In each issue of The Chronicle of Skin & Allergy, Dr. Ronald B. Vender of Hamilton, Ont. comments on recent papers related to psoriasis. Dr. Vender has more than 30 years of clinical practice experience and more than 100 clinical trials in psoriasis.
Following is an excerpt from his most recent column that summarizes a paper published in the peer-review literature, followed by his commentary.
Risk of developing psoriatic arthritis in psoriasis cohorts with arthralgia: Exploring the subclinical psoriatic arthritis stage
In a study published in RMD Open (2024; 10:e004314), researchers shed new light on the progression from psoriasis (PsO) to psoriatic arthritis (PsA), focusing on the critical “subclinical PsA” stage. This research provides valuable insights for clinicians aiming to identify and potentially prevent PsA in at-risk patients.
The study analyzed data from two cohorts totaling 384 patients with PsO, followed for an average of 33 months. Of these, 311 patients (80.9%) were classified as having subclinical PsA, primarily due to the presence of arthralgia.
The findings reveal a significantly higher risk of PsA development in the subclinical PsA group compared to those with PsO alone (HR=11.7, 95% CI 1.57 to 86.7, p=0.016). The cumulative incidence function (CIF) estimated the probability of new-onset PsA in subclinical PsA patients at 9.4% (95% CI 4.7% to 10.6%) at 12 months and 22.7% (95% CI 17.2% to 28.6%) at 36 months.
Notably, the study characterized the musculoskeletal (MSK) symptoms preceding PsA diagnosis. While 58.9% of cases reported inflammatory symptoms immediately before PsA onset, a surprising 83.9% had experienced non-inflammatory symptoms earlier. The researchers identified three distinct patterns of symptom progression:
1. Inflammatory pattern (16.1% of patients): Mean duration of 1.9 months before PsA diagnosis.
2. Non-inflammatory pattern (41.1%): Prolonged symptom duration, averaging 57.2 months before diagnosis.
3. Mixed pattern (42.8%): Initial non-inflammatory symptoms (mean 22.8 months) followed by inflammatory symptoms (mean 3.9 months).
The dominant clinical presentation of new-onset PsA was peripheral joint swelling (82.1%), with oligoarthritis being particularly common. This aligns with previous studies on early PsA, which have reported mean active joint counts between 1 and 3.
Interestingly, the frequency of dactylitis at PsA diagnosis (3.6%) was notably lower than in early PsA inception cohorts, where it’s typically observed in 40 to 50% of patients. This discrepancy likely reflects the low disease activity in the study's new-onset PsA cases.
The researchers emphasize the importance of characterizing arthralgia in terms of pain type, affected sites, and symptom duration to optimize therapeutic targeting of subclinical PsA. They also note the challenge in understanding symptomatology in this phase, given the substantial number of patients reporting non-inflammatory MSK pain before PsA onset.
While the study has limitations, including heterogeneous imaging data and retrospective collection of pre-PsA symptoms, it provides crucial insights into the subclinical phases of PsA. The findings underscore the need for vigilant monitoring of emergent MSK symptoms in patients with PsO, particularly those with arthralgia, to facilitate early detection and potential prevention of PsA.
This research marks a significant step forward in understanding the transition from PsO to PsA, offering clinicians valuable guidance for identifying patients at high risk of PsA development and potentially intervening before the onset of clinical disease.
Comment from Dr. Vender: This study marks a significant step forward in understanding the transition from PsO to PsA. It provides clinicians with crucial insights into the subclinical phases of PsA, emphasizing the need for detailed symptom characterization and vigilant monitoring of at-risk patients. By identifying high-risk individuals early, clinicians can potentially intervene before the onset of clinical disease, improving outcomes for patients with psoriasis and preventing the debilitating effects of PsA.
The findings of this research should prompt dermatologists and rheumatologists to adopt a proactive approach in managing psoriasis patients, focusing on early detection and individualized treatment strategies. As our understanding of subclinical PsA evolves, it is hoped that these insights will lead to more effective prevention and management of PsA, ultimately enhancing the quality of life for patients with psoriasis.
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