European Journal of Cardiovascular Medicine

Psoriatic arthritis (PsA) is a complex, chronic inflammatory disease that manifests both cutaneously and within the musculoskeletal system. It is estimated to affect up to 30% of patients with psoriasis, a common dermatological condition characterized by erythematous, scaly skin lesions. ^[1] The dual nature of PsA necessitates a collaborative approach between dermatologists and orthopedists to ensure comprehensive patient care. ^[2]

The pathogenesis of PsA involves an interplay of genetic, immunological, and environmental factors. HLA-B27 and other genetic markers have been implicated in the susceptibility to PsA, while cytokines such as TNF-α, IL-17, and IL-23 play pivotal roles in the inflammatory process. ^[3] These immunological pathways not only contribute to the skin manifestations but also to the joint inflammation and damage seen in PsA. ^[4]

Clinically, PsA presents with a heterogeneous spectrum of symptoms, ranging from mild joint pain to severe, debilitating arthritis. The most common patterns include asymmetric oligoarthritis, symmetric polyarthritis, and spondylitis. ^[5] Dermatological manifestations often precede joint symptoms, providing a critical window for early intervention. ^[6]

However, the lack of a definitive diagnostic test for PsA poses a challenge, necessitating a high index of suspicion and thorough clinical evaluation. ^[7]

The management of PsA requires a multidisciplinary approach, integrating dermatological and orthopedic perspectives. Traditional treatment modalities include nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and biologics targeting specific cytokines. ^[8] Recent advances in biologic therapies have revolutionized the treatment landscape, offering targeted interventions that address both skin and joint manifestations. ^[9]

Despite these advancements, gaps remain in the understanding and management of PsA. The variability in clinical presentation and disease progression complicates the development of standardized treatment protocols. ^[10] Furthermore, the psychological and socioeconomic burden of PsA is substantial, impacting patients' quality of life and overall well-being. ^[11]

This study aims to explore the intersection of dermatology and orthopedics in the context of PsA, emphasizing the need for a collaborative approach to diagnosis and treatment. By analyzing a cohort of PsA patients, we seek to identify key factors that influence disease outcomes and to propose strategies for optimizing patient care.

A prospective cohort study was conducted on 200 patients diagnosed with PsA over a period of 1 year. The study population was recruited from a tertiary care hospital with specialized dermatology and orthopedic departments.

Inclusion criteria included a confirmed diagnosis of PsA based on the Classification Criteria for Psoriatic Arthritis (CASPAR), age above 18 years, and availability of complete medical records.

Exclusion criteria were other forms of arthritis (e.g., rheumatoid arthritis, osteoarthritis), incomplete data, and age below 18 years.

Data Collection

Data were collected from electronic medical records and included demographic characteristics (age, gender, ethnicity), clinical features (duration of psoriasis, pattern of joint involvement, presence of dactylitis or enthesitis), treatment modalities (NSAIDs, DMARDs, biologics), and outcomes (disease activity scores, quality of life measures). Disease activity was assessed using the Disease Activity Index for Psoriatic Arthritis (DAPSA), while quality of life was evaluated using the Psoriatic Arthritis Quality of Life (PsAQoL) questionnaire.

Statistical Analysis

Descriptive statistics were used to summarize demographic and clinical characteristics. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were expressed as frequencies and percentages. Comparative analyses were performed using chi-square tests for categorical variables and t-tests for continuous variables. Multivariate logistic regression was used to identify predictors of treatment response. A p-value of <0.05 was considered statistically significant.

Ethical Considerations

The study was approved by the institutional review board, and informed consent was obtained from all participants. Patient confidentiality was maintained by anonymizing data and using secure storage systems.

Table 1: Demographic Characteristics

The demographic analysis revealed a slight male predominance (55%) and a mean age of 45.3 years. The majority of patients were Caucasian (60%), with a mean duration of psoriasis of 10.2 years.

Table 2: Clinical Features

Asymmetric oligoarthritis was the most common pattern of joint involvement (40%), followed by symmetric polyarthritis (35%). Dactylitis and enthesitis were present in 25% and 30% of patients, respectively.

Table 3: Treatment Modalities

Treatment modalities varied, with NSAIDs being the most commonly prescribed (75%), followed by DMARDs (60%) and biologics (40%).

Table 4: Disease Activity Scores

Disease activity scores indicated moderate to high disease activity, with a mean DAPSA score of 25.4.

Table 5: Quality of Life Measures

Quality of life measures reflected a significant impact on patients' well-being, with a mean PsAQoL score of 45.6.

Table 6: Predictors of Treatment Response

Multivariate logistic regression identified early diagnosis, use of biologics, and presence of dactylitis as significant predictors of treatment response. Early diagnosis was associated with a 2.5-fold increase in the likelihood of a positive treatment response, while the use of biologics and presence of dactylitis were associated with 1.8-fold and 1.5-fold increases, respectively.

The findings of this study underscore the importance of a multidisciplinary approach in the management of PsA. The interplay between dermatological and orthopedic manifestations necessitates collaboration between specialists to ensure comprehensive care. Early diagnosis emerged as a critical factor in improving treatment outcomes, highlighting the need for heightened awareness and timely referral between dermatologists and orthopedists.

The demographic profile of our cohort aligns with previous studies, showing a slight male predominance and a mean age in the mid-40s. ^[12] The prevalence of asymmetric oligoarthritis as the most common pattern of joint involvement is consistent with existing literature, reinforcing the heterogeneity of PsA presentations. ^[13] The presence of dactylitis and enthesitis in a significant proportion of patients further emphasizes the systemic nature of the disease and the need for targeted therapies. ^[14]

Treatment modalities in our cohort reflect current clinical practices, with NSAIDs and DMARDs being widely used. However, the relatively lower utilization of biologics (40%) suggests potential barriers to access or adherence, which warrant further investigation. ^[15] The association between biologic use and improved treatment outcomes aligns with evidence supporting the efficacy of these agents in modulating the inflammatory cascade. ^[16]

Disease activity scores indicated moderate to high disease activity, consistent with the chronic and progressive nature of PsA. The impact on quality of life was substantial, as reflected by the PsAQoL scores, underscoring the need for holistic care that addresses both physical and psychosocial aspects of the disease. ^[17]

The identification of early diagnosis, use of biologics, and presence of dactylitis as predictors of treatment response provides valuable insights for clinical practice. Early intervention, particularly with biologics, can significantly alter the disease trajectory, reducing joint damage and improving long-term outcomes. ^[18] The role of dactylitis as a predictor highlights the importance of recognizing and managing specific clinical features that may influence disease progression. ^[19]

Psoriatic arthritis is a multifaceted disease that requires a collaborative approach between dermatologists and orthopedists. Early diagnosis, targeted therapies, and a focus on quality of life are essential components of effective management. By bridging the gap between these two disciplines, we can improve patient outcomes and provide holistic care that addresses both the cutaneous and musculoskeletal manifestations of PsA

1. Ritchlin CT, Colbert RA, Gladman DD. Psoriatic Arthritis. N Engl J Med. 2017;376(10):957-970.
2. FitzGerald O, Haroon M, Giles JT, Winchester R. Concepts of pathogenesis in psoriatic arthritis: genotype determines clinical phenotype. Arthritis Res Ther. 2015;17:115.
3. Mease PJ, Armstrong AW. Managing patients with psoriatic disease: the diagnosis and pharmacologic treatment of psoriatic arthritis in patients with psoriasis. Drugs. 2014;74(4):423-441.
4. Scarpa R, Soscia E, Peluso R, et al. Nail and distal interphalangeal joint in psoriatic arthritis. J Rheumatol. 2006;33(7):1315-1319.
5. Taylor W, Gladman D, Helliwell P, et al. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54(8):2665-2673.
6. Coates LC, Kavanaugh A, Mease PJ, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68(5):1060-1071.
7. McInnes IB, Kavanaugh A, Gottlieb AB, et al. Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet. 2013;382(9894):780-789.
8. Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Ann Rheum Dis. 2005;64 Suppl 2:ii3-ii8 .
9. Kavanaugh A, Helliwell P, Ritchlin CT. Psoriatic arthritis and burden of disease: patient perspectives from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey. Rheumatol Ther. 2016;3(1):91-102.
10. Wilson FC, Icen M, Crowson CS, McEvoy MT, Gabriel SE, Kremers HM. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum. 2009;61(2):233-239.
11. Brockbank JE, Stein M, Schentag CT, Gladman DD. Dactylitis in psoriatic arthritis: a marker for disease severity? Ann Rheum Dis. 2005;64(2):188-190.
12. Saad AA, Symmons DP, Noyce PR, Ashcroft DM. Risks and benefits of tumor necrosis factor-alpha inhibitors in the management of psoriatic arthritis: systematic review and metaanalysis of randomized controlled trials. J Rheumatol. 2008;35(5):883-890.
13. Mease PJ, Goffe BS, Metz J, VanderStoep A, Finck B, Burge DJ. Etanercept in the treatment of psoriatic arthritis and psoriasis: a randomised trial. Lancet. 2000;356(9227):385-390.
14. Husted JA, Gladman DD, Farewell VT, Cook RJ. Health-related quality of life of patients with psoriatic arthritis: a comparison with patients with rheumatoid arthritis. Arthritis Rheum. 2001;45(2):151-158.
15. Kavanaugh A, McInnes I, Mease P, et al. Golimumab, a new human tumor necrosis factor alpha antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: Twenty-four-week efficacy and safety results of a randomized, placebo-controlled study. Arthritis Rheum. 2009;60(4):976-986.
16. Mease PJ, Gladman DD, Papp KA, et al. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol. 2013;69(5):729-735.
17. Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008;58(5):851-864.
18. Coates LC, Helliwell PS. Methotrexate efficacy in the tight control in psoriatic arthritis study. J Rheumatol. 2016;43(2):356-361.
19. Kavanaugh A, Ritchlin C, Rahman P, et al. Ustekinumab, an anti-IL-12/23 p40 monoclonal antibody, inhibits radiographic progression in patients with active psoriatic arthritis: results of an integrated analysis of radiographic data from the phase 3, multicentre, randomised, double-blind, placebo-controlled PSUMMIT-1 and PSUMMIT-2 trials. Ann Rheum Dis. 2014;73(6):1000-1006.