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Psoriatic arthritis

Abstract

Psoriatic arthritis (PsA) is a complex inflammatory disease with heterogeneous clinical features, which complicates psoriasis in 30% of patients. There are no diagnostic criteria or tests available. Diagnosis is most commonly made by identifying inflammatory musculoskeletal features in joints, entheses or the spine in the presence of skin and/or nail psoriasis and in the usual absence of rheumatoid factor and anti-cyclic citrullinated peptide. The evolution of psoriasis to PsA may occur in stages, although the mechanisms are unclear. In many patients, there may be little or no relationship between severity of musculoskeletal inflammation and severity of skin or nail psoriasis. The reason for this disease heterogeneity may be explained by differences in genotype, especially in the HLA region. New targeted therapies for PsA have been approved with additional therapies in development. These developments have substantially improved both short-term and long-term outcomes including a reduction in musculoskeletal and skin manifestations and in radiographic damage. With efforts underway aimed at improving our understanding of the molecular basis for the heterogeneity of PsA, a personalized approach to treating PsA may become possible.

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Fig. 1: Stages in the evolution of psoriasis to psoriatic arthritis.
Fig. 2: Proposed pathogenetic pathways activated in key subtypes of psoriatic disease.
Fig. 3: The complex model of quality of life for patients with PsA.

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Acknowledgements

V.C. acknowledges support of the Pfizer Chair Rheumatology Research Award from the Department of Medicine, University of Toronto. L.C.C. is an NIHR Clinician Scientist funded by a National Institute for Health Research Clinician Scientist award. The research was supported by the National Institute for Health Research (NIHR) and the Oxford Biomedical Research Centre (BRC). Y.Y.L. is supported by National Medical Research Council, Singapore.

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Contributions

Introduction (O.F. and P.J.M.); Epidemiology (A.O.); Mechanisms/pathophysiology (O.F. and V.C.); Diagnosis, screening and prevention (L.C.C.); Management (P.J.M. and A.K.); Quality of life (W.T., Y.Y.L. and M.deW.); Outlook (J.U.S.); Overview of Primer (O.F.).

Corresponding author

Correspondence to Oliver FitzGerald.

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Competing interests

O.F. has received research grants and/or consulting fees from AbbVie, Amgen, Bristol Myers Squibb (BMS), Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc. and UCB. A.O. has consulted for AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, Pfizer and UCB, and has received grants from Novartis and Pfizer. Her husband has received royalties from Novartis. V.C. reports grants and personal fees from Amgen, grants and personal fees from AbbVie, grants and personal fees from (and other potential interest (spouse employment) in) Eli Lilly and personal fees from BMS, Janssen, Novartis, Pfizer and UCB, outside the submitted work. L.C.C. is a recipient of research funds from AbbVie, Amgen, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer and UCB. She has received consultancy fees from AbbVie, Amgen, BMS, Boehringer Ingelheim, Celgene, Domain, Gilead, Janssen, Lilly, Novartis, Pfizer, Serac and UCB. She reports reimbursement for attending a symposium from Janssen and AbbVie, and fees for organizing education from UCB. She has received fees for speaking and hospitality from AbbVie, Amgen, BMS, Biogen, Celgene, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer and UCB. A.K. conducted clinical trials sponsored by and/or consulted for Amgen, AbbVie, BMS, Eli Lilly, Janssen, Novartis, Pfizer and UCB. W.T. has received research grants, and consulting or speaker fees from AbbVie, Amgen, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer and UCB. Y.Y.L. is supported by the National Medical Research Council, Singapore. She has received honoraria from Janssen, AbbVie, Novartis and DKSH. M.deW. has received fees for lectures or consultancy through Stichting Tools from Celgene, Eli Lilly, Pfizer and UCB. J.U.S. has received funding for investigator-initiated studies from Novartis and Janssen and has served as a consultant for Janssen, Novartis, Pfizer, Lilly, AbbVie, Sanofi and UCB. P. J. M. has received research grants from AbbVie, Amgen, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, Sun and UCB. He acts as a consultant with AbbVie, Amgen, Boehringer Ingelheim, BMS, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Sun and UCB. He has been a speaker for AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer and UCB.

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Glossary

Psoriasis

Psoriasis is a skin disease that causes itchy, scaly patches commonly on the extensor aspects of the knees and elbows and in the scalp.

Entheses

The enthesis is the site of attachment of ligament to bone.

Rheumatoid factor

Rheumatoid factor is an anti-immunoglobulin antibody found commonly in patients with rheumatoid arthritis.

Anti-cyclic citrullinated peptide

This peptide is an antibody found commonly in patients with rheumatoid arthritis.

Uveitis

Uveitis is inflammation of the uveal tract of the eye.

Sacroiliitis

Inflammation of the sacroiliac joints

Synovitis

Synovitis is inflammation of the synovial tissue, which is normally a thin layer of tissue lining the inside of joints.

Joint erythema

Joint erythema is one of the features of an inflamed joint or arthritis when the joint is red in appearance.

Dactylitis

Dactylitis is sausage-like swelling of a finger or toe.

PEST questionnaire

A questionnaire designed to screen for psoriatic arthritis in patients with psoriasis.

Treatment to target of remission

Treatment to target of remission is where treatment is escalated according to patient response until a target of remission has been achieved.

BASDAI question 2

A questionnaire commonly used to assess disease activity in patients with ankylosing spondylitis.

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FitzGerald, O., Ogdie, A., Chandran, V. et al. Psoriatic arthritis. Nat Rev Dis Primers 7, 59 (2021). https://doi.org/10.1038/s41572-021-00293-y

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