022 guidelines, consider preferring IL-17 inhibitors in patients with significant psoriasis.

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  • Patients with extra-articular manifestations (uveitis)

  • Patients with extra-articular manifestations (IBD)

Patient education

General counseling: as per ASAS/EULAR 2022 guidelines, educate patients with axial spondyloarthritis about their condition.

Preventative measures

Routine immunizations: as per ACR 2023 guidelines, consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in ≥ 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications.
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  • Prophylaxis for P. jirovecii pneumonia

Follow-up and surveillance

Monitoring of disease activity: as per ASAS/EULAR 2022 guidelines, assess patient-reported outcomes and clinical findings, obtain laboratory tests and imaging, all with the appropriate instruments and relevant to the clinical presentation, for disease monitoring of patients with axial spondyloarthritis. Decide on the frequency of monitoring on an individual basis depending on symptoms, severity, and treatment.

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  • Assessment of treatment response

  • Management of inadequate response to biologic agents