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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 3  |  Page : 606-611

A study on the rheumatic manifestations of psoriasis


1 Department of Rheumatology, Physical Medicine and Rehabilitation, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Dermatology, Venereology and Sexually Transmitted Diseases, Faculty of Medicine, Menoufia University, Menoufia, Egypt
4 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission05-May-2013
Date of Acceptance24-Nov-2013
Date of Web Publication26-Nov-2014

Correspondence Address:
Jehan D Fayed
4 Gamal Abo El-Ghar Street, Shibin El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.145527

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  Abstract 

Objectives
The aim of this study was to determine the types of rheumatic manifestations in psoriasis patients and their correlation with psoriasis skin and nail lesions.
Background
The characteristic of inflammatory arthropathy associated with psoriasis is termed psoriatic arthritis (PsA) and is placed in a group known as seronegative spondyloarthropathies.
Materials and methods
In all, 100 patients with psoriasis were included in this study. They were divided according to the presence of rheumatic manifestations: patients with no rheumatic manifestations, patients with PsA, and patients with other rheumatic manifestations. Disease assessment scores such as the Psoriasis Area and Severity Index score for psoriasis severity and the Moll and Wright criteria for the PsA type were used.
Results
Forty-two percent had no rheumatic manifestations, 40% had PsA according to CASPAR criteria, and 18% had other rheumatic manifestations. In the PsA group, 57.5% had spondyloarthritis, 20% had a distal interphalangeal joint, 7.5% had polyarthritis, 10% had oligoarthritis, and 5% had arthritis mutilans. Clinical sacroiliitis occurred in 18% of the psoriasis patients and in 45% with PsA. Axial arthritis occurred in 21% of the psoriasis patients and in 52.5% with PsA. Clinical enthesitis occurred in 27% of the psoriasis patients and in 55% with PsA. Dactylitis occurred in 4% of the psoriasis patients and in 10% with PsA. Peripheral arthritis occurred in 20% of the psoriasis patients and in 42.5% with PsA. Distal interphalangeal arthritis occurred in 7% of the psoriasis patients and in 17.5% with PsA.
Conclusion
The prevalence of PsA was 40% in the studied patients with psoriasis, and the most prevalent type of PsA was spondyloarthritis. PsA occurred most commonly at an older age and with a longer duration of psoriasis. The most prevalent rheumatic manifestations were arthralgia, enthesitis, axial arthritis, sacroiliitis, and peripheral arthritis.

Keywords: arthritis, psoriasis, psoriatic arthritis, rheumatic manifestation


How to cite this article:
El-Hewala ASI, Soliman SG, Fayed JD, Gaber MA, Yassen YS. A study on the rheumatic manifestations of psoriasis. Menoufia Med J 2014;27:606-11

How to cite this URL:
El-Hewala ASI, Soliman SG, Fayed JD, Gaber MA, Yassen YS. A study on the rheumatic manifestations of psoriasis. Menoufia Med J [serial online] 2014 [cited 2020 Sep 19];27:606-11. Available from: http://www.mmj.eg.net/text.asp?2014/27/3/606/145527


  Introduction Top


Psoriasis is a chronic inflammatory cell-mediated disease affecting skin and usually presenting with symmetric, well-demarcated, erythematous plaques with overlying silvery scales, often with accompanying pruritus. Nail involvement occurs in 40-50% of psoriasis patients [1] .

Psoriatic arthritis (PsA) is a common autoimmune inflammatory condition affecting the joints and entheses of patients with psoriasis. The prevalence of inflammatory arthritis in psoriasis patients varies from 6 to 42% [2],[3] . The articular manifestation affects peripheral joints, the axial skeleton, and entheses. Some studies showed a strong association between nail lesions and distal interphalangeal (DIP) joint involvement [4] .

Arthritis in PsA is inflammatory in nature; early in the disease course, the arthritis tends to be oligoarticular, but may become polyarticular as more joints are affected over time. In addition, people with psoriasis are also more likely to develop an inflammatory spinal disease similar to ankylosing spondylitis [5] . Five major patterns of PsA are recognized: DIP involvement, symmetrical polyarthritis, asymmetrical oligoarthritis, psoriatic spondyloarthropathy, and arthritis mutilans [6] .

Dactylitis occurs in 16-48% of reported cases and is predominantly due to swelling and inflammation in the flexor tendon sheaths [7] . Enthesitis may be a presenting feature in PsA. The most common entheseal sites involved are the Achilles and plantar fascia insertions [8] .

The exact prevalence of PsA is unknown and its estimation has been difficult, partly due to the lack of a widely accepted classification or diagnostic criteria, and partly due to the fact that even experts may fail to make the correct diagnosis.


  Materials and methods Top


Patients

This study included 100 patients with psoriasis who were selected from the Dermatology Outpatient Clinic and Physical Medicine and Rehabilitation Clinic at Menoufia University Hospitals in the period from June 2011 to October 2012. Inclusion criteria were the presence of psoriatic skin lesions diagnosed by the dermatologist and patient's age above 16 years. All patients approached agreed to participate in this study, and informed consent was obtained. Exclusion criteria were the presence of other dermatological diseases, the presence of other rheumatological diseases, recent history of any drug intake, and a history of previous joint trauma or fracture. These patients were divided according to the presence or the absence of rheumatic manifestations: patients with no rheumatic manifestations, patients with PsA according to CASPAR criteria of diagnosis of PsA [9] , and patients with other rheumatic manifestations.

Methods

Patients were questioned about their current age and the age of onset of psoriasis. Inquiry was made about skin and nail lesions of psoriasis. Joint, back, buttock and entheseal pain, joint and digit swelling, morning stiffness, and deformity were also inquired about.

Clinical examination of all patients was performed in the form of general, locomotor, and dermatological examinations.

Locomotor system assessment included the assessment of peripheral joints, the spine, and periarticular structures. Peripheral joints and the spine were examined. Limitations of the range of motion were determined by the modified Schober's test [10] . The sacroiliac joints were examined. Periarticular structures were examined for dactylitis and enthesitis. Enthesitis at four major sites were examined: lateral and medial epicondyles of the humerus and the calcaneal insertions of planter fascia and Achilles tendon.

Dermatological assessment of the skin lesions was performed. The site, the size, the edge, and the color were noted along with scales, erythema, induration, and desquamation. The clinical types of psoriatic lesions were noted. Fingers and toenails were examined.

Laboratory investigations were performed in the form of complete blood count, erythrocyte sedimentation rate (by the Westergren method), rheumatoid factor (by the Rose-Waaler method), and C-reactive protein.

Radiological assessment in the form of plain radiograph of wrists, hands, ankles, feet, lumbar spine, and pelvis were performed. Both hands and feet were graded according to the Psoriatic Arthritis Ratingen Score (PARS) [11] . The pelvis and the sacroiliac joint (sacroiliitis) were graded according to the New York criteria [12] .

Disease assessment: The severity of psoriasis was assessed by the Psoriasis Area and Severity Index (PASI) [13] . Types of PsA were determined by the Moll and Wright classification [6] .

Statistical analysis results were collected, tabulated, and statistically analyzed with an IBM personal computer and SPSS version 16. Two types of statistics were performed: descriptive statistics included percentage (%), mean (x), and SD, and analytical statistics included Student's t-test, the Mann-Whitney U-test, χ2 -test, Fisher's exact test, Z-test, and Pearson's correlation analysis. The difference was considered significant if P-value was less than 0.05, nonsignificant if P-value was greater than 0.05, and highly significant if P-value was less than 0.001.


  Results Top


This study included 100 patients with psoriasis skin disease; patient's age ranged from 19 to 78 years, with a mean age of 45.9 years, and the number of male patients was slightly higher than the number of female patients. Also, the disease duration of psoriasis in the study group ranged from 0.25 to 25 years, with a mean disease duration of 5.9 years.

Types of psoriasis in this study were as follows: 86 (86%) plaque psoriasis, nine (9%) guttate psoriasis, four (4%) erythrodermic psoriasis, and one (1%) inverse psoriasis. Also, psoriasis nail lesion was found in 29 (29%) patients.

In the study group, 42 (42%) patients had no rheumatic manifestations, 40 (40%) patients had PsA according to CASPAR criteria, and 18 (18%) patients had other rheumatic manifestations as shown in [Table 1].
Table 1: Distribution of the studied psoriasis patients according to the presence of rheumatic manifestations


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The types of PsA in the study psoriasis group according to the Moll and Wright criteria were as follows: 23 (57.5%) spondyloarthritis, eight (20%) DIP joint, four (10%) oligoarthritis, three (7.5%) polyarthritis, and two (5%) arthritis mutilans as shown in [Table 2].
Table 2: Distribution of the psoriatic arthritis patients regarding Moll and Wright criteria


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The mean age and the disease duration of the PsA group were significantly higher than that of the non-PsA group. There was no significant difference regarding sex between the two groups as shown in [Table 3].
Table 3: Relation between the psoriatic arthritis group and the nonpsoriatic arthritis group regarding demographic criteria


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[Table 4] shows that arthralgia was found in 44 (44%) psoriasis patients and in 22 of 40 (55%) patients with PsA. Morning stiffness of the back was found in 10 (10%) psoriasis patients and in nine of 40 (22.5%) patients with PsA. Clinical sacroiliitis was found in 18 (18%) psoriasis patients and in 18 of 40 (45%) patients with PsA. Axial arthritis was found in 21 (21%) psoriasis patients and in 21 of 40 (52.5%) patients with PsA. Clinical enthesitis was found in 27 (27%) psoriasis patients and in 22 of 40 (55%) patients with PsA. Dactylitis was found in four (4%) psoriasis patients and in four of 40 (10%) patients with PsA. Peripheral arthritis was found in 20 (20%) psoriasis patients and in 17 of 40 (42.5%) patients with PsA. DIP arthritis was found in seven (7%) psoriasis patients and in seven of 40 (17.5%) patients with PsA. Radiological enthesitis was found in 35 (35%) psoriasis patients and in 27 of 40 (67.5%) patients with PsA. Radiological sacroiliitis was found in 21 (21%) psoriasis patients and in 21 of 40 (52.5%) patients with PsA. The mean PARS score was found to be higher in the PsA group (9.8) than in psoriasis group (7.08).
Table 4: Distribution and frequency of the studied psoriasis group and the psoriatic arthritis group regarding rheumatic manifestations


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There was no significant relation between the presence of psoriatic nail lesion and DIP joint arthritis as shown in [Table 5].
Table 5: Relation between distal interphalangeal and nail lesion


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There was no significant difference regarding the PASI score (mild, moderate, or severe) between the psoriasis group and the PsA group.


  Discussion Top


There is no general agreement in the literature regarding the prevalence of PsA. The estimate of prevalence has been difficult because of the paucity of a widely accepted classification or diagnostic criteria and the difficulty of most experts in making a correct diagnosis [14] .

The typical clinical features of PsA include DIP involvement, which occurs in more than half of the patients; oligoarticular involvement and the spondyloarthropathy form occur in about half of the patients; patients also have dactylitis and enthesitis [15] .

In this study, plaque psoriasis (86%) was the most common type of psoriasis, followed by guttate (9%), erythrodermic (4%), and inverse (1%) types. This is in agreement with Gunal et al. [16] and Carneiro et al. [17] , who found plaque psoriasis (68%) to be the most common type.

In this study, psoriatic nail lesion was found in 29% of the study group, which is in disagreement with Gunal et al. [16] , who found nail changes in 57% of their patients.

In this study, the prevalence of rheumatic manifestations was 58% of psoriasis patients. This is in agreement with Sadek et al. [2] , who found rheumatic manifestations in 73% of their psoriasis patients.

In contrast, Gisondi et al. [18] found the prevalence of rheumatic manifestations in 17% of psoriasis patients.

In this study, the prevalence of PsA was 40% of psoriasis patients. This is in agreement with Carneiro et al. [17] , who found the prevalence of PsA to be 35%. This high frequency may be due to the increased awareness of the manifestation of the disease or the recent use of a more sensitive criteria of diagnosis.

In contrast, Radtke et al. [19] found the prevalence of PsA to be 19% of psoriasis patients. The low prevalence in this study may be due to the young age of the study group or the use of different diagnostic criteria.

In this study, 18% of the psoriasis patients had no rheumatic manifestations. This is in disagreement with Carneiro et al. [17] , who found 31% of psoriasis patients with no rheumatic manifestations.

In this study, the most common type of PsA was spondyloarthritis (57%), followed by DIP joint arthritis (20%), oligoarthritis (10%), polyarthritis (7.5%), and arthritis mutilans (5%) according to the Moll and Wright criteria. This is in disagreement with Yang et al. [20] , who found oligoarthritis in 48.2%, followed by spondyloarthritis in 26.8%, polyarthritis in 19.6%, and DIP joint arthritis in 5.4% of the cases.

In contrast, Reich et al. [21] found polyarthritis in 58%, followed by oligoarthritis in 31.6%, DIP joint arthritis in 41.0%, and arthritis mutilans in 4.9% of the cases. This variability may be due to the fact that PsA starts as oligoarticular early in the disease, and then evolves into polyarticular and spondyloarticular as more joints become affected with longer disease duration.

In this study, the age was significantly higher in the PsA group than in the non-PsA group. This is in agreement with Carneiro et al. [17] , who found a statistically significantly higher age in PsA patients and this may be due to the increase of arthritis with advanced age.

In this study, the disease duration was significantly longer in the PsA group than in the non-PsA group. Also, El-Kayam et al. [22] found a statistically significantly longer disease duration in PsA patients.

In this study, there was no significant difference between the PsA group and the non-PsA group regarding sex. This is in agreement with Gunal et al. [16] .

In contrast, Gisondi et al. [18] found that the number of female patients was significantly higher in the PsA group than in the non-PsA group.

In this study, clinical sacroiliitis was found in 18% of the psoriasis patients and in 45% of the PsA group. A similar frequency was reported by Sadek et al. [2] , who found clinical sacroiliitis in 18% of their psoriasis patients, but the frequency was lower in the PsA group (25%) compared with this study. In contrast, Kacar et al. [23] found a higher frequency of sacroiliitis: 26% of psoriasis patients in a study sample including 133 psoriasis patients; their large sample size may explain the higher frequency of sacroiliitis.

In this study, axial arthritis was found in 21% of the psoriasis patients and in 52.5% of the PsA group. A higher frequency was reported by Sadek et al. [2] , who found axial arthritis in 42% of their psoriasis patients, but the frequency in the PsA group (51%) was the same as in this study [2] . This difference in frequency may be due to the small sample size in this study.

In this study, clinical enthesitis was found in 27% of the psoriasis patients and in 55% of the PsA group. A higher frequency was reported by Sadek et al. [2] , who found clinical enthesitis in 44% of their psoriasis patients, but the frequency in the PsA group (61%) was similar to this study. In contrast, Ibrahim et al. [24] found clinical enthesitis in a lower frequency (10%) of psoriasis patients.

In this study, dactylitis was found in 4% of the psoriasis patients and in 10% of the PsA group. A similar frequency was reported by Ibrahim et al. [24] , who found dactylitis in 1% of their psoriasis patients and in 8% of the PsA group.

In this study, peripheral arthritis was found in 20% of the psoriasis patients and in 42.5% of the PsA group. Gisondi et al. [18] found peripheral arthritis in 10% of their psoriasis patients. However, Sadek et al. [2] found peripheral arthritis in 42% of their psoriasis patients. Both authors found frequencies of peripheral arthritis in the PsA group to be higher than that in our study: 67.5 and 58%, respectively.

In this study, DIP joint arthritis was found in 7% of the psoriasis patients and in 17% of the PsA group. This is in agreement with Jamshidi et al. [25] , who found DIP joint arthritis in 17.3% of the PsA group. In contrast, Reich et al. [21] found DIP joint arthritis in 41% of the PsA group, which is much higher than in this study.

In this study, radiological enthesitis was found in 35% of the psoriasis patients and in 67.5% of the PsA group. However, Sadek et al. [2] found radiological enthesitis in 58% of their psoriasis patients and in 64% of the PsA group. In contrast, Carneiro et al. [17] found a lower frequency of radiological enthesitis: 13% of their psoriasis patients and 33% of the PsA group, which may be due to the use of a smaller sample size.

In this study, radiological sacroiliitis was found in 21% of the psoriasis patients and in 52.5% of the PsA group. This is in agreement with Kacar et al. [23] , who found a similar frequency of 26% radiological sacroiliitis in psoriasis patients. However, Sadek et al. [2] found radiological sacroiliitis in 39% of the PsA group, which is lower than that found in this study. Radiographic sacroiliitis was found to be as high as 34-78% in patients with PsA [26] .

In this study, the mean PARS score was higher in the PsA group than in the psoriasis patient group. This is in agreement with Sadek et al. [2] .

In this study, there was no significant relation between psoriatic nail lesion and DIP joint arthritis. This is in agreement with Gunal et al. [16] . In contrast, Scarpa et al. [27] found a significant relation between psoriatic nail lesion and DIP joint arthritis in PsA patients.

In this study, there was no significant difference between the PsA group and the non-PsA group regarding the PASI score. This is in agreement with Sadek et al. [2] .

In this study, there was significant correlation between the PASI score and the sacroiliitis score. This is in agreement with Kacar et al. [23] . In contrast, Busquets-Pιrez et al. [28] found the PASI score to be significantly higher in PsA patients.


  Conclusion Top


Our results showed that there was a high prevalence of PsA (40%) in the studied patients with psoriasis, and the most prevalent type of PsA was spondyloarthritis (57.5%). PsA occurs most commonly at an older age and with long disease duration of psoriasis. The most prevalent clinical rheumatic manifestations were arthralgia, enthesitis, axial arthritis, sacroiliitis, and peripheral arthritis in descending order. The most prevalent radiological rheumatic manifestations were enthesitis followed by sacroiliitis. There was no significant relation between nail lesion and DIP joint arthritis.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

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