Psoriatic Arthritis Clinical Manifestation

In general, there are five clinical phenotypes of psoriatic arthritis (PsA), which may occur individually or in combination.  One subtype may evolve over time into a different one:

  1. Symmetrical polyarthritis (30-50% of cases) is likely the most common phenotype of PsA.
  2. Asymmetrical oligoarthritis is also a common presentation of PsA.
  3. Distal interphalangeal (DIP) joint involvement is virtually always associated with nail psoriasis (image below).
    dip involvement
  4. Arthritis mutilans is characterized by resorption of the phalanges (image below).
    dip involvement
  5. Axial arthritis may be different in character from ankylosing spondylitis, the prototypical HLA-B27-associated spondyloarthritis. It may present as inflammatory low back pain with radiographic evidence of sacroiliitis, which is usually asymmetrical and can be asymptomatic, or spondylitis, which may occur without sacroiliitis and may affect any level of the spine in a non-contiguous manner.

In addition to psoriasiform lesions, there are a number of other characteristic, though not necessarily pathognomonic, clinical features of PsA:

  • Nail involvement may be manifested as onycholysis (image below),
    example of onycholysis
    or nail pitting (image below).
    oil-drop sign
  • Dactylitis presents as the so-called “sausage digit”, diffuse swelling of the entire digit likely due to a combination of both arthritis and tenosynovitis (image below).
    dactylitis
  • Enthesitis, inflammation at insertion sites of tendon to bone (images below), is a shared characteristic of the spondyloarthritis.
    enthesitis
  • Extra-articular manifestations occur infrequently, but may include ocular inflammation (e.g. conjunctivitis, episcleritis, scleritis, and iritis), oral ulcers, and urethritis.

References

1. Willkens RF, Williams HJ, Ward JR, et al: Randomized, double blind, placebo-controlled trial of low dose pulse methotrexate in psoriatic arthritis. Arthritis Rheum 27:376, 1984.

2. Espinoza LR, Zakraoni L, Espinoza CG, et al: Psoriatic arthritis: Clinical response and side effects of methotrexate therapy. J Rheumatol 19:872, 1992.

3. Gupta AK, Matteson EI, Ellis CN, et al: Cyclosporin in the treatment of psoriatic arthritis. Arch Dematol 125:507, 1989.

4. Salvarani C, Macchioni P, Olivieri I, et al: A comparison of cyclosporine, sulfasalazine, and symptomatic therapy in the treatment of psoriatic arthritis. J Rheumatol 28:2274, 2001.

5. Sarzi-Puttini P, Cazzola M, Panni B, et al: Long-term safety and efficacy of low-dose cyclosporin A in severe psoriatic arthritis. Rheumatol Int 21:234, 2002.

6. Mease PJ: Etanercept in the treatment of psoriatic arthritis and psoriasis: a randomized trial. Lancet 356:385, 2000.

7. Mease PJ: Cytokine blockers in psoriatic arthritis. Ann Rheum Dis 60:iii37, 2001.

8. Iyer S, Yamauchi P, Lowe NJ: Etanercept for severe psoriasis and psoriatic arthritis: observations on combination therapy. Br J Dermatol 146:118, 2002.

9. Cauza R, Spak M, Cauza K, Hanusch-Enserer U, Dunky A, Wagner E. Treatment of psoriatic arthritis and psoriasis vulgaris with the tumor necrosis factor inhibitor infliximab. Rheumatol Int 22(6):227, 2002.

10. Antoni C, Dechant C, Hannis-Martin Lorenz PD, Wendler J, Ogilvie A, Lueftl M, Kalden-Nemeth D, Kalden JR, Manger B. Open-label study of infliximab treatment for psoriatic arthritis: clinical and magnetic resonance imaging measurements of reduction of inflammation. Arthritis Rheum 47(5):506, 2002.

11. Mease PJ, Gladman DD, Ritchlin CT, Ruderman EM, Steinfeld SD, Choy EH, Sharp JT, Ory PA, Perdok RJ, Weinberg MA; Adalimumab Effectiveness in Psoriatic Arthritis Trial Study Group.Arthritis Rheum. Adalimumab for the treatment of patients with moderately to severely active psoriatic arthritis: results of a double-blind, randomized, placebo-controlled trial. Arthritis Rheum 52(10):3279-89, 2005.

*Images within this article are from the American College of Rheumatology Slide Collection.

Updated: March 27, 2012

Grant Louie, M.D., M.H.S.

About Grant Louie, M.D., M.H.S.

Assistant Professor of Medicine
Johns Hopkins University