A clinical perspective on risk factors and signs of subclinical and early psoriatic arthritis among patients with psoriasis

Figures & data

Figure 1. Continuum of preclinical phases of PsA (12,13). MRI: magnetic resonance imaging; MSK: musculoskeletal; PsA: psoriatic arthritis.

Table 1. Summary of MRI and classical radiography for the identification of PsA-associated changes to peripheral and axial joints.

	Peripheral PsA	Axial PsA
MRI
Features detectable upon imaging	Inflammation: Synovitis, tenosynovitis, periarticular inflammation, bone marrow edema Structural changes: Erosions, bone proliferation
Anatomical regions to image	Hands (39,40) Feet (39)	SI joints (43) Spine (not recommended by EULAR for diagnosis, but may provide useful information on disease activity) (43)
Useful MRI sequences	T1-weighted sequences acquired in 2 planes (inflammation and structural changes) (40) T2-weighted FS or STIR (inflammation and structural changes) (40) T1-weighted with Gd contrast agent (tissue inflammation, synovitis, and tenosynovitis) (40)	EULAR recommends that STIR is sufficient to detect inflammation, and contrast enhancement is generally not necessary (43)
Classical radiography
Features detectable upon imaging	Structural changes: Erosions, joint space narrowing
Anatomical regions to image	Hands (44) Feet (44)	SI joints (43) Spine (43)

EULAR: European Alliance of Associations for Rheumatology (formerly European League Against Rheumatism); FS: fat saturation; Gd: gadolinium; MRI: magnetic resonance imaging; PsA: psoriatic arthritis; SI: sacroiliac STIR: short-tau inversion recovery.

Table 2. Summary of risk factors of subclinical PsA or progression to PsA among patients with psoriasis.

Risk factor	Magnitude of effect	What dermatologists should know
Inverse psoriasis	Increased risk of PsA; HR = 2.35 (49)	Patients with inverse psoriasis should be routinely screened for PsA
Scalp psoriasis	Increased risk of PsA; HR = 3.89 (49)	Dermatologists should be aware of the increased risk of PsA among patients with scalp psoriasis
Nail psoriasis	Nail psoriasis; OR = 1.76 (50) Nail dystrophy; HR = 2.24 (49) Nail pitting; RR = 2.21 (51)	Dermatologists should closely monitor patients for nail involvement and screen for PsA in patients with nail disease
Psoriasis severity	Number of affected sites (≥3 sites vs 1 site); HR = 2.24 (49) Maximum BSA 76%–100%; OR = 2.52 (52)	Although PsA can manifest in patients with psoriasis of any severity, dermatologists should be aware of the increased risk of PsA in patients with the most severe cutaneous disease
PROs capturing MSK symptoms	Stiffness (VAS > 2); HR = 3.06 (12) Pain (VAS > 2); HR = 2.66 (12) Morning joint stiffness; HR = 2.25 (12) Back stiffness; HR = 3.71 (12) Fatigue (mFSS > 5); HR = 3.09 (12)	Dermatologists should routinely ask about/screen for MSK symptoms
Obesity	BMI ≥ 30 vs 18–25 kg/m^2; OR = 2.2 (51) Obesity at age 18 years is associated with the development of PsA; OR = 1.06 (50)	Obese patients with psoriasis are more likely to develop PsA; history of obesity should be considered
Family history	Family history of PsA is highly associated with the development of PsA in patients with psoriasis; OR = 20.5 (52)	Dermatologists should thoroughly investigate family history of PsA in patients with psoriasis

BMI: body mass index; BSA: body surface area; HR: hazard ratio; mFSS: modified Fatigue Severity Scale; MSK: musculoskeletal; OR: odds ratio; PRO: patient-reported outcome; PsA: psoriatic arthritis; RR: relative risk; VAS: visual analog scale.

Table 3. Summary of current screening tools for PsA in patients with psoriasis.

	Advantages	Disadvantages
Clinical instruments
PASE (76,80)	Self-administered assessment Designed to identify patients with inflammatory MSK disease in dermatology clinics Can distinguish between PsA and osteoarthritis	Susceptible to detection of degenerative or osteoarthritis as false-positive results (81)
PEST (75,82)	Convenient, based on 5 questions Nonproprietary, free to use	Specificity is relatively low (0.78) (82) Susceptible to detection of degenerative or osteoarthritis as false-positive results (81)
EARP (42)	Straightforward and fast, robust for detection of early PsA
ToPAS/ToPAS II (77,78)	Patients use reference images to identify symptoms Sensitivity and specificity > 85% have been demonstrated in a variety of clinical settings (77) Slightly higher sensitivity vs PASE at detecting PsA in patients with psoriasis (81)	Susceptible to detection of degenerative or osteoarthritis as false-positive results (81)
CONTEST	Slightly higher sensitivity and specificity in direct comparison with other questionnaires (79)
‘PsA’ mnemonic (83)	Convenient and helpful for rapid assessment of subclinical PsA symptoms in any clinical setting	Not validated as a screening tool; should prompt screening tool use and/or referral

EARP: Early Arthritis for Psoriatic Patients; MSK: musculoskeletal; PASE: Psoriatic Arthritis Screening and Evaluation; PEST: Psoriasis Epidemiology Screening Tool; PsA: psoriatic arthritis; ToPAS: Toronto Psoriatic Arthritis Screen.

Figure 2. Proposed framework for the clinical identification of MSK symptoms in patients with psoriasis (87). IDEOM: International Dermatology Outcome Measures; MSK: musculoskeletal; PEST: Psoriasis Epidemiology Screening Tool; PsA: psoriatic arthritis; PsAID: Psoriatic Arthritis Impact of Disease. *Based on validated cutoff values for patient acceptable symptoms state. Reprinted with permission from The Journal of Rheumatology, Perez-Chada LM, et al. Report of the Skin Research Working Groups From the GRAPPA 2020 Annual Meeting. J Rheumatol. 2021;jrheum.201668. All Rights reserved.

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