|Year : 2022 | Volume
| Issue : 4 | Page : 479
|A joint consensus of rheumatologists and dermatologists on early detection and effective management of psoriatic arthritis: India's perspective
Manas Chatterjee1, Chitra Nayak2, Abhishek De3, Samir Rajadhyaksha4, GK Singh5, Phani Kumar6, S Balameena7, M Harish Kumar8, M Hema9, Gautam Dhar Choudhury10, Ghan Shyam Pangtey11, Jatinder Singh12, Neeraj Jain13
1 From the Command Hospital, Kolkata, West Bengal, India
2 Nair Hospital, Mumbai, Maharashtra, India
3 Calcutta National Medical College, Kolkata, West Bengal, India
4 Global Hospital, Parel, Mumbai, Maharashtra, India
5 Base Hospital, Delhi, India
6 NIMS, Hyderabad, Telangana, India
7 Department of Rheumatology, Kilpauk Medical College, Chennai, Tamil Nadu, India
8 Department of Rheumatology, Command Hospital, Bangalore, Karnataka, India
9 Department of Rheumatology, Stanley Medical College, Chennai, Tamil Nadu, India
10 Department of Rheumatology and Clinical Immunology, Command Hospital (Eastern Command), Alipore Road, Kolkata, West Bengal, India
11 LHMC, Delhi, India
12 AFMC, Pune, Maharashtra, India
13 Sir Ganga Ram Hospital, Delhi, India
|Date of Web Publication||2-Nov-2022|
Calcutta National Medical College, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Psoriatic arthritis (PsA) is a chronic inflammatory disease with clinical manifestations, including inflammatory arthritis and the presence of psoriasis (PsO). The present consensus statement evaluated the early diagnosis and treatment approaches in the management of psoriasis and psoriatic arthritis by rheumatologists and dermatologists. For PAN India representation, a panel of eight rheumatologists and five dermatologists from different institutes in India were constituted. These thirteen experts were divided into two groups (rheumatologists group and dermatologist group) who received a set of questionnaires each for diagnosis and treatment approaches in the management of psoriasis and psoriatic arthritis. Based on the responses received, a panel discussion took place, where the experts identified the early diagnostic criteria for PsA considering: Clinical signs and symptoms, and questionnaire-based PsA screening, which includes Psoriasis Epidemiology Screening Tool (PEST) for dermatologists and Classification Criteria for Psoriatic Arthritis (CASPAR) for rheumatologists. The experts also recommended shift from conventional disease-modifying anti-rheumatic drugs (DMARDs) to biologics like secukinumab, when there is extensive skin involvement and TNF inhibitors when there is extensive joint involvement. Overall, the objective of the consensus was to assist rheumatologists and dermatologists in the early diagnosis and management of patients of PsA and PsO in their clinical practice.
Keywords: Classification criteria for psoriatic arthritis, psoriasis epidemiology screening tool, psoriatic arthritis
|How to cite this article:|
Chatterjee M, Nayak C, De A, Rajadhyaksha S, Singh G K, Kumar P, Balameena S, Kumar M H, Hema M, Choudhury GD, Pangtey GS, Singh J, Jain N. A joint consensus of rheumatologists and dermatologists on early detection and effective management of psoriatic arthritis: India's perspective. Indian J Dermatol 2022;67:479
|How to cite this URL:|
Chatterjee M, Nayak C, De A, Rajadhyaksha S, Singh G K, Kumar P, Balameena S, Kumar M H, Hema M, Choudhury GD, Pangtey GS, Singh J, Jain N. A joint consensus of rheumatologists and dermatologists on early detection and effective management of psoriatic arthritis: India's perspective. Indian J Dermatol [serial online] 2022 [cited 2022 Nov 26];67:479. Available from: https://www.e-ijd.org/text.asp?2022/67/4/479/360367
| Introduction|| |
Psoriatic arthritis (PsA) is a complex chronic inflammatory disease. It is associated with various clinical phenotypes, such as arthritis, enthesitis, dactylitis and axial disease. The hallmarks of PsA are inflammatory arthritis, with the presence of psoriasis (PsO) and the absence of positive serological tests for rheumatoid arthritis (RA).
The prevalence of PsA among psoriasis patients varies from 6.25% to 48% in western countries, whereas data in India is lacking. Underreporting by patients in the early/asymptomatic stages of the disease may lead to underestimating the burden of PsA.
In 60%–70% of patients, PsO precedes PsA, while in 15–20%, arthritis precedes the onset of PsO. The typical clinical signs and symptoms in PsO patients are vague pain, stiffness followed by inflammation and distal interphalangeal joints involvement, and pitting of nails. However, due to the diverse nature of the clinical spectrum of PsA, psoriatic patients may present with axial skeleton disorders, peripheral joint inflammation, nail changes, entheses, tenosynovitis or dactylitis. Each of these conditions can be found in isolation or in combination with others.
In 20% of cases, rheumatologic manifestations can occur before the skin lesions of psoriatic disease, making the diagnosis difficult. The early diagnosis of PsA is challenging due to similar signs and symptoms with diseases like osteoarthritis, RA and other spondyloarthritic conditions. Early diagnosis of PsA mainly depends on a thorough clinical examination as no biomarker is available for the confirmation of disease. Few studies conducted in Asia reported a delayed diagnosis. A study from Japan observed the onset of arthritis after a mean period of 11.2 years of onset of psoriasis in approximately 76% of patients., Another study demonstrated a delay of 6–12 months in rheumatologic consultation, resulting in a delay in the diagnosis of PsA; this delay contributes to worst outcomes like long-term joint damage and functional disability.,, Thus, early diagnosis and management are recommended to achieve better outcomes.
Considering the gravity of late diagnosis and for enhancing early recognition by dermatologists and General Practitioners (GPs), several screening questionnaires have been developed by various authorities. The tools include Psoriasis Epidemiology Screening Tool (PEST), Psoriatic Arthritis Screening and Evaluation (PASE), Early Arthritis for Psoriatic Patients (EARP), Toronto Psoriatic Arthritis Screening Questionnaire (ToPAS), and the Psoriasis and Arthritis Screening Questionnaire (PASQ). Another criteria used is Classification Criteria for Psoriatic Arthritis (CASPAR), which includes several features of the established inflammatory articular disease typical of PsA, such as psoriasis, nail disease, dactylitis and negative serology.,
PsA leads to impairment of functional status and reduced quality of life (QoL). Symptomatic manifestations in PsA can be controlled with the help of traditional DMARD, but there is no evidence that they prevent or significantly decrease the rate of progression of structural joint damage.
In the therapeutic regimen, to alleviate the signs and symptoms of PsA, DMARDs and methotrexate demonstrated insufficient efficacy. There are few guidelines or recommendations on its management despite the significant clinical relevance of PsA. The rapid development of effective targeted therapies has significantly changed the scope of PsA treatment.
It is critical to bridge the gap between rheumatologists and dermatologists in the management of patients with PsA. The present consensus statement on diagnosis and management is made to ensure that patients with PsA are not missed during screening and are effectively treated before irreversible damage is caused.
| Methodology and Objective|| |
An expert group of eight rheumatologists and five dermatologists from major institutes in India were invited for a panel discussion at Mumbai in Oct 2018 to have a joint consensus on early detection and effective management of psoriatic arthritis [Figure 1]. The major points discussed included: (i) Patient presentation and early diagnosis of psoriasis and psoriatic arthritis by rheumatologists and dermatologists, and (ii) development of a common protocol for treatment approaches in the management of psoriasis and psoriatic arthritis with respect to different stages of disease progression and comorbidities.
Focus on screening/Diagnosis: Patient presentation and early diagnosis of psoriasis and psoriatic arthritis
Almost 50% of cases in primary care and secondary care clinics are unrecognised. Around 30% of the patients with psoriasis develop rheumatologic manifestations.
There is a significant delay in the diagnosis of PsA due to the presence of undifferentiated signs and symptoms of other diseases, including osteoarthritis, RA and other spondyloarthritic conditions.
Several screening questionnaires for PsA have been developed for use in dermatology and primary care centres across the globe. The sensitivity and specificity of these questionnaires are mentioned in [Table 1].
Proper use of these tools will facilitate early diagnosis of PsA and minimise comorbidities of PsA and disease complications.
The Classification Criteria for Psoriatic Arthritis (CASPAR) was developed using data collected from patients with long-standing PsA. It is based on established diagnostic criteria for inflammatory articular disease. A patient is established as a psoriatic arthritis case if presented with inflammatory arthritis, spondylitis or enthesitis with ≥3 points. The modified criteria include additional clinical findings specific to PsA, such as the presence of psoriatic nail dystrophy, a negative Rheumatoid Factor (RF) test, dactylitis and radiographic evidence of juxta-articular bone formation. It was suggested that rheumatologists should use CASPAR criteria for the diagnosis of PsA because of its increased diagnostic yield. Also, this criterion is widely used and accepted among rheumatologists.
Based on expert opinion, the group suggested PEST as a useful screening questionnaire for dermatologists. The reason behind this is that PEST is simple and easy to score and has high sensitivity. [Figure 2] presents brief recommendations for patient presentation and early diagnosis of psoriasis and psoriatic arthritis.
|Figure 2: Brief recommendations (from meeting excerpts): Patient presentation and early diagnosis of psoriasis and psoriatic arthritis (PsA: Psoriatic Arthritis, CASPAR: Classification Criteria for Psoriatic Arthritis)|
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A dermatologist should routinely screen PsO patients for signs and symptoms of PsA. These signs and symptoms include complaining about the beginning of joint involvement like vague pain, major joint pain, stiffness and inflammation, more in the morning on waking up from bed or waking up the patient at night and improving during the course of the day. The severity of joint symptoms can be assessed in psoriasis patients with a careful look at patient history, which includes detailed personal and family history of psoriasis; thorough clinical examination; and radiographic evidences of juxta-articular new bone formation. Reports of routine blood investigations, including acute phase reactant, erythrocyte sedimentation rate (ESR), RF, C-Reactive Protein (CRP) and standard radiology, should be checked.
A dermatologist should refer PsA patients to a rheumatologist once the musculoskeletal and systemic involvement is established, along with a positive screening questionnaire. Similarly, rheumatologists should refer patients to dermatologists if there is the involvement of scaly lesions or extensive skin involvement. The dermatologist will check for psoriasis in hidden areas such as gluteal region and scalp.
Topical treatments are not enough for patients with underlying PsA. Hence, systemic therapies should be introduced. Several expert groups developed standard protocols for the management of PsA, which mainly deal with pharmacological treatments. At the international level, two recommendation sets are available: One developed by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and another by the European League against Rheumatism (EULAR) [Figure 3] and [Figure 4]. Both recommendation sets propose an overlapping approach to the treatment of PsA. [Table 2] presents the comparison of GRAPPA and EULAR Guidelines.
|Figure 3: GRAPPA Management recommendations (GRAPPA: Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, NSAID: Non-steroid anti-inflammatory drugs, IA DMARDs: Intra-Articular Disease-Modifying Anti-Rheumatic Drugs, MTX: Methotrexate, CsA: Cyclosporine A, SSZ: Sulfasalazine, LEF: Leflunomide, Anti-TNF: Anti-Tissue Necrosis Factor)|
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|Figure 4: EULAR Management recommendations. (a) Phase I, (b) Phase II, (c) Phase III (EULAR: European League Against Rheumatism, DMARDs: Disease-Modifying Anti-Rheumatic Drugs, MTX: Methotrexate, TNF: Tissue Necrosis Factor)|
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The use of disease-modifying anti-rheumatic drugs (DMARDs) is considered when the patients become non-responsive to non-steroid anti-inflammatory drugs (NSAIDs) and steroids. The addition of biologics is recommended if the response to DMARDs is inadequate and if there is axial involvement. Depending upon treatment response, generally, the dosage is adjusted. The biologics are generally considered if there is a flare in psoriasis. Also, there should be a change in treatment modality if new comorbidities, adverse effects develop, or there is a decrease in QoL. [Table 3] presents the conditions for switching conventional DMARDs to biologics.
The parameters taken into consideration for the management apart from pain are extra-articular symptoms such as uveitis, inflammatory bowel disease, and comorbidities like cardiac disease, obesity, fatty liver disease, psychiatric disorders, etc. The experts recommended that a switch from conventional DMARDs to biologics is considered if there is an inadequate response to conventional DMARDs by 3 to 6 months, and extra-articular manifestation and comorbidities are present. [Figure 5] presents brief recommendations from meeting excerpts for treatment approaches in the management of psoriasis and psoriatic arthritis.
|Figure 5: Brief Recommendations (from meeting excerpts): Treatment approaches in the management of psoriasis and psoriatic arthritis (PsO: Psoriasis, PsA: Psoriatic Arthritis, DMARDs: Disease-Modifying Anti-Rheumatic Drugs, IBD: Inflammatory Bowel Disease, TB: Tuberculosis, TNF: Tissue Necrosis Factor)|
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Limitation and strengths in line with current recommendations
Management recommendations have strengths like:
- They help in presenting the consensus in a rationalised manner and in a simple format such as how to manage disease in terms of treatment choices, usually in a table and/or an algorithm/figure.
- They provide the latest vision to choose the optimal management for PsA patients, which is helpful for physicians and other stakeholders who treat patients with PsA with a practical approach.
- They provide information about recent treatment recommendations, which are undoubtedly valuable.
Management recommendations also have limitations, which must be recognised.
- With advancements in research and availability of new effective modalities, these recommendations may become quickly outdated.
- They cannot represent the view of all physicians as they only include the consensus of a limited number of persons, though senior recognised experts in the field in India.
- They represent group-level general outlines that may not apply to a specific, individual patient.
| Summary|| |
This was an expert consensus to guide rheumatologists and dermatologists in the early diagnosis and management of psoriasis patients with PsA in their clinical practice. In particular, the most useful screening questionnaires, various approaches to detect PsA early, management recommendations and the criteria for referral to rheumatologists and dermatologists were agreed. The perspective of rheumatologists and dermatologists were similar both on the early detection of PsA as well as management. The recommendations covered the standard protocols to be followed for the early diagnosis and management of the disease. The consensus adapted the management of conditions like 'psoriatic spondylitis, predominant enthesitis and treatment in the presence of concomitant inflammatory bowel disease, diabetes or serious infections' similar to recommendations given by American College of Rheumatology (ACR).
Psoriatic arthritis (PsA) is associated with psoriasis and significant morbidity. Patients with psoriasis should be routinely screened by a dermatologist for the early detection of PsA. The PEST questionnaire is helpful and easy to implement in routine practice for a dermatologist to screen suspected patients for PsA. The management of PsA can be initiated by the dermatologist depending upon the intensity and progression of the disease. For further management of the patients, they can be referred to a rheumatologist. Treatment aims to control the sign and symptoms and disease progression to avoid irreversible damage to joints. Hence, rheumatologists and dermatologists should collaborate to manage the disease and achieve preferred long-term patient outcomes.
Financial support and sponsorship
There was no significant financial support that could have influenced its outcome. The study and the medical writing work of the manuscript were supported and funded by Novartis Pharmaceuticals, India.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]