Biologics and Advanced Therapies in the Management of Psoriatic Arthritis - Episode 4

Clinical Manifestations of PsA

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Anthony M. Turkiewicz, MD:We’ll move into discussion on diagnosis and standard of care, and try to hit on both, the rheumatology perspective and dermatology perspective.

We’ll start out with Hillary on this. Hillary, if you don’t mind, talk about the clinical manifestations of psoriatic arthritis; in your clinic, how a typical psoriatic arthritis patient may present.

Hillary E. Norton, MD: That’s one of the challenges of psoriatic arthritis, that there is no typical presentation of this disease. This is such a heterogeneous disease, and as we mentioned before, most patients are going to have psoriasis prior to developing the musculoskeletal manifestations. But about 10% of patients, or in my practice that’s even higher, will present with a hallmark of the disease from an arthritis aspect, but they just don’t know they have psoriasis. And sometimes, as we know, they do, and it’s in their ear or their scalp or their gluteal crease, and they’re not aware that’s psoriasis. This can be really challenging.

Oftentimes in rheumatology these patients are going to present to us with joint paint. That’s the most typical feature. But we see some of these other very classic features, such as enthesitis or dactylitis.

I had a young patient come in in her early 30s, and she had very severe dactylitis in a couple of her toes, and she was having trouble walking due to this but no known history of psoriasis. She later found out that there was a family history.

We see the patients also with joint paint. This is not as often symmetric the way that it is in rheumatoid arthritis. We see enthesitis. Patients often don’t realize that the tenderness at their elbows or at their Achilles is actually inflammation of where the tendons and ligaments connect to the bone. The sausage digit, dactylitis of the fingers and toes. Patients can present with very severe nail disease. I’ve had a couple of patients where that was actually their primary issue, that their nails were very affected. And we don’t talk too much about nail pain, but pain can go along with nail disease.

And axial involvement. We always need to be evaluating for whether patients have sacroiliitis that goes along with their psoriatic arthritis. This is different than AS [ankylosing spondylitis] axial involvement, and sometimes patients don’t have as much pain that goes along with it, but it’s something that we need to look at.

Then of course the other systemic manifestations, fatigue and depression, are real issues in this disease. And as John mentioned earlier, these are not just secondary to the disease, but these actually can come primarily from inflammatory cytokines and are part of the pathophysiology of psoriatic arthritis.

It’s a very heterogeneous presentation, and we all have that bucket of patients where we’re pretty sure it’s psoriatic arthritis based on some of these hallmark findings, but sometimes it takes a while for this disease to really declare itself.

Anthony M. Turkiewicz, MD: The true heterogeneity of this disease is quite remarkable.

Transcript Edited for Clarity