patient care perspectives

Screening for Psoriatic Arthritis and Axial Involvement: Tips for Dermatologists

by Bruce E. Strober, MD, PhD

Overview

Patients with psoriasis can be screened for psoriatic arthritis relatively quickly, using a series of questions. Both the presence of joint involvement and its distribution (ie, distal vs axial) in psoriatic arthritis may have a bearing on treatment.

Expert Commentary

Bruce E. Strober, MD, PhD

Clinical Professor, Department of Dermatology
Yale University School of Medicine
New Haven, CT
Central Connecticut Dermatology
Cromwell, CT

“Upon meeting a patient for the first time, I advocate asking them a series of screening questions, derived from published screening tools. These questions require very little time, yet they can uncover an inflammatory arthritis that is associated with a skin disease.”

Bruce E. Strober, MD, PhD

I think that every patient who presents with psoriasis, regardless of their skin severity, should be screened for the presence of psoriatic arthritis by a dermatologist, as joint disease can have a large impact on an individual’s quality of life and the presence and character of the inflammatory arthritis can have a bearing on treatment. Upon meeting a patient for the first time, I advocate asking them a series of screening questions, derived from published screening tools. These questions require very little time, yet they can uncover an inflammatory arthritis that is associated with a skin disease.

The questions that I employ assess the presence and character of joint pain and joint swelling. I ask my patients whether they have individual joints, fingers, or toes that have become swollen. I then ask them whether they are experiencing any neck pain/stiffness, low back pain/stiffness, and an inability to turn the neck to ascertain if axial disease may be present. I also inquire about morning stiffness and whether it lasts for 15 to 30 minutes, especially after awakening, or stiffness that occurs only after long periods of inactivity (eg, stiffness that occurs after a long car drive). If it is very difficult for the patient to become limbered up, then that is indicative of an inflammatory arthritis. It is also important to determine whether joint pain, either axial or distal, awakens the patients in the middle of the night. Additionally, I ask about a family history of psoriatic arthritis. I also examine the patient’s nails, as nail disease likely indicates a greater probability of psoriatic arthritis. And, finally, I ask my patients about specific ligaments that may commonly become inflamed in those with psoriasis, such as the Achilles tendon; plantar fasciitis with heel pain that appears suddenly; carpal tunnel syndrome; or tennis/golf elbow. These types of tendinitis are not specific for psoriatic arthritis, but, if they are present in combination with some of the other factors that I questioned the patient about, they increase the index of suspicion. Generally, if the patient has 3 or more “yes” answers to the screening questions, I suspect that they might have psoriatic arthritis.

The involvement of the neck, lower back, and sacroiliac joints also steers us into a direction of therapy that may differ for someone who has only distal involvement of their joints (eg, just dactylitis of a toe or Achilles tendinitis). You would not use methotrexate, as it does not work for axial disease, and I would be inclined to use a tumor necrosis factor inhibitor or an interleukin-17 pathway blocker, particularly secukinumab or ixekizumab. I think that they are very well established in treating not only the distal disease but also the axial disease. It should be noted that interleukin-23 inhibitors might also be effective for psoriatic arthritis.

References

Elmets CA, Leonardi CL, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073-1113. doi:10.1016/j.jaad.2018.11.058

Gladman DD. Axial psoriatic arthritis. Curr Rheumatol Rep. 2021;23(6):35. doi:10.1007/s11926-021-00999-8

Gottlieb AB, Merola JF. A clinical perspective on risk factors and signs of subclinical and early psoriatic arthritis among patients with psoriasis. J Dermatolog Treat. 2021 Jun 28;1-9. doi:10.1080/09546634.2021.1942423

Gottlieb AB, Merola JF. Axial psoriatic arthritis: an update for dermatologists. J Am Acad Dermatol. 2021;84(1):92-101. doi:10.1016/j.jaad.2020.05.089

Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019;80(4):1029-1072. doi:10.1016/j.jaad.2018.11.057

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