pre-activity question 1 psoriasis and psa clinical ... · psoriasis and psa clinical features,...

5/15/2015

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Psoriasis and PsA Clinical Features, Associated Conditions,

Screening, and Assessment

Amit Garg, MDAssociate Professor and Founding Chair

Department of DermatologyHofstra NSLIJ School of Medicine

North Shore LIJ Health SystemManhasset, New York

Kristina Callis Duffin, MD, MSAssociate Professor

Department of DermatologyUniversity of Utah

Salt Lake City, Utah

Laura Coates, MBChB, MRCP, PhDNIHR Clinical Lecturer in Rheumatology

Leeds Institute of Rheumatic and Musculoskeletal MedicineUniversity of Leeds and the

Leeds Musculoskeletal Biological Research UnitLeeds Teaching Hospitals NHS Trust

Leeds, England

Content Developers

Kristina Callis-Duffin, MD, MSAssociate Professor

Department of DermatologyUniversity of Utah

Salt Lake City, Utah

Philip Mease, MDDirector, Rheumatology Research

Swedish Medical CenterClinical Professor

University of Washington School of MedicineSeattle, Washington

Speakers

Pre-Activity Question 1

How confident are you in your ability to establish a clinical framework to diagnose and screen the psoriasis patient for psoriatic arthritis?

1. Very confident

2. Confident

3. Somewhat confident

4. Not confident


PASI includes a component for patient-reported outcomes.

1. True

2. False


For what percentage of psoriasis patients do you currently perform an annual assessment for PsA?

1. 0-25%

2. 26-50%

3. 51-75%

4. 76-100%

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Objective:

• After this presentation, the attendee will be able to:

– Establish a clinical framework to diagnose and screen the patient with psoriasis and psoriatic arthritis

Psoriasis Phenotypes

• Plaque

• Inverse

• Guttate

• Erythrodermic

• Pustular (generalized, localized)

• Palmoplantar

• Nail disease

• Overlap

6p4 16 17

Photos courtesy of Kristina Callis Duffin

Plaque Type Psoriasis

Photo courtesy of Kristina Callis Duffin



Plaque Type Psoriasis

• Most common morphology (80%)

• Well demarcated plaques with varying degrees of

– Erythema (pink to red)

– Scale (desquamation)

– Induration (thickness)

Inverse Psoriasis

• Involves skin folds

• Smooth, well-demarcated red patches

• Scale is minimal or entirely absent

• Sometimes eroded, moist

• Often mistaken for a dermatophyte or candidalinfection

Photos courtesy of Kristina Callis Duffin& Amit Garg

Guttate Psoriasis

• Eruptive

• Red erythematous, scaly papules and small plaques

• May follow streptococcal pharyngitis


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Erythrodermic Psoriasis

• Means “red skin”

– Warm, red, scaly patches covering almost entire body surface

• Disrupted barrier function: temperature, fluids, electrolytes

• Differential diagnosis includes drug reaction, cutaneous T cell lymphoma, atopic dermatitis


Pustular Psoriasis

• Localized

– PPP

– steroid withdrawal

• Generalized (von Zumbusch)

– Mimics include other pustular dermatoses(pustular drug eruption/ AGEP)


Palmar Plantar Psoriasis (PPP):Pustular and non-Pustular

• Spectrum:

– Non-pustular: hyperkeratotic plaques

– Pustular: predominance of pustules

• Pustular variant: (palmoplantar pustulosis)

– Regarded as a distinct entity by some

• Not associated with HLA-Cw62

– Associated with smoking

– Treatment poses a challenge

– Associated with plaque psoriasis in ~20%

1. Farley E, Masrour S, McKey J, Menter A. Palmoplantar psoriasis: A phenotypical and clinical review with introduction of a new quality-of-life assessment tool. J Am AcadDermatol. 2009;60:1024-31. 2. Asumalahti K, Ameen M, Suomela S, et al. Genetic analysis of PSORS1 distinguishes guttate psoriasis and palmoplantar pustulosis. J Invest Dermatol. 2003;120:627-32.

Photos courtesy of Kristina Callis Duffin and Amit Garg

Palmar Psoriasis

Photos courtesy of Amit Garg

Plantar Psoriasis

Plantar Psoriasis

• Keratoderma over weight bearing areas of the foot

Photo courtesy of Amit Garg

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Psoriatic Nail Disease

• Affects 50% - 85% of psoriasis pts

• Difficult to treat

• May be associated with joint involvement

Jiaravuthisan, et al. Psoriasis of the nail: anatomy, pathology, clinical presentation,and a review of the literature on therapy. J Am Acad Dermatol, 2007;57:1-27. Zaias N: Psoriasis of the nail. A clinical-pathology study. Arch Dermatol. 1969;99:567-579.Samman PD: The Nails in Disease, ed 3. London, William Heinemann Medical, 1978.


pitting

crumbling

oil spot

Clues to the Diagnosis of Psoriasis

• Phenotypes

• Demarcation

• Type of Scale

• Distribution

• Hidden places


Places Psoriasis Likes to Hide

Photos courtesy of Kristina Callis Duffin and Amit Garg

Silver colored scale

Margination along hairline

Photos courtesy of Amit Garg

Is the Distinction Clear?

Dx: Psoriasis


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Dx: Atopic Dermatitis


Dx: Dyshidosis


Dx: Nummular Eczema


Dx: Psoriasis

Dx: Contact Dermatitis




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Dx: Lichen Planus


Dx: Tinea Corporis


Dx: Lichen Simplex Chronicus


Dx: CTCL


Cutaneous T-cell Lymphoma/Mycosis Fungoides

Increased risk of CTCL: biologic vs misdiagnosed?

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Differential Dx

• Some conditions which may be difficult to distinguish from Psoriasis

– Seborrheic dermatitis

– Nummular eczema

– Atopic Dermatitis

– Contact dermatitis

– Hand Dermatitis

– Balanitis

– Dermatophyte or Candidal infection

– Palmoplantar keratodermas

– Cutaneous T Cell Lymphoma

– Onychodystrophy related to a number of etiologies including Dermatophyteinfection and trauma

Assessment of Psoriasis: PASI

• Most commonly utilized disease severity measure in clinical trials

• Quantify severity based on:

– Erythema, Induration, and Scale

– Body parts and surface area involved

• Separate calculation for head, trunk, upper extremities, and lower extremities

PASI Strengths

• Assesses both lesion quality and extent of involvement

• Validated instrument – Low intra-observer variability

– Moderate inter-observer variability

– Reproducible when performed by trained individuals

• Allows some historical comparison across several treatments

PASI Limitations

• Erythema, induration, and scaling are equally weighted

• Interpretation not so intuitive

– Nonlinear

– Composite score has no clinical frame of reference

• Lacks sensitivity to change at lower ranges

• No component for patient input

Seeking Out Your Dermatology Colleague

• When diagnosis of psoriasis is not certain

• Optimization of topical therapies and regimens

• When use of oral retinoid may be appropriate

• When phototherapy may be useful

– Guttate psoriasis, or with diffuse thin plaques

– Adjunctive to systemic therapy

– Poor candidacy for systemic therapy

• When Psoriasis is flaring or unstable

• “Undifferentiated” or seronegative inflammatory disease and a rash

Diagnosis/Presentation of PsA

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Features of PsA

• An inflammatory arthritis that occurs in 6%-42% of patients with psoriasis1

• Psoriasis typically precedes development of the arthritic component of PsA

– In 70% of patients with PsA, psoriasis is the first symptom to present2,3

– 20% have PsA before psoriasis2,3

– 10%-15% report simultaneous onset of skin and joint disease2,3

• Severity of psoriasis is not predictive of severity of PsA3

1. Gladman D, et al. Ann Rheum Dis. 2005; 64 (Suppl II): ii14-7. 2. Leung Y, et al. J Postgrad Med. 2007; 53: 63-71. 3. Cohen M, et al. J Rheumatol. 1999; 26: 1752-6.

Assessing the Psoriasis Patient

• Annual assessment for PsA to people with any type of psoriasis. Especially important within the first 10 years of onset of psoriasis.

• Use a validated tool to assess adults for psoriatic arthritis in primary care and specialist settings, such as the Psoriasis Epidemiological Screening Tool (PEST).

– PEST does not detect axial arthritis or inflammatory back pain

• As soon as psoriatic arthritis is suspected, refer to a rheumatologist for assessment and advice about planning their care.

NICE clinical guideline 153 ‘The assessment and management of psoriasis’. 2012. Available at: http://www.nice.org.uk/nicemedia/live/13938/61190/61190.pdf. Date accessed: November 2013.

Psoriatic Disease

Arthritis

Skin and nails

Enthesitis

Dactylitis

Axial Disease

Metabolic Syndrome

Inflammatory bowel

disease

Uveitis

Identifying PsA

• Dermatology

– Recognize relevant MSKL sxs among Pso pts

– CASPAR may not yet be applicable without a definition of inflammatory arthritis

• Rheumatology

– Distinguish inflammatory and non-inflammatory disease

– Identify PsA within inflammatory arthritis

– CASPAR criteria applicable to all patients

Clinical Presentation of PsA

Peripheral Arthritis

Arthritis

Present

Absent

Helliwell, et al. ARD. 2007;66:113-7.

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Mease P, van der Heijde D. Int J Adv Rheumatol. 2006;4:38-48.

PsA: Radiographic Features

• Juxta-articular periostitis and ankylosis

• Joint osteolysis(pencil-in-cup)

PM3

Other Radiological Features of PsA

Tuft Resorption

Periostitis

Mease P, van der Heijde D. Int J Adv Rheumatol. 2006;4:38-48.

PsA vs RA

Psoriatic Arthritis Rheumatoid Arthritis

RF and anti-CCP seronegative1 RF and anti-CCP seropositive1

Inflammatory markers often normal Inflammatory markers usually raised

Absence of rheumatoid nodules1 Rheumatoid nodules present over bony prominences1

Asymmetric oligoarticular manifestations1 Symmetric polyarticular manifestations1

Predilection for the distal interphalangeal(DIP) joints2

Typically affects the metacarpophalangealand proximal interphalangeal (PIP) joints2

Radiological damage commonly involves periostitis, ‘pencil-in-cup’ changes and

ankylosis2Radiological changes include osteopenia2

50% of patients have spinal manifestations2 Spine is largely unaffected2

Skin manifestations (psoriasis) Skin manifestations are atypical

1. Gladman D, et al. Ann Rheum Dis. 2005;64 (Suppl II):ii14-7. 2. Gladman D. Ann Rheum Dis. 2006;5 (Suppl III):iii22-4.

Enthesitis

Enthesitis

Present

Absent


Inflammation at the site of insertion of muscle/tendon into bone

PM5

How to Spot PsA – Enthesitis

• Common sites

– Achilles tendon

– Plantar fascia

– Elbows

– Costochondral joints

– Patellar

MRI of 3rd MCP

Namey TC. Arthritis Rheum. 1976;19(3):607. Offidani A, et al. ActaDerm Venereol. 1998;78:463. Gisondi, et al. Ann Rheum Dis. 2008;67:26-30.

T2W

US of AT

Scintigraphy

Sub-clinical Bone and EnthesealInflammation in Psoriasis Patients

PM3 Reference I have added to this slide and next is a general review article on radiologic features of PsA and is not specific to the specific imagesadmin, 10/29/2014

Slide 58

PM5 remove build pleaseadmin, 10/29/2014

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Lower Limb Enthesopathy in Psoriasis Patients without PsA

• Ultrasound evaluation of Achilles, quadriceps, patellar entheses and plantar aponeurosis according to Glasgow Ultrasound EnthesitisScoring System (GUESS)

– 30 psoriasis patients

– 30 controls

• The mean thickness of all tendons was higher in psoriasis patients than controls

• Mean GUESS score was significantly higher with 7.9 in psoriasis patients vs. 2.9 in controls

enthesophyte

Bursitis

Gisondi, et al. Ann Rheum Dis. 2008;67:26-30.*Girolomoni, et al. JEADV. 2009;23(Suppl. 1):3-8.

“10% of patients with psoriasisprogressed to PsA over 2 yrs”*

Dactylitis

Dactylitis

Present

Absent


uniform/fusiformswelling of a digit

PM6

Spinal Involvement

Spinal pain/stiffness

Present

Absent


How to Spot PsA – Axial Disease

Inflammatory back pain

• Chronic back pain >3 months

• Onset at age <40 yrs

• Pain eased by exercise, worse at rest

• Early morning stiffness

• Waking in second half of the night

PsA in Dermatology Clinics

OA, 24

No MSK diagnosis,

28

SeverePsA,7

MildPsA,10

Other, 17

Husni. JAAD. 2007;57(4):581-7.

Referral to Rheumatology

• Arthralgia that doesn’t settle

• Inflammatory features

– Early morning stiffness

– Better with exercise

– Swollen joints

– Enthesitis

– Low back / buttock pain

PM6 remove build pleaseadmin, 10/29/2014

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Screening Tools for PsA

• Most people have psoriasis before joint symptoms

• Is there a simple screening test for PsA?– Quick and easy

– Patient completed

– Sensitive

– Reasonably specific

• Patient-completed questionnaires– PAQ (1997) and modified PAQ (2002)

– PASE (2007)

– ToPAS (2008)

– PEST (2008)

– PASQ (2009)

PAQ = Psoriasis and Arthritis Questionnaire; PASE = Psoriatic Arthritis Screening and Evaluation. ToPAS = Toronto Psoriatic Arthritis Screen; PEST = Psoriasis Epidemiology Screening Tool. PASQ =Psoriatic Arthritis Screening Questionnaire.

PASE – Symptoms

• I feel tired for most of the day

• My joints hurt

• My back hurts

• My joints become swollen

• My joints feel ‘hot’

• Occasionally, my entire finger or toe becomes swollen, making it look like a ‘sausage’

• I have noticed that the pain in my joints moves from one joint to another, for example, my wrist will hurt for a few days, then my knee will hurt, and so on

Husni M, et al. J Am Acad Dermatol. 2007;57:581-7.

ToPAS 1 and 2

Features:

• Pictures

• Questions on

– joint symptoms

– back pain

– dactylitis

Gladman D, et al. Ann Rheum Dis. 2009;68:497-501.

PEST

• Have you ever had a swollen joint (or joints)?

• Has a doctor ever told you that you have arthritis?

• Do your finger nails or toe nails have holes or pits?

• Have you had pain in your heel?

• Have you had a finger or toe that was completely swollen and painful for no apparent reason?

Ibrahim G, et al. Clin Exp Rheumatol. 2009;27:469-74.

In the drawing below, please tick the joints that have

caused you discomfort (i.e stiff, swollen or painful joints)

Identifying PsA in Early Arthritis Clinics

• Presence of psoriasis!

• Psoriatic nail disease

• Negative immunology

• Features of SpA

• Use CASPAR features...

PsA Disease – Complex and Variable

Images supplied by Laura Coates, University of Leeds, UK.

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Current Practice

• Poor documentation of outcome measures

• UK – DAS28 used in 25% of biologic assessments

• 68/66 joint count used for most

• Some assessment of skin disease

• Poor documentation of enthesitis/dactylitis/axial disease activity

• Generally composite measure of arthritis (RA) used

Assessment of PsA

Assessment of Psoriatic Arthritis in Clinical Trials

Domains Instruments

Joint assessment 68/66 T/S joint count, ACR, DAS, PsARC

Axial assessment BASDAI, BASFI, BASMI

Skin assessment PASI, Target lesion, Global

Pain VAS

Patient global VAS (global, skin + joints)

Physician global VAS (global, skin + joints)

Function/QOL HAQ, SF-36, PsAQoL, DLQI

Fatigue FACIT, Krupp, MFI, VAS

Enthesitis assessment Mander, MASES, Leeds, Berlin, SPARCC, 4-point

Dactylitis assessment Leeds, present/absent, acute/chronic

Acute phase reactant ESR, CRP

Imaging Xray (modified Sharp or van der Heijde-Sharp), MRI, US

Mease P. Arth Care & Research. 2011;63:64-85. Mease P, et al. Ann Rheum Dis. 2005;64:ii49-ii54. Mease P, van der Heijde D. Int J Adv Rheum. 2006;4:38-48.

Arthritis

• 68/66 (tenderness/swelling) joint count recommended

Mease P. Arth Care & Research. 2011;63:64-85.

• BSA

• PASI (often only if BSA>3)

• Target Lesion score

• Lattice System PGA (very severe – clear)

• Copenhagen Psoriasis Severity Index (CoPSI)

• NPF Psoriasis Score

Coates, et al. J Rheum. 2011 Jul;38(7):1496-501.

Skin Disease

1% BSA

Assessing Enthesitis - LEI

• Lateral epicondyle of elbow

• Medial condyle of femur

• Achilles tendon insertion

Healy PJ and Helliwell PS. Arthritis Rheum. 2008;59(5):686-691.

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Assessing Enthesitis - SPARCC

• Supraspinatus

• Med/lat epicondyles

• Greater trochanter

• Patellar insertion

• Quads insertion

• Tibial tuberosity

• Achilles tendons

• Plantar fascia

Dactylitis

• Simple count (tender/swollen)1

• Count + grade 0-3 score2

• Leeds Dactylitis Instrument (LDI)3

Images supplied by Laura Coates, University of Leeds, UK

1. Kyle S, et al. Rheumatology. 2005;44:390-7. 2. Antoni CE, et al. [erratum appears in Arthritis Rheum. 2005 Sep;52(9):2951] Arthritis & Rheumatism. 52(4):1227-1236. 3. Helliwell PS, et al. Journal of Rheumatology. 2005;32(9):1745-1750.

Axial Disease

• BASDAI – doesn’t differentiate axial activity

• BASFI – doesn’t differentiate axial activity

• BASMI

• ASDAS

Image supplied by Laura C

oates, University

of Leeds, UK

Coates, et al. J Rheum. 2011 Jul;38(7):1496-501.

IMPART: Arthritis and Dactylitis

MeasureOverall

ICC (95% CI)Rheumatologist

ICC (95% CI)Dermatologist ICC

(95% CI)

Tender joint count

0.78 (0.65, 0.89) 0.81 (0.68, 0.91) 0.73 (0.56, 0.86)

Swollenjoint count

0.24 (0.12, 0.45) 0.42 (0.23, 0.65) 0.31 (0.12, 0.57)

Dactylitis 0.29 (0.15, 0.51) 0.69 (0.52, 0.84) 0.08 (-0.07, 0.32)

PGA-PsA 0.39 (0.23, 0.60) 0.29 (0.11, 0.54) 0.50 (0.29, 0.72)

PGA = physician’s global assessment; ICC = intraclass correlation coefficients. Chandran V, et al. Arthritis Rheum. 2009;27;61:1235-1242.

PM7

Quality of Life and Function

• SF-36

• EQ5D

• DLQI

• PsAQOL

• HAQ-DI

– MID 0.35

• HAQ-S

Mease P. Arth Care & Research. 2011;63:64-85. Mease P, et al. J Rheum. 2011;38:2461-5.

Composite Measures ofPsoriatic Disease

ENB1049a Date of Preparation November 2012

PM7 ICC for swollen joint count for "Overall" is 0.24? Yet ICC for rheum is 0.42 and derm is 0.31 so theoretically the Overall should be in between those two numbers. Please check manuscript. admin, 10/29/2014

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Composite Assessment of PsA

• Composite Measures of Arthritis

– DAS

– ACR responses

– PsARC

– DAPSA

– PsAJAI

– CDAI

– SDAI

• Composite Measures of PsA

– MDA

– CPDAI

– PASDAS

– AMDF

Mease P. Arth Care & Research. 2011;63:64-85.

A Disease State Measure

• Minimal disease activity is ideal concept

– “a state which is deemed a useful target of treatment by both physician and patient, given current treatment possibilities and limitations”

• Can act as a target for treatment

• Developed for PsA including 7 key outcome measures covering arthritis, enthesitis, skin disease, patient reported outcomes and functional ability

Wells GA, et al. J Rheumatol. 2005;32:2016-24; Coates LC, et al. Ann Rheum Dis. 2010;69(1):48-53.

MDA Criteria for PsA

• A patient is classified as in MDA when they meet 5 of 7 of the following criteria:

– tender joint count ≤1

– swollen joint count ≤1

– PASI ≤1 or BSA ≤3

– patient pain VAS ≤15

– patient global activity VAS ≤20

– HAQ ≤0.5

– tender entheseal points ≤1

Coates LC, et al. Ann Rheum Dis. 2010;69(1):48-53.

Observational Database - Toronto

• n=344

• 59% male, mean age 43 years

Coates LC, et al. Arthritis Care and Res. 2010;62(7):970-6.

Patients Achieving MDA

>1 year

<1 year

never

0

0.5

1

1.5

2

2.5

3

MDA not MDA

Progression of Joint Damage per year

Increasedamaged JC

P=.0005

Interventional Trial Cohort

• Achieving MDA in IMPACT and IMPACT2 studies

Coates LC, et al. Arthritis Care and Res. 2010;62(7):965-9.

0

5

10

15

20

25

30

35

40

45

50

55

Week 16 Week 52

Percentage of patients achieving M

DA

Infliximab

Placebo

Week 16 P<.0001

0

5

10

15

20

25

30

35

40

45

50

55

Week 24 Week 52

Percentage of patients achieving M

DA

Infliximab

Placebo

Week 24 P<.001

MDA

• Validated measure of disease state

• Doesn’t measure disease activity

• Now being reported as outcome in RCTs

• Being used in clinical trials as target

Coates LC, et al. Arthritis Care and Res. 2010;62(7):965-9 and 970-6. Coates, et al. BMC Musculoskelet Disord. 2013 Mar 21;14:101.

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Composite Psoriatic Disease Activity Index (0 -15)

None (0) Mild (1) Moderate (2) Severe (3)

Peripheral Arthritis NONE≤ 4 joints; normal function (HAQ ≤0.5)

≤ 4 joints but function impaired; or > 4 joints, normal function

> 4 joints and function impaired

Skin Disease NONE PASI ≤ 10 and DLQI ≤ 10PASI ≤ 10 but DLQI >10; or PASI > 10 but DLQI ≤ 10

PASI > 10 and DLQI > 10

Enthesitis NONE≤ 3 sites; normal function (HAQ ≤0.5)

≤ 3 sites but function impaired; or >3 sites but normal function

>3 sites and function impaired

Dactylitis NONE≤ 3 digits; normal function (HAQ ≤0.5))

≤ 3 digits but function impaired; or >3 digits but normal function

>3 digits and has function impaired

Spinal Disease NONEBASDAI ≤4; normal function (ASQol ≤ 6)

BASDAI >4 but normal function; BASDAI ≤4 but function impaired

BASDAI >4 and function impaired

HAQ only counted for most severe domain involved (enthesitis/dactylitis/peripheral arthritis)

Mumtaz, A. Ann Rheum Dis. 2011;70:272-7.

GRACE Project (GRAPPA)

• Longitudinal international cohort

• High disease activity identified by increase in therapy

• 2 different methods for development

– PASDAS

• following methodology of RA DAS or ASDAS

• Logistic regression to develop weighting

– AMDF

• Each component translated to 0-1 desirability function

• Simple addition of each component

PASDAS

• 0.18 x √physician global

• + 0.159 x √patient global

• - 0.253 x √SF36-PCS

• + 0.101 x ln (SJC+1)

• + 0.048 x ln (TJC+1)

• + 0.23 x ln (LEI+1)

• + 0.37 x ln (tender dactylitis count+1)

• + 0.102 x ln (CRP+1)

Helliwell PS, et al. Ann Rheum Dis. 2013;72:986-991.

AMDF

• Sum of

– TJC

– SJC

– HAQ

– Patient VAS global

– Patient VAS joints

– Patient VAS skin

– PASI

– PsAQOL

Helliwell PS, et al. Ann Rheum Dis. 2013;72:986-991.

Optimizing Rolesof Dermatologist and Rheumatologist

Screening for PsA in at-risk population

Confirm presence of inflammatory arthritis in pt with psoriasis

Post-Activity Question 1

How confident are you in your ability to establish a clinical framework to diagnose and screen the psoriasis patient for psoriatic arthritis?

1. Very confident

2. Confident

3. Somewhat confident

4. Not confident

5/15/2015

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PASI includes a component for patient reported outcomes.

1. True

2. False


For what percentage of psoriasis patients do you intend to perform an annual assessment for PsA?

1. 0-25%

2. 26-50%

3. 51-75%

4. 76-100%

Questions & Answers

pre-activity question 1 psoriasis and psa clinical ... · psoriasis and psa clinical features,...

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