Eur J Dermatol 2015; 25(1): 57-63
Clinical report 1 ´ ´ Jose Luis LOPEZ ESTEBARANZ 2 Pedro ZARCO-MONTEJO M Luz SAMANIEGO3 4 ´ Carmen GARCIA-CALVO , on behalf of the PREVAL Study Groupa 1
Department of Dermatology, Fundación Hospital Alcorcón, Madrid, Spain 2 Department of Rheumatology, Fundación Hospital Alcorcón, Madrid, Spain 3 Statistical Department, Trial Form Support, Madrid, Spain 4 Medical Department, Pfizer Spain, Avenida de Europa 20B, Parque Empresarial La Moraleja, Alcobendas, Madrid, Spain
Reprints: J. L. L. Estebaránz
Article accepted on 9/16/2014
Prevalence and clinical features of psoriatic arthritis in psoriasis patients in Spain. Limitations of PASE as a screening tool Background: Diagnosing and initiating treatment of psoriatric arthritis (PsA) as early as possible is essential to prevent irreversible joint destruction and poor clinical outcomes. Dermatologists are uniquely placed to identify early symptoms of PsA in psoriasis patients but levels of under- and late-diagnosis remain high. Objective: To evaluate the prevalence and clinical features of PsA in Spanish psoriatic patients attended by dermatologists and then referred to rheumatologic units for PsA diagnosis confirmation. Methods: a multicenter, non-interventional, cross-sectional trial conducted at 40 hospitals in Spain. Patients were initially screened for PsA by a dermatologist based on clinical evaluation and results from the Psoriatic Arthritis Screening and Evaluation (PASE) Questionnaire. All patients were then evaluated by a blinded rheumatologist for the presence of PsA using Moll and Wright criteria and Classification Criteria for Psoriatic Arthritis (CASPAR). Results: Of 375 psoriatic patients enrolled at dermatology units, 28.6% patients scored ≥44 in PASE, whereas 32.3% patients screened positive for suspicion of PsA (clinical evaluation and/or PASE). Correlation of suspicion of PsA by dermatologists and PASE score was 0.368 (Pearson correlation coefficient). Following rheumatologic assessment, prevalence of PsA was 22.9% (86/375 patients) according to Moll and Wright and CASPAR criteria. The correlation of diagnosis of PsA between dermatologists and rheumatologists was 0.410 (Kappa Index). Conclusions: Prevalence of PsA in our study was within the range reported in other studies. Our analyses found only a moderate correlation in the diagnosis of PsA between dermatologists and rheumatologists. The screening questionnaire, PASE, showed a moderate predictive value for the diagnosis of PsA.
doi:10.1684/ejd.2014.2449
Key words: assessment, dermatologist, diagnosis, prevalence, psoriasis, psoriatic arthritis, rheumatologist
a PREVAL Study Group Amparo Pérez Ferriols, Amalia Rueda (H. General, Valencia), Pablo Almeida, Antonio Rosas Romero, Javier Hernandez, Ma Zaida Hernandez, Dunia Lujan, Rosa Martel, Ma Noelia Hernandez, Leopoldo Borrego, Eduardo Girona, Jose Antonio Hernández Beriain, Daniel Batista Perdomo, Sergio Machín (H. Insular de Gran Canaria, Tenerife), Jose Suarez, Manuel Brito Suarez, Laura Feliciano Divasson (H. Candelaria, Las Palmas de Gran Canaria), Conrad Pujol, Bego˜na Escutia, Miguel Naranco (H. La Fe, Valencia), Francisco Albero Blanes, Enrique Barbeito (H. Virgen de los Lirios, Alcoy), Amparo Pe˜na García, Carmelo Tornero Ramos (H. Morales Meseguer, Murcia), Enrique Gimeno Carpio, Juan Antonio Castellano Cuesta, Esther Quecedo Estebanez, Manuel Velasco Pastor, Fernando Millán Parrilla, Virginia Pont San Juan (H. Arnau de Vilanova, Valencia), Diana Ruiz Genao, Raquel Almodovar, Javier Quirós, Ramon Mazzucchelli (H. Fundación de Alcorcón, Madrid), Gastón Roustan Gullón, Jesus Sanz Sanz (H. Puerta de Hierro, Madrid), Jose Manuel Hernanz, Teresa Navío, Laura Cebrián (H. Infanta Leonor, Madrid), Cristina Schoendor Ortega, Jose Santos Rey (H. Virgen de la Salud, Toledo), Juan Sánchez Estella, Olga Martínez Gonzalez, Jose Angel Cabezas Lefler (H. Virgen de la Concha, Zamora), Cristina Rubio Flores, Santiago Mu˜noz, Rosa Díaz Díaz, Tatiana Cobo (H. Infanta Sofia, Madrid),
EJD, vol. 25, n◦ 1, January-February 2015
Miguel Ángel Gallego, Ana Cruz Valenciano, Antonio Aguilar, Inmaculada Garcia Cano, Eva Fernández, Houmani Houmani (H. Severo Ochoa, Madrid), Elena Sánchez-Largo Uceda, Ana Pérez Gómez (H. Príncipe de Asturias, Alcalá de Henares), Yolanda Gilaberte, Rosa Rosselló Pardo(H. San Jorge, Huesca), Juan Escalas, Luis Espadaler (H. Son Dureta, Mallorca), Jordi Rex Caballé, Jordi del Blanco Barnusell (Hospital de la Calella, Barcelona), Jesús Luelmo, Jordi Gratacós, Mireya Moreno (H. Parc Taulí, Sabadell), David Vidal Sarró, Ramon Figuls Poch, Joan Antoni Smandia Domínguez, Alejandro Fernández Casado, Laura Peramiquel Fonollosa ,Emili Masferrer i Niubó, Dacia Cerdá Gabaroi, Héctor Corominas Macías, Delia Reina Sanz (H. Sant Joan Despí Moises Broggi, Barcelona), Isabel Bielsa Marsol, Alejandro Olivé (H. Germans Trias i Pujol, Badalona), Rubén del Rio, Concepción Pitarch Grau, Miriam Sidró, Yolanda León, Teresa Marine Hernandez (H. Esperit Sant, Barcelona), Susana Armesto, Ricardo Blanco (H. Marqués de Valdecilla, Santander), I˜nigo Martínez de Lizarduy, Eva Galíndez (H. Civil de Basurto, Bilbao), Jorge Santos Juanes, Javier Ballina, Pablo Coto Segora Mercedes Alperi, Ruben Queiro (H. Central Asturias, Asturias), Victoria Almeida, Juan Carlos Vesga (H. Txagorritxu, Vitoria), Carlos de la Torre, Juan Cruz Martínez, Ma Teresa Abalde (H. Provincial, Pontevedra), Luisa Fernandez Diaz, Amalia Sánchez Andrade(H. Xeral-Calde, Lugo), Patricia Garcia
57
To cite this article: López Estebaránz JL, Zarco-Montejo P, Samaniego ML, García-Calvo C. Prevalence and clinical features of psoriatic arthritis in psoriasis patients in Spain. Limitations of PASE as a screening tool. Eur J Dermatol 2015; 25(1): 57-63 doi:10.1684/ejd.2014.2449
P
soriatic arthritis (PsA) is a debilitating inflammatory joint disease associated with psoriasis, which is heterogeneous in presentation and clinical course and often results in impaired physical function and quality of life [1, 2]. Recent evidence indicates that PsA can be associated with significant morbidity and an increased risk of mortality compared with general and psoriasis populations [3]. Up to 47% of patients with PsA have been reported to develop erosive changes within 2 years of disease onset [4, 5], with this percentage increasing to 68% after 5 years of evolution [6]. It is therefore essential to diagnose and initiate treatment of PsA as early as possible in order to prevent irreversible joint destruction and poor clinical outcomes. However, according to a recent National Psoriasis Foundation Survey, nearly one in four people with psoriasis may have undiagnosed PsA, while almost a third of patients with psoriasis and PsA did not receive their diagnosis for 2 years or more after they first experienced symptoms [7]. In the vast majority of cases, dermatologists will see patients with psoriasis before arthritis develops, making them uniquely placed to identify early joint symptoms and provide a clinical diagnosis of PsA [8]. Elevating awareness among dermatologists about potential PsA in patients with psoriasis could therefore be vital in prompting detection and preventing the potentially irreversible damage of the affected joints [9, 10]. Due to the fact that only around 30% of PsA patients treated with disease-modifying antirheumatic drugs (DMARDs) or biologic agents achieve disease remission [10], recently minimal disease activity (MDA) criteria in PsA have been developed as proposed objective targets of satisfactory states of disease activity for treatments, as a way to improving the therapeutic management of patients [11, 12]. Data describing PsA in psoriatic populations in Spain are scarce [13]. The main aim of this study was to evaluate the prevalence of PsA in a population of Spanish psoriatic patients attended by dermatologists and then referred to rheumatologic units for PsA diagnosis confirmation; clinical patterns and functional activity of PsA patients were also evaluated.
Methods The PREVAL study was a multicenter, non-interventional, cross-sectional trial conducted to evaluate the prevalence of PsA in patients with psoriasis presenting to dermatologists
Morras, Valvanera Pinillos Aransay (Centro Alta Resolución, Logro˜no), Inés García, Elena Aurrecoechea (H. Sierrallana, Torrelavega), Jose Carlos Ruiz Carrascosa, Isabel Ma Camacho Avelino (H. Clínico San Cecilio, Granada),Trinidad Martín González, Inmaculada Ure˜na Garnica (H. Carlos Haya, Málaga), Ma Victoria Mendiola Fernández, Rosa García Portales (H. Virgen de la Victoria, Málaga), José Neila Iglesias, Ma Dolores Garcia (H. Virgen Macarena, Sevilla), Julio González Fernández, Fermín Medina Varo (H. Puerta del Mar, Cádiz), Rafael Jiménez Puya, Ma Dolores López Montilla (H. Reina Sofia, Córdoba), Jerónimo Escudero Ordó˜nez, Juan Sanchez Bursón (H. Valme, Sevilla), Javier Quintana del Olmo, Reyes Martín Walls (Ambulatorio Virgen de los Reyes, Sevilla), Ricardo Ruiz Villaverde, Ma Cármen Ramirez, Ma José Pérez (H. Ciudad de Jaén), Antonio Chávez Alvárez, Jose Ma Salazar Vallinas (H. Infanta Cristina, Badajoz)
58
and then referred to rheumatologic units for PsA diagnosis confirmation. Consecutive patients with a confirmed diagnosis of plaque-type psoriasis were enrolled at 40 hospitals in Spain from June 2010 to March 2011. Eligible patients (at study entry: dermatologic units) were aged at least 18 years, with a confirmed diagnosis of psoriasis, who had a clinical record at the outpatient clinic and who provided written signed consent. Main exclusion criteria were patients currently participating in a clinical trial. The PREVAL study was conducted in compliance with the ethical principles of the Declaration of Helsinki and the International Guidelines for Ethical Review of Epidemiological Studies. The study was approved by a national reference Independent Ethic Committee
Dermatologic evaluation Patients were initially examined by a dermatologist who completed a medical history and physical examination and made a first determination regarding a potential diagnosis of PsA based on clinical evaluation and results from the Psoriatic Arthritis Screening and Evaluation (PASE) Questionnaire. Socio-demographic variables recorded during the visit were age, sex, weight, height, blood pressure, work situation, alcohol consumption and smoking status. Clinical variables collected from the data obtained in the structured interview and the review of the patient clinical records included: date of diagnosis of the psoriasis and form of presentation, family history of psoriasis, severity and location of the lesions, parameters to determine the severity of the psoriasis: determination of BSA (Body Surface Area), determination of the PASI (Psoriasis Activity and Severity Index), determination of PGA (Psoriasis Global Assessment), determination of the NAPSI (Nail Psoriasis Severity Index) and concomitant diseases. Questionnaires to be completed by the patient were: 1) the PASE questionnaire consisting of 15 questions, each of which are assessed on a 5-point scale that rates the subject’s agreement with each question from strongly disagree (scored as 1 point) to strongly agree (scored as 5 points; table 1) [14]. The PASE questionnaire is divided into a 7item Symptom subscale and an 8-item Function subscale; the total score (which ranges from a minimum of 15 points to a maximum of 75 points) is calculated by summing responses to all 15 questions. Patients with a PASE score ≥44 were defined as having suspicion of PsA; and 2) a questionnaire on work productivity and activity impairment and general health (WPAI-GH) specifically designed to evaluate work absenteeism and deterioration of work associated with health problems [15].
Rheumatologic evaluation Following dermatologic examination, all patients were referred to the rheumatologic units. Each rheumatologist, at that time, was blind to the diagnosis made in the Dermatology Unit of their hospital site. A clinical evaluation of the patient was performed in the Rheumatology Unit, and a diagnosis was, or was not, made of PsA or other type of arthritic disease. The Moll and Wright and/or Classification Criteria for Psoriatic Arthritis (CASPAR) criteria were used for PsA diagnosis confirmation [16, 17]. By the Moll and Wright criteria, PsA is diagnosed by the presence EJD, vol. 25, n◦ 1, January-February 2015
Table 1. Comparison of characteristics for patients with and without PsA from dermatological evaluation. Characteristic Age, years, Mean (SD) Gender, males, n (%) BMI, kg/m2 , Mean (SD) SBP, mm Hg, Mean (SD) DBP, mm Hg, Mean (SD) Disease duration, years, Mean (SD) Plaque psoriasis, n (%) Moderate-severe disease, n (%) Location of lesion, n (%) Scalp Flexures Palmo-plantar Nails Genitals Other areas Activity measures, Mean (SD) PASI BSA PGA, 0-1, n (%) NAPSI Past symptoms, n (%) Low back pain Peripheral symptoms Current presence, n (%) Low back pain Peripheral symptoms DLQI questionnaire, Mean (SD) WPAI-GH questionnaire, Mean (SD) Work productivity involvement Leisure activities involvement
Patients with PsA (n = 86)
Patients without PsA (n = 289)
48.6 (12.8) 45 (53.6) 29.0 (49)* 131.3 (165)* 78.6 (114)* 19.9 (12.3) 75 (87.2) 37 (43.0)
47.1 (13.5) 166 (58.2) 27.2 (5.0) 126.4 (15.2) 74.6 (96) 17.9 (13.3) 244 (84.4) 131 (45.6)
40 (46.5) 8 (9.3) 10 (11.6) 36 (41.9)* 6 (7.0) 65 (75.6)
116 (40.1) 28 (9.7) 45 (15.6) 88 (30.4) 18 (6.2) 213 (73.7)
6.6 (7.2) 8.5 (10.0) 31 (36.4) 9.6 (13.0)*
6.5 (6.5) 10.1 (13.0) 112 (38.8) 7.2 (13.0)
38 (44.2)* 53 (61.6)*
55 (19.0) 68 (23.5)
21 (24.4)* 35 (40.7)* 6.6 (5.6)
44 (15.2) 63 (21.8) 6.4 (6.7)
2.1 (2.6) 3.4 (3.2)*
1.4 (2.2) 2.4 (2.8)
*p
Clinical report 1 ´ ´ Jose Luis LOPEZ ESTEBARANZ 2 Pedro ZARCO-MONTEJO M Luz SAMANIEGO3 4 ´ Carmen GARCIA-CALVO , on behalf of the PREVAL Study Groupa 1
Department of Dermatology, Fundación Hospital Alcorcón, Madrid, Spain 2 Department of Rheumatology, Fundación Hospital Alcorcón, Madrid, Spain 3 Statistical Department, Trial Form Support, Madrid, Spain 4 Medical Department, Pfizer Spain, Avenida de Europa 20B, Parque Empresarial La Moraleja, Alcobendas, Madrid, Spain
Reprints: J. L. L. Estebaránz
Article accepted on 9/16/2014
Prevalence and clinical features of psoriatic arthritis in psoriasis patients in Spain. Limitations of PASE as a screening tool Background: Diagnosing and initiating treatment of psoriatric arthritis (PsA) as early as possible is essential to prevent irreversible joint destruction and poor clinical outcomes. Dermatologists are uniquely placed to identify early symptoms of PsA in psoriasis patients but levels of under- and late-diagnosis remain high. Objective: To evaluate the prevalence and clinical features of PsA in Spanish psoriatic patients attended by dermatologists and then referred to rheumatologic units for PsA diagnosis confirmation. Methods: a multicenter, non-interventional, cross-sectional trial conducted at 40 hospitals in Spain. Patients were initially screened for PsA by a dermatologist based on clinical evaluation and results from the Psoriatic Arthritis Screening and Evaluation (PASE) Questionnaire. All patients were then evaluated by a blinded rheumatologist for the presence of PsA using Moll and Wright criteria and Classification Criteria for Psoriatic Arthritis (CASPAR). Results: Of 375 psoriatic patients enrolled at dermatology units, 28.6% patients scored ≥44 in PASE, whereas 32.3% patients screened positive for suspicion of PsA (clinical evaluation and/or PASE). Correlation of suspicion of PsA by dermatologists and PASE score was 0.368 (Pearson correlation coefficient). Following rheumatologic assessment, prevalence of PsA was 22.9% (86/375 patients) according to Moll and Wright and CASPAR criteria. The correlation of diagnosis of PsA between dermatologists and rheumatologists was 0.410 (Kappa Index). Conclusions: Prevalence of PsA in our study was within the range reported in other studies. Our analyses found only a moderate correlation in the diagnosis of PsA between dermatologists and rheumatologists. The screening questionnaire, PASE, showed a moderate predictive value for the diagnosis of PsA.
doi:10.1684/ejd.2014.2449
Key words: assessment, dermatologist, diagnosis, prevalence, psoriasis, psoriatic arthritis, rheumatologist
a PREVAL Study Group Amparo Pérez Ferriols, Amalia Rueda (H. General, Valencia), Pablo Almeida, Antonio Rosas Romero, Javier Hernandez, Ma Zaida Hernandez, Dunia Lujan, Rosa Martel, Ma Noelia Hernandez, Leopoldo Borrego, Eduardo Girona, Jose Antonio Hernández Beriain, Daniel Batista Perdomo, Sergio Machín (H. Insular de Gran Canaria, Tenerife), Jose Suarez, Manuel Brito Suarez, Laura Feliciano Divasson (H. Candelaria, Las Palmas de Gran Canaria), Conrad Pujol, Bego˜na Escutia, Miguel Naranco (H. La Fe, Valencia), Francisco Albero Blanes, Enrique Barbeito (H. Virgen de los Lirios, Alcoy), Amparo Pe˜na García, Carmelo Tornero Ramos (H. Morales Meseguer, Murcia), Enrique Gimeno Carpio, Juan Antonio Castellano Cuesta, Esther Quecedo Estebanez, Manuel Velasco Pastor, Fernando Millán Parrilla, Virginia Pont San Juan (H. Arnau de Vilanova, Valencia), Diana Ruiz Genao, Raquel Almodovar, Javier Quirós, Ramon Mazzucchelli (H. Fundación de Alcorcón, Madrid), Gastón Roustan Gullón, Jesus Sanz Sanz (H. Puerta de Hierro, Madrid), Jose Manuel Hernanz, Teresa Navío, Laura Cebrián (H. Infanta Leonor, Madrid), Cristina Schoendor Ortega, Jose Santos Rey (H. Virgen de la Salud, Toledo), Juan Sánchez Estella, Olga Martínez Gonzalez, Jose Angel Cabezas Lefler (H. Virgen de la Concha, Zamora), Cristina Rubio Flores, Santiago Mu˜noz, Rosa Díaz Díaz, Tatiana Cobo (H. Infanta Sofia, Madrid),
EJD, vol. 25, n◦ 1, January-February 2015
Miguel Ángel Gallego, Ana Cruz Valenciano, Antonio Aguilar, Inmaculada Garcia Cano, Eva Fernández, Houmani Houmani (H. Severo Ochoa, Madrid), Elena Sánchez-Largo Uceda, Ana Pérez Gómez (H. Príncipe de Asturias, Alcalá de Henares), Yolanda Gilaberte, Rosa Rosselló Pardo(H. San Jorge, Huesca), Juan Escalas, Luis Espadaler (H. Son Dureta, Mallorca), Jordi Rex Caballé, Jordi del Blanco Barnusell (Hospital de la Calella, Barcelona), Jesús Luelmo, Jordi Gratacós, Mireya Moreno (H. Parc Taulí, Sabadell), David Vidal Sarró, Ramon Figuls Poch, Joan Antoni Smandia Domínguez, Alejandro Fernández Casado, Laura Peramiquel Fonollosa ,Emili Masferrer i Niubó, Dacia Cerdá Gabaroi, Héctor Corominas Macías, Delia Reina Sanz (H. Sant Joan Despí Moises Broggi, Barcelona), Isabel Bielsa Marsol, Alejandro Olivé (H. Germans Trias i Pujol, Badalona), Rubén del Rio, Concepción Pitarch Grau, Miriam Sidró, Yolanda León, Teresa Marine Hernandez (H. Esperit Sant, Barcelona), Susana Armesto, Ricardo Blanco (H. Marqués de Valdecilla, Santander), I˜nigo Martínez de Lizarduy, Eva Galíndez (H. Civil de Basurto, Bilbao), Jorge Santos Juanes, Javier Ballina, Pablo Coto Segora Mercedes Alperi, Ruben Queiro (H. Central Asturias, Asturias), Victoria Almeida, Juan Carlos Vesga (H. Txagorritxu, Vitoria), Carlos de la Torre, Juan Cruz Martínez, Ma Teresa Abalde (H. Provincial, Pontevedra), Luisa Fernandez Diaz, Amalia Sánchez Andrade(H. Xeral-Calde, Lugo), Patricia Garcia
57
To cite this article: López Estebaránz JL, Zarco-Montejo P, Samaniego ML, García-Calvo C. Prevalence and clinical features of psoriatic arthritis in psoriasis patients in Spain. Limitations of PASE as a screening tool. Eur J Dermatol 2015; 25(1): 57-63 doi:10.1684/ejd.2014.2449
P
soriatic arthritis (PsA) is a debilitating inflammatory joint disease associated with psoriasis, which is heterogeneous in presentation and clinical course and often results in impaired physical function and quality of life [1, 2]. Recent evidence indicates that PsA can be associated with significant morbidity and an increased risk of mortality compared with general and psoriasis populations [3]. Up to 47% of patients with PsA have been reported to develop erosive changes within 2 years of disease onset [4, 5], with this percentage increasing to 68% after 5 years of evolution [6]. It is therefore essential to diagnose and initiate treatment of PsA as early as possible in order to prevent irreversible joint destruction and poor clinical outcomes. However, according to a recent National Psoriasis Foundation Survey, nearly one in four people with psoriasis may have undiagnosed PsA, while almost a third of patients with psoriasis and PsA did not receive their diagnosis for 2 years or more after they first experienced symptoms [7]. In the vast majority of cases, dermatologists will see patients with psoriasis before arthritis develops, making them uniquely placed to identify early joint symptoms and provide a clinical diagnosis of PsA [8]. Elevating awareness among dermatologists about potential PsA in patients with psoriasis could therefore be vital in prompting detection and preventing the potentially irreversible damage of the affected joints [9, 10]. Due to the fact that only around 30% of PsA patients treated with disease-modifying antirheumatic drugs (DMARDs) or biologic agents achieve disease remission [10], recently minimal disease activity (MDA) criteria in PsA have been developed as proposed objective targets of satisfactory states of disease activity for treatments, as a way to improving the therapeutic management of patients [11, 12]. Data describing PsA in psoriatic populations in Spain are scarce [13]. The main aim of this study was to evaluate the prevalence of PsA in a population of Spanish psoriatic patients attended by dermatologists and then referred to rheumatologic units for PsA diagnosis confirmation; clinical patterns and functional activity of PsA patients were also evaluated.
Methods The PREVAL study was a multicenter, non-interventional, cross-sectional trial conducted to evaluate the prevalence of PsA in patients with psoriasis presenting to dermatologists
Morras, Valvanera Pinillos Aransay (Centro Alta Resolución, Logro˜no), Inés García, Elena Aurrecoechea (H. Sierrallana, Torrelavega), Jose Carlos Ruiz Carrascosa, Isabel Ma Camacho Avelino (H. Clínico San Cecilio, Granada),Trinidad Martín González, Inmaculada Ure˜na Garnica (H. Carlos Haya, Málaga), Ma Victoria Mendiola Fernández, Rosa García Portales (H. Virgen de la Victoria, Málaga), José Neila Iglesias, Ma Dolores Garcia (H. Virgen Macarena, Sevilla), Julio González Fernández, Fermín Medina Varo (H. Puerta del Mar, Cádiz), Rafael Jiménez Puya, Ma Dolores López Montilla (H. Reina Sofia, Córdoba), Jerónimo Escudero Ordó˜nez, Juan Sanchez Bursón (H. Valme, Sevilla), Javier Quintana del Olmo, Reyes Martín Walls (Ambulatorio Virgen de los Reyes, Sevilla), Ricardo Ruiz Villaverde, Ma Cármen Ramirez, Ma José Pérez (H. Ciudad de Jaén), Antonio Chávez Alvárez, Jose Ma Salazar Vallinas (H. Infanta Cristina, Badajoz)
58
and then referred to rheumatologic units for PsA diagnosis confirmation. Consecutive patients with a confirmed diagnosis of plaque-type psoriasis were enrolled at 40 hospitals in Spain from June 2010 to March 2011. Eligible patients (at study entry: dermatologic units) were aged at least 18 years, with a confirmed diagnosis of psoriasis, who had a clinical record at the outpatient clinic and who provided written signed consent. Main exclusion criteria were patients currently participating in a clinical trial. The PREVAL study was conducted in compliance with the ethical principles of the Declaration of Helsinki and the International Guidelines for Ethical Review of Epidemiological Studies. The study was approved by a national reference Independent Ethic Committee
Dermatologic evaluation Patients were initially examined by a dermatologist who completed a medical history and physical examination and made a first determination regarding a potential diagnosis of PsA based on clinical evaluation and results from the Psoriatic Arthritis Screening and Evaluation (PASE) Questionnaire. Socio-demographic variables recorded during the visit were age, sex, weight, height, blood pressure, work situation, alcohol consumption and smoking status. Clinical variables collected from the data obtained in the structured interview and the review of the patient clinical records included: date of diagnosis of the psoriasis and form of presentation, family history of psoriasis, severity and location of the lesions, parameters to determine the severity of the psoriasis: determination of BSA (Body Surface Area), determination of the PASI (Psoriasis Activity and Severity Index), determination of PGA (Psoriasis Global Assessment), determination of the NAPSI (Nail Psoriasis Severity Index) and concomitant diseases. Questionnaires to be completed by the patient were: 1) the PASE questionnaire consisting of 15 questions, each of which are assessed on a 5-point scale that rates the subject’s agreement with each question from strongly disagree (scored as 1 point) to strongly agree (scored as 5 points; table 1) [14]. The PASE questionnaire is divided into a 7item Symptom subscale and an 8-item Function subscale; the total score (which ranges from a minimum of 15 points to a maximum of 75 points) is calculated by summing responses to all 15 questions. Patients with a PASE score ≥44 were defined as having suspicion of PsA; and 2) a questionnaire on work productivity and activity impairment and general health (WPAI-GH) specifically designed to evaluate work absenteeism and deterioration of work associated with health problems [15].
Rheumatologic evaluation Following dermatologic examination, all patients were referred to the rheumatologic units. Each rheumatologist, at that time, was blind to the diagnosis made in the Dermatology Unit of their hospital site. A clinical evaluation of the patient was performed in the Rheumatology Unit, and a diagnosis was, or was not, made of PsA or other type of arthritic disease. The Moll and Wright and/or Classification Criteria for Psoriatic Arthritis (CASPAR) criteria were used for PsA diagnosis confirmation [16, 17]. By the Moll and Wright criteria, PsA is diagnosed by the presence EJD, vol. 25, n◦ 1, January-February 2015
Table 1. Comparison of characteristics for patients with and without PsA from dermatological evaluation. Characteristic Age, years, Mean (SD) Gender, males, n (%) BMI, kg/m2 , Mean (SD) SBP, mm Hg, Mean (SD) DBP, mm Hg, Mean (SD) Disease duration, years, Mean (SD) Plaque psoriasis, n (%) Moderate-severe disease, n (%) Location of lesion, n (%) Scalp Flexures Palmo-plantar Nails Genitals Other areas Activity measures, Mean (SD) PASI BSA PGA, 0-1, n (%) NAPSI Past symptoms, n (%) Low back pain Peripheral symptoms Current presence, n (%) Low back pain Peripheral symptoms DLQI questionnaire, Mean (SD) WPAI-GH questionnaire, Mean (SD) Work productivity involvement Leisure activities involvement
Patients with PsA (n = 86)
Patients without PsA (n = 289)
48.6 (12.8) 45 (53.6) 29.0 (49)* 131.3 (165)* 78.6 (114)* 19.9 (12.3) 75 (87.2) 37 (43.0)
47.1 (13.5) 166 (58.2) 27.2 (5.0) 126.4 (15.2) 74.6 (96) 17.9 (13.3) 244 (84.4) 131 (45.6)
40 (46.5) 8 (9.3) 10 (11.6) 36 (41.9)* 6 (7.0) 65 (75.6)
116 (40.1) 28 (9.7) 45 (15.6) 88 (30.4) 18 (6.2) 213 (73.7)
6.6 (7.2) 8.5 (10.0) 31 (36.4) 9.6 (13.0)*
6.5 (6.5) 10.1 (13.0) 112 (38.8) 7.2 (13.0)
38 (44.2)* 53 (61.6)*
55 (19.0) 68 (23.5)
21 (24.4)* 35 (40.7)* 6.6 (5.6)
44 (15.2) 63 (21.8) 6.4 (6.7)
2.1 (2.6) 3.4 (3.2)*
1.4 (2.2) 2.4 (2.8)
*p
