para>Do not use anti-TNF agents in the setting of active infection (including TB and hepatitis B). Do not use anti-TNF agents with concurrent live vaccinations, with New York Heart Association classes III to IV congestive heart failure, with malignancy, or in patients with a history of demyelinating disease.
Do not use ustekinumab in patients with active infection, mycobacterial or Salmonella infection, with concurrent live vaccinations, including Bacillus Calmette-Gu ©rin vaccination, or with history of malignancy.
Pregnancy Considerations
Avoid teratogenic medications (e.g., Category X medications such as methotrexate, leflunomide) during pregnancy.
Adalimumab, etanercept, golimumab, infliximab, and ustekinumab are currently listed as Category B medications.
ISSUES FOR REFERRAL
SURGERY/OTHER PROCEDURES
Joint fusion or replacement for advanced destruction
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Epidemiologic evidence suggests a relationship between psoriasis, metabolic syndrome, myocardial infarction, and stroke. Measurement of blood pressure, fasting lipids and glucose, cholesterol, and body mass index is recommended (12).
PATIENT EDUCATION
- Stress noncontagious nature of condition.
- National Psoriasis Foundation, 6600 SW 92nd Ave., Suite 300, Portland, OR 97223. Also see http://www.psoriasis.org/i-have-psoriatic-arthritis.
- Arthritis Foundation, 2970 Peachtree Road NW, Suite 200, Atlanta, GA 30305, 404-237-8771. Also see http://www.arthritis.org/about-arthritis/types/psoriatic-arthritis/.
- American College of Rheumatology, 2200 Lake Boulevard NE, Atlanta, GA 30319, 404-633-3777.
- http://www.arthritis.org/about-arthritis/types/psoriatic-arthritis/
PROGNOSIS
- Course: insidious and chronic joint disease and recurring and remitting chronic skin disease
- More favorable than for RA (except for patients who develop arthritis mutilans)
COMPLICATIONS
- Chronicity
- Disability
- Psychosocial impact of psoriasis
REFERENCES
11 Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011;65(1):137-174.22 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):851-864.33 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):2665-2673.44 Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009;60(4):643-659.55 Ramiro S, Radner H, van der Heijde D, et al. Combination therapy for pain management in inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis). Cochrane Database Syst Rev. 2011;(10):CD008886.66 Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61(3):451-485.77 Ash Z, Gaujoux-Viala C, Gossec L, et al. A systematic literature review of drug therapies for the treatment of psoriatic arthritis: current evidence and meta-analysis informing the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis. 2012;71(3):319-326.88 Ritchlin CT, Kavanaugh A, Gladman DD, et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis. 2009;68(9):1387-1394.99 Kavanaugh A, Mease PJ, Gomez-Reino JJ, et al. Treatment of psoriatic arthritis in a phase 3 randomised, placebo-controlled trial with apremilast, an oral phosphodiesterase 4 inhibitor. Ann Rheum Dis. 2014;73(6):1020-1026.1010 McInnes IB, Kavanaugh A, Gottlieb A, 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): 780-789.1111 McInnes IB, Sieper J, Braun J, et al. Efficacy and safety of secukinumab, a fully human anti-interleukin-17A monoclonal antibody, in patients with moderate-to-severe psoriatic arthritis: a 24-week, randomised, double-blind, placebo-controlled, phase II proof-of-concept trial. Ann Rheum Dis. 2014;73(2):349-356.1212 Gottlieb AB, Dann F. Comorbidities in patients with psoriasis. Am J Med. 2009;122(12):1150.e1-1150.e9.1313 Prey S, Paul C, Bronsard V, et al. Assessment of risk of psoriatic arthritis in patients with plaque psoriasis: a systematic review of the literature. J Eur Acad Dermatol Venereol. 2010;24(Suppl 2):31-35.
ADDITIONAL READING
- Donahue KE, Jonas D, Hansen RA, et al. Drug Therapy for Psoriatic Arthritis in Adults: Update of a 2007 Report. Comparative Effectiveness Review No. 54. AHRQ Publication No. 12-EHC024-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2012.
- Tillett W, McHugh N. Treatment algorithms for early psoriatic arthritis: do they depend on disease phenotype? Curr Rheumatol Rep. 2012;14(4):334-342.
CODES
ICD10
- L40.50 Arthropathic psoriasis, unspecified
- L40.51 Distal interphalangeal psoriatic arthropathy
- L40.53 Psoriatic spondylitis
- L40.52 Psoriatic arthritis mutilans
- L40.59 Other psoriatic arthropathy
- L40.54 Psoriatic juvenile arthropathy
ICD9
696.0 Psoriatic arthropathy
SNOMED
- Psoriasis with arthropathy (disorder)
- Psoriatic arthritis with distal interphalangeal joint involvement
- Psoriatic arthritis with spine involvement
- Arthritis mutilans
- Juvenile psoriatic arthritis with psoriasis
CLINICAL PEARLS
- Severity of psoriasis may correlate with the likelihood of developing arthritis; however, severity of psoriasis does not correlate with severity of arthritis; 24% of psoriasis patients develop PsA (13)[A].
- Often overlooked locations of psoriasis include scalp, ears, umbilicus, and gluteal cleft.
- Other conditions may mimic or coexist with PsA, such as osteoarthritis and polyarticular gout.
- The polyarticular pattern of PsA may mimic RA; however, the presence of enthesitis and psoriasis characterize PsA.
- Axial skeleton involvement in PsA is asymmetric and discontinuous.