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Ace the Case: A 29-year-old Woman With Psoriasis Vulgaris
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A 29-year-old woman presents to the clinic to establish care for her psoriasis vulgaris. She states her psoriasis began when she was 22 years old and she has been treated with topical glucocorticoids in the past. During the past 2 years, she has not used any topical medications because her psoriasis has not been bothersome. However, lately her psoriasis plaques have been pruritic and she has several new lesions on her legs that make her embarrassed to wear shorts.
On physical examination, she has 4% body surface area involvement, with involvement mostly on her extensor surfaces and her scalp. She denies joint pain, morning joint stiffness, swelling of any digits, back pain/stiffness, heel pain or elbow pain.
She is prescribed topical medications that have been effective for her psoriasis in the past and a follow-up appointment is scheduled for 6 months.
Clinical Review
Psoriasis is a chronic, immune-mediated disease that is associated with systemic inflammation that can affect multiple organ systems, especially in patients with moderate to severe disease. Numerous studies have supported that psoriasis is associated with a variety of comorbid diseases. Studies have also suggested that the relative risk of many comorbid diseases increase with increased severity of psoriasis.
Psoriatic arthritis (PsA) is a seronegative inflammatory arthritis and represents one of the most common comorbid diseases that occurs in patients with psoriasis. Approximately 30% of patients with psoriasis will develop PsA during their disease. Psoriatic arthritis affects men and women equally and currently no serologic test is useful in definitively diagnosing a patient. The age of PsA onset is typically between 30 years and 50 years. Patients with psoriasis may develop PsA regardless of the severity of their cutaneous disease. However, as seen with other comorbid diseases that occur in patients with psoriasis, PsA appears to be more prevalent in patients with severe disease. There are several different clinical subtypes of PsA, including distal interphalangeal predominant, oligoarticular, polyarticular, arthritis mutilans and spondyloarthritis. These may overlap in real clinical practice.
Psoriatic arthritis can be associated with numerous symptoms, including joint pain, swelling and stiffness. Additionally, an erosive arthropathy with irreversible structural changes and even obliteration of the joint space has been shown to occur in up to 40% to 60% of affected patients. Furthermore, it has been demonstrated that irreversible joint damage can occur early after the onset of PsA. In one study, joint erosions increased between baseline and 2 years from 27% to 47% of patients, while joint space narrowing increased from 21% to 37% of patients during the same period. This underscores the importance of early diagnosis, especially since biologics have been shown to be able to halt progression of structural damage of PsA, thus preserving patients’ quality of life (QoL).
Although patients may develop PsA prior to, coincident with or after onset of psoriasis, research has shown that up to 85% of patients who develop PsA first develop psoriasis. Importantly, there can be a long lag-time between onset of psoriasis and PsA. In one study, the lag-time between psoriasis and psoriatic arthritis was 12 years on average. This places dermatologists in a unique position to be the first clinicians to detect the onset of PsA, aide in making a diagnosis and ensuring patients are placed on appropriate treatment regimens early to minimize symptoms, structural joint damage, and negative impact on patients QoL.
The American Academy of Dermatology recommends that dermatologists screen all patients with psoriasis, regardless of disease severity, at every clinical visit to optimize chances that patients are diagnosed early and when treatments that can minimize symptoms and structural joint damage can be initiated. There are numerous ways dermatologists can screen patients with psoriasis patients for onset of PsA. For one, they can simply question patients about symptoms highly suggestive of PsA onset (Table). Additionally, are several validated PsA screening tools are available for dermatologists to use in their clinics to determine how suspicious they should be about the presence of PsA in a patient. Such tools include the psoriasis epidemiology screening tool, psoriatic arthritis screening and evaluation questionnaire and the Toronto psoriatic arthritis screening questionnaire. These can typically be administered and completed within 5 minutes, so these are feasible to use in a busy dermatology clinic setting.
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Learning Objectives:
Upon successful completion of this educational activity, participants should be better able to assess patients with with psoriatic disease
Overview
Author(s)/Faculty: Anthony P. Fernandez, MD, PhD
Source: Healio Rheumatology Education Lab
Type: Monograph
Articles/Items: 4
Release Date: 8/15/2017
Expiration Date: 8/14/2018
Credit Type: CME/ABIM MOC
Number of Credits: 0.25
Cost: Free
Provider: Vindico Medical Education
CME Information
Provider Statement: This continuing medical education activity is provided by Vindico Medical Education.
Support Statement:
No commercial support for this activity.
Target Audience:
This activity is designed for this activity is rheumatologists and other health care professionals involved in the treatment of patients with rheumatological disorders.