Diagnosing Psoriatic Arthritis for the Dermatologist: Guidance From the Experts

Drs Alice Gottlieb and Joseph Merola present a masterclass for dermatologists in how to recognize psoriatic arthritis in their patients, thereby enabling prompt intervention.
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-- TRANSCRIPT --
Joseph F. Merola, MD, MMSc, FAAD, FACR: Hello, and welcome. I'm Joe Merola. I'm absolutely delighted to be with a dear friend and colleague here from Medscape, presenting our masterclass in psoriatic arthritis. Alice, I'll turn it over to you for introductions.
Alice B. Gottlieb, MD, PhD: I'm going to talk about the key importance of dermatologists in preventing disability due to psoriatic arthritis. As you see on this slide, be a hero, and your patients will think you are a hero for doing it. We're going to talk about diagnosing psoriatic arthritis for the dermatologist and making a real difference in our patients' lives. I'll show you that it's easy.
As you know, both Joe and I are dermatologists and rheumatologists, boarded in both specialties. I'm at Mount Sinai in New York City, and Joe is chair of dermatology at UT Southwestern Medical Center. Here are our disclosures.
I'm going to say, for myself, my biggest disclosure is my mother, of blessed memory, who had psoriasis and psoriatic arthritis and was truly helped by one of the drugs I helped develop. I am grateful to these companies for giving us these great drugs.
Here's, from my point of view, my most important slide. Psoriatic arthritis is common. It occurs overall in about 25%-30% of patients with psoriasis, and in most cases, it's not hard to diagnose.
If you make the mistake and you give the rheumatologist an osteoarthritis, rheumatoid arthritis, or fibromyalgia patient, they need a doctor, too. You haven't done any harm. You've done good.
However, if you've missed a psoriatic arthritis patient, you may make the wrong treatment choice and do the patient harm. Why? Because psoriatic arthritis is potentially disabling, and it's a real shame that psoriatic arthritis frequently goes undiagnosed up to 41% in dermatology practices.
It's even more of a shame, because we have a lot of time to make that diagnosis. The cutaneous disease precedes the arthritis in 84% of patients by 10 or 12 years. Who's the first doctor who really can detect arthritis? It's a dermatologist. This is not the responsibility of primary care. It is our responsibility.
Why does it matter? We have tumor necrosis factor (TNF) blockers, interleukin (IL)-17 blockers, and Janus kinase (JAK) inhibitors that not only control signs and symptoms but also inhibit radiographic progression. By diagnosing psoriatic arthritis early, we can prevent disability by initiating the correct treatment early on.
Also, I don't see how you can treat psoriasis if you don't know if the patient has psoriatic arthritis. If somebody has a little bit of psoriasis - many psoriatic arthritis patients have limited disease - and you give them a topical steroid and you don't ask about their joint complaints, you will have missed an essential part of the diagnosis and you may do harm because you delayed diagnosis.
This brings me to the point that although people with moderate to severe psoriasis are more likely to have psoriatic arthritis, there are patients who have almost no psoriasis, who basically have bad psoriatic arthritis.
Here are the domains of psoriatic arthritis. Peripheral arthritis signs and symptoms. Axial disease, spinal disease. Enthesitis - inflammation where the ligaments and tendons insert into bone. Dactylitis - fat sausage fingers caused by inflammation of the whole finger or toe unit. Skin and nail issues.
Dr Merola developed with his team this easy physical exam. “It's as easy as PSA”: P is for pain in joints. S is for stiffness - either prolonged stiffness after a period of inactivity, for at least 30 minutes when waking up or after a long car trip - and sausage digits (dactylitis). And A is for axial disease, a spinal disease associated with stiffness that is exacerbated by inactivity and improves with activity.
If two or more of the above are present, then a formal screening for psoriatic arthritis should be completed. Thank you, Joe, for this easy physical exam.
There are doctors who don't really want to do anything to diagnose psoriatic arthritis, so we developed a methodology so that the patient does most of the work, if not all the work.
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