Joint pain, skin rash...These 5 symptoms appear, beware of "psoriatic arthritis"!

*Only for medical professionals to read and refer to thousands of cases of joint pain etiology Wang, male, 56 years old
.

Main complaint: Repeated swelling and pain of multiple joints all over the body for more than 3 months
.

History of present illness: The patient began to have multiple joints swelling and pain before 3 months without obvious inducement, which successively affected the proximal interphalangeal joint of the left little finger, the interphalangeal joint of the right thumb, and the right ankle joint
.

Go to the Department of Rheumatology and Immunology of the local hospital, and check rheumatoid factor, anti-CCP antibody, and antinuclear antibody are all negative, erythrocyte sedimentation rate and C-reactive protein (CRP) are higher than normal, and the diagnosis is "seronegative rheumatoid arthritis".
Good
.

Upon follow-up medical history and physical examination, it was found that the patient's scalp was scattered with a red rash, covered with scales
.

The patient complained of a history of "psoriasis"
.

Diagnosis: psoriatic arthritis
.

Psoriatic arthritis is a chronic inflammatory musculoskeletal disease associated with psoriasis that can affect the synovial attachment points and axial structures
.

Clinical manifestations are divided into musculoskeletal and non-musculoskeletal manifestations, the latter including skin, nails and intestinal (inflammatory bowel disease) or eye (uveitis) involvement
.

Patients with active chronic psoriasis are also often accompanied by cardiovascular, psychological, and metabolic complications, which significantly increase the economic burden of the patients, affect the life of the patients, and increase the mortality rate
.

1.
What does psoriasis look like? Psoriasis, commonly known as psoriasis, is a common skin disease worldwide.
About 1% to 3% of people suffer from psoriasis
.

Although the prevalence rates in China and Japan are low, studies in some areas in China have confirmed that the prevalence of psoriasis is increasing
.

Psoriasis often presents as red macules with itching, which is different from idiopathic dermatitis, which is milder in psoriasis
.

Psoriasis generally affects the scalp and extensible limbs; secondly, it affects the nails, hands, feet, trunk and gluteal groove
.

The skin morphology characteristics of psoriasis are as follows: 1.
The edge of the rash is clear; 2.
Pink and red macules, thickened skin of the rash; 3.
The skin scales cover the macules, and the scales adhere firmly and look like when scraped off.
Wax-like, needle-like bleeding can be seen after removal, which is called Auspitz's sign
.

2.
How to recognize psoriatic arthritis early? Most patients with psoriatic arthritis have skin lesions that precede joint lesions.
About 15% of skin lesions and arthritis occur at the same time or arthritis precedes skin lesions, which makes early diagnosis difficult
.

Therefore, strengthening early screening and early diagnosis of patients with psoriasis and arthritis can reduce missed and misdiagnosed psoriatic arthritis
.

When any of the following manifestations occur, you should go to the rheumatology and immunology clinic in time to rule out the possibility of psoriasis: ① Swelling of the fingers or toes: Dachshund fingers (toes), manifested as complete swelling of one or more fingers or toes, yes A hallmark symptom of psoriatic arthritis
.

② Finger/toenail depression or nail separation: Nail changes are an important feature of psoriatic arthritis, manifested as punctate depression, white nails, nail meniscus erythema and nail rupture, nail separation and other changes
.

③ Heel pain: Excluding other causes, heel pain caused by unknown causes is another clinical manifestation of psoriatic arthritis
.

④ Pain in the lower back and buttocks: Psoriatic arthritis usually involves the axial joints, causing pain and discomfort in the lower back and buttocks
.

Similar to ankylosing spondylitis, but sacroiliitis is the diagnostic criterion for ankylosing spondylitis, and a small number of psoriatic arthritis may only have spondylitis without sacroiliitis
.

⑤ Family history of psoriasis: The patient complained of a history of psoriasis in first-degree or second-degree relatives
.

3.
Psoriatic arthritis diagnosis/classification criteria Since Moll and Wright first proposed the classification criteria for psoriatic arthritis in 1973, the Bennett diagnostic criteria, Vasey-Espinoza criteria, Gladman criteria, European Spondyloarthritis Research (ESSG) ) Standard, McGonagle standard, Fournie standard and the 2006 CASPAR classification standard.
Different standards have different sensitivity and specificity in clinical work
.

Currently the most commonly used is the 2006 CASPAR classification standard, which has a sensitivity of 91.
4% and a specificity of 98.
7%
.

This standard evaluates patients with inflammatory arthropathy of the joints, spine or tendon ends
.
Psoriatic arthritis can be diagnosed if the score is ≥3 in the following 5 items .

4.
How to distinguish psoriatic arthritis from other arthritis? ▎The early lesions of osteoarthritis and psoriatic arthritis mainly involve the distal interdigital (toe) joints
.

However, patients with osteoarthritis can also experience joint involvement between the distal ends
.

Rheumatoid factor (RF) is more common in 50 years of age and older.
It is mostly negative.
It mainly involves the spine, weight-bearing joints and distal interphalangeal joint articular surface sclerosis.
Bouchard nodules can be seen in the interphalangeal joints) ▎Rheumatoid arthritis Psoriatic arthritis has finger swelling, which can be manifested as finger joints swelling and tenderness during the active stage of rheumatoid arthritis
.

Psoriatic arthritis with polyarticular involvement is difficult to distinguish from typical rheumatoid arthritis
.

However, the characteristics of rheumatoid arthritis are as follows: morning stiffness is mostly involved in the proximal interphalangeal joints, wrist joints, elbow joints and other small joints.
RF is mostly positive anti-CCP antibodies and mostly positive without psoriatic skin lesions.
X-rays of family history of psoriasis suggest osteoporosis▎Axial spondyloarthritis Psoriatic arthritis can also involve the spine in addition to peripheral joint disease of the limbs, which is called axial (spinal) arthritis-type psoriatic joints Inflammation, which accounts for about 5%, is 3-5 times that of female patients in male patients, and it is more common in older patients
.

It is often difficult to distinguish between it and psoriatic arthritis, especially when the psoriatic rash does not appear
.

At this time, multi-joint involvement, involvement of the joints between the distal ends, sausage finger (toe), nail (toe) lesions, family history of psoriasis, CT suggesting unilateral sacroiliac arthritis and skipping vertebral osteophytes are helpful Diagnosis of psoriatic arthritis
.

5.
The treatment of psoriatic arthritis.
Psoriatic arthritis is a highly heterogeneous disease.
Peripheral arthritis, axial arthritis, enthesitis, dactylitis, skin lesions, nail lesions and The manifestations and severity of extra-articular comorbidities are different, and the response to treatment is also different.
Individualized treatment should be stratified
.

Psoriatic arthritis commonly used drugs and non-drug treatment options for different pathological changes.
Skin lesions and onychomycosis: local treatment and methotrexate (MTX), cyclosporine or biological agents can be given; axial joints: non- Steroid anti-inflammatory drugs (NSAIDs), physical therapy, biological treatment; Peripheral joints: NSAIDs can be used in combination with disease-improving anti-rheumatic drugs (DMARD), intra-articular injection of glucocorticoids, biological treatment; dactylitis: Yes NSAIDs, intra-articular injection of glucocorticoids, and biological preparations are used for treatment; attachment point inflammation: NSAIDs and biological preparations can be used for treatment
.

How to choose biological agents for psoriatic arthritis? There are currently a variety of biological agents with different effects on the market.
It is generally considered that tumor necrosis factor inhibitors (TNFi), interleukin 17 inhibitors (IL-17i) and interleukin 12/23 inhibitors (IL-12/23i) are Peripheral joint involvement of psoriatic arthritis is effective; TNFi and IL-17i can also be used for axial joint involvement
.

Generally speaking, TNFi is better than IL-17i, IL-12/23i, abatacept or tofacitinib; IL-17i is better than IL-12/23i, and other biologics are popularized by abatacept
.

Active psoriatic arthritis with special comorbidities ① Crohn’s disease: The choice of monoclonal antibody TNFi is better than oral small molecule compounds (OSM) and IL-12/23i
.

Studies have shown that the monoclonal antibody TNFi is effective for Crohn's disease, while the receptor fusion proteins TNFi and IL-17i are not effective for Crohn's treatment
.

For patients who have contraindications to TNFi or who wish to reduce the frequency of medication, IL-12/23i can be used
.

② Diabetes: OSM other than MTX is recommended to be better than TNFi
.

Studies have shown that the incidence of fatty liver and liver toxicity is higher when using MTX in this type of population
.

TNFi can be considered for patients with psoriatic arthritis with severe psoriasis, or patients with well-controlled diabetes
.

③Previous severe infection: OSM is recommended instead of TNFi as the first-line treatment, because the use of TNFi for patients with previous severe infection is a black box warning on the instructions
.

Unlike most of the previous recommendations, for patients with previous severe infections, IL-17i and IL-12/23i are recommended to be better than TNFi
.

Summary Psoriatic arthritis is a group of diseases whose main manifestations are arthritis, tendinitis, dactylitis, spondylitis and psoriasis skin lesions, and there is high heterogeneity in clinical manifestations and diseases
.

Part of psoriasis occurs after arthritis, which makes clinical diagnosis more difficult
.

The later the adequate treatment of psoriatic arthritis is obtained, the greater the possibility of irreversible joint damage and other cardiovascular and metabolic diseases
.

Therefore, it is very important to pay attention to the early screening, early diagnosis and early treatment of psoriatic arthritis
.

References [1] Chinese consensus on diagnosis and treatment of arthritis-type psoriasis (2020)[J].
Chinese Journal of Dermatology, 2020,53(08):585-595.
[2]Lu Chaofan, Leng Xiaomei, Zeng Xiaofeng.
Interpretation of "2018 ACR/NPF Psoriatic Arthritis Treatment Guidelines"[J].
Chinese Journal of Clinical Immunity and Allergy, 2019,13(01):5-10.
[3] Singh JA, Guyatt G, Ogdie A, et al.
Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis[J].
Arthritis Rheumatol, 2019,71(1):5-32.
In order to better provide you with interesting, For useful and attentive content, the Medical Rheumatism Channel welcomes everyone to move their fingers to complete the following research, it only takes five seconds!