JEADV
DOI: 10.1111/jdv.12551
EDITORIAL
Risk factors, diagnosis and management of psoriatic arthritis: systematic literature reviews and expert opinion of a panel of dermatologists
The medical progress effort in the understanding and management of psoriasis has shed light on psoriasis comorbid conditions. Among those, psoriatic arthritis (PsA) may represent a significant burden to psoriasis patients.1 PsA results from chronic joint inflammation associated with psoriasis and is clinically highly heterogeneous. Patients with PsA may develop peripheral arthritis, axial disease, dactilytis, enthesitis at any time during the course of psoriasis skin disease. PsA evolution is variable and unpredictable, ranging from mild inflammation to a severe destructive and debilitating arthropathy. Left untreated, patients with PsA may experience chronic joint inflammation, progressive joint damage, severe physical limitations, disability and increased mortality. PsA occurs in about one third of patients in patients with psoriasis although the systematic review we performed showed highly variable prevalence figures.2 Dermatologists should be encouraged to actively screen patients for signs and symptoms of PsA, as early detection of PsA may improve patient outcome through early and appropriate treatment. Recent evidence shows that PsA is underdiagnosed by dermatologists who may feel uncomfortable investigating joint symptoms in patients. A recent work published by Mease3 from a multicentre international cohort of 949 psoriasis patients (PREPARE), underlined the high frequency of undiagnosed PsA in psoriasis patients followed in dermatology centres. The authors showed that careful clinical evaluation alone is often sufficient to identify PsA, whereas the need for biology or X-ray remains low. There is no commonly used PsA screening tool in the dermatology community. There is a need to better define how to identify psoriasis patients at risk of PsA who should be referred to the rheumatologist for further diagnostic investigation. The fifth French Psoriasis expert meeting held in June 2013 was specifically dedicated to psoriasis arthritis risk factors, diagnostic and primary management (PsA). The meeting aimed to define more clearly the role a dermatologist should play in PsA detection and management. The expert group comprising 43 dermatologists and one rheumatologist proposed 10 recommendations on PsA significant risk factors in psoriasis patients, methods for PsA screening that can be used by the dermatologist based on systematic literature review (SLR) and expert opinions of a panel of dermatologists with a special interest in psoriasis. The experts were all practising physicians from private practice, hospitals and/or academic institutions. The methodology for elaborating the
JEADV 2014, 28 (Suppl. 5), 1–2
recommendations followed a structured procedure already described in previously published recommendations.4–7 The recommendations presented in this issue of the journal obtained good agreement from the expert group.8 We are pleased to report here, on behalf of the expert group, the results of the SLR and the 10 recommendations regarding PsA risk factors, diagnostic and management. A first series of recommendations focus on the risk factors for PsA. Some specific skin features of psoriasis are significantly associated with a higher risk of PsA. Their presence may prompt Dermatologist to screen patients for PsA with higher scrutiny. A second series of recommendations investigate simple methods for PsA screening that can be used by dermatologist in every day clinical practice, the goal being to increase our ability to detect PsA which is frequently unrecognized. A third series of recommendations regard the treatment of PsA based upon a critical analysis of published guidelines on PsA treatment. This last series of recommendations was established to facilitate a better coordination of psoriasis and PsA management by rheumatologists and dermatologists. Finally, recommendations were established for the treatment of chronic palmoplantar pustulosis, a specific form of psoriasis frequently associated PsA. We hope these recommendations will be helpful to promote early detection of PsA by dermatologists in their daily practice. We also hope that these recommendations will prompt dermatologists and rheumatologists to work together in a “joint” approach through shared psoriasis clinics.9
Conflicts of interest Carle Paul has been paid as a consultant by AbbVie; Marie-Aleth Richard has been an investigator for Amgen, Lilly, Novartis and Leo Pharma and a paid consultant for MSD, Pfizer, Novartis, Janssen, AbbVie, UCB.
Funding sources AbbVie France provided financial support for publication but took no further part in the study. The authors have no financial interest in the subject matter or materials discussed in the manuscript. M.-A. Richard,1,* C. Paul2 1
Aix-Marseille University, UMR 911, INSERM CRO2, Assistance Publique and Dermatology Department, Timone Hospital, Marseille, France,
© 2014 European Academy of Dermatology and Venereology
Editorial
2
2
Dermatology Department, Paul Sabatier University, UMR CNRS 5165, INSERM 1056, Toulouse, France *Correspondence: M-A Richard. E-mail: [email protected]
References 1 Meyer N, Paul C, Feneron D et al. Psoriasis: an epidemiological evaluation of disease burden in 590 patients. J Eur Acad Dermatol Venereol 2010; 24: 1075–1082. 2 Prey S, Paul C, Bronsard V et al. J Eur Acad Dermatol Venereol 2010; 24 (Suppl 2): 31–35. 3 Mease PJ, Gladman DD, Papp KA et al. Prevalence of rheumatologistdiagnosed psoriatic arthritis in patients with psoriasis in European/ North American dermatology clinics. J Am Acad Dermatol 2013; 69: 729–735. 4 Paul C, Gourraud PA, Bronsard V et al. Evidence-based recommendations to assess psoriasis severity: systematic literature review and expert opinion of a panel of dermatologists. J Eur Acad Dermatol Venereol 2010; 24(Suppl 2): 2–9.
JEADV 2014, 28 (Suppl. 5), 1–2
5 Paul C, Gallini A, Maza A et al. Evidence-based recommendations on conventional systemic treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists. J Eur Acad Dermatol Venereol 2011; 25(Suppl 2): 2–11. 6 Paul C, Gallini A, Archier E et al. Evidence-based recommendations on phototherapy and topical treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists. J Eur Acad Dermatol Venereol 2012; 26(Suppl 3): 1–10. 7 Richard MA, Barnetche T, Horreau C et al. Psoriasis, cardiovascular events, cancer risk and alcohol use: evidence-based recommendations based on systematic review and expert opinion. J Eur Acad Dermatol Venereol 2013; 27(Suppl 3): 2–11. 8 Richard MA, Barnetche T, Rouzaud M et al. Evidence-based recommendations on the role of dermatologists in the diagnosis and management of psoriatic arthritis: systematic review and expert opinion. J Eur Acad Dermatol Venereol 2014; 28 (Suppl. 5): 3–12. 9 Warren RB, Helliwell PS, Chinoy H. Time for a ‘joint’ approach? Br J Dermatol 2013; 168: 683–684.
© 2014 European Academy of Dermatology and Venereology
DOI: 10.1111/jdv.12551
EDITORIAL
Risk factors, diagnosis and management of psoriatic arthritis: systematic literature reviews and expert opinion of a panel of dermatologists
The medical progress effort in the understanding and management of psoriasis has shed light on psoriasis comorbid conditions. Among those, psoriatic arthritis (PsA) may represent a significant burden to psoriasis patients.1 PsA results from chronic joint inflammation associated with psoriasis and is clinically highly heterogeneous. Patients with PsA may develop peripheral arthritis, axial disease, dactilytis, enthesitis at any time during the course of psoriasis skin disease. PsA evolution is variable and unpredictable, ranging from mild inflammation to a severe destructive and debilitating arthropathy. Left untreated, patients with PsA may experience chronic joint inflammation, progressive joint damage, severe physical limitations, disability and increased mortality. PsA occurs in about one third of patients in patients with psoriasis although the systematic review we performed showed highly variable prevalence figures.2 Dermatologists should be encouraged to actively screen patients for signs and symptoms of PsA, as early detection of PsA may improve patient outcome through early and appropriate treatment. Recent evidence shows that PsA is underdiagnosed by dermatologists who may feel uncomfortable investigating joint symptoms in patients. A recent work published by Mease3 from a multicentre international cohort of 949 psoriasis patients (PREPARE), underlined the high frequency of undiagnosed PsA in psoriasis patients followed in dermatology centres. The authors showed that careful clinical evaluation alone is often sufficient to identify PsA, whereas the need for biology or X-ray remains low. There is no commonly used PsA screening tool in the dermatology community. There is a need to better define how to identify psoriasis patients at risk of PsA who should be referred to the rheumatologist for further diagnostic investigation. The fifth French Psoriasis expert meeting held in June 2013 was specifically dedicated to psoriasis arthritis risk factors, diagnostic and primary management (PsA). The meeting aimed to define more clearly the role a dermatologist should play in PsA detection and management. The expert group comprising 43 dermatologists and one rheumatologist proposed 10 recommendations on PsA significant risk factors in psoriasis patients, methods for PsA screening that can be used by the dermatologist based on systematic literature review (SLR) and expert opinions of a panel of dermatologists with a special interest in psoriasis. The experts were all practising physicians from private practice, hospitals and/or academic institutions. The methodology for elaborating the
JEADV 2014, 28 (Suppl. 5), 1–2
recommendations followed a structured procedure already described in previously published recommendations.4–7 The recommendations presented in this issue of the journal obtained good agreement from the expert group.8 We are pleased to report here, on behalf of the expert group, the results of the SLR and the 10 recommendations regarding PsA risk factors, diagnostic and management. A first series of recommendations focus on the risk factors for PsA. Some specific skin features of psoriasis are significantly associated with a higher risk of PsA. Their presence may prompt Dermatologist to screen patients for PsA with higher scrutiny. A second series of recommendations investigate simple methods for PsA screening that can be used by dermatologist in every day clinical practice, the goal being to increase our ability to detect PsA which is frequently unrecognized. A third series of recommendations regard the treatment of PsA based upon a critical analysis of published guidelines on PsA treatment. This last series of recommendations was established to facilitate a better coordination of psoriasis and PsA management by rheumatologists and dermatologists. Finally, recommendations were established for the treatment of chronic palmoplantar pustulosis, a specific form of psoriasis frequently associated PsA. We hope these recommendations will be helpful to promote early detection of PsA by dermatologists in their daily practice. We also hope that these recommendations will prompt dermatologists and rheumatologists to work together in a “joint” approach through shared psoriasis clinics.9
Conflicts of interest Carle Paul has been paid as a consultant by AbbVie; Marie-Aleth Richard has been an investigator for Amgen, Lilly, Novartis and Leo Pharma and a paid consultant for MSD, Pfizer, Novartis, Janssen, AbbVie, UCB.
Funding sources AbbVie France provided financial support for publication but took no further part in the study. The authors have no financial interest in the subject matter or materials discussed in the manuscript. M.-A. Richard,1,* C. Paul2 1
Aix-Marseille University, UMR 911, INSERM CRO2, Assistance Publique and Dermatology Department, Timone Hospital, Marseille, France,
© 2014 European Academy of Dermatology and Venereology
Editorial
2
2
Dermatology Department, Paul Sabatier University, UMR CNRS 5165, INSERM 1056, Toulouse, France *Correspondence: M-A Richard. E-mail: [email protected]
References 1 Meyer N, Paul C, Feneron D et al. Psoriasis: an epidemiological evaluation of disease burden in 590 patients. J Eur Acad Dermatol Venereol 2010; 24: 1075–1082. 2 Prey S, Paul C, Bronsard V et al. J Eur Acad Dermatol Venereol 2010; 24 (Suppl 2): 31–35. 3 Mease PJ, Gladman DD, Papp KA et al. Prevalence of rheumatologistdiagnosed psoriatic arthritis in patients with psoriasis in European/ North American dermatology clinics. J Am Acad Dermatol 2013; 69: 729–735. 4 Paul C, Gourraud PA, Bronsard V et al. Evidence-based recommendations to assess psoriasis severity: systematic literature review and expert opinion of a panel of dermatologists. J Eur Acad Dermatol Venereol 2010; 24(Suppl 2): 2–9.
JEADV 2014, 28 (Suppl. 5), 1–2
5 Paul C, Gallini A, Maza A et al. Evidence-based recommendations on conventional systemic treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists. J Eur Acad Dermatol Venereol 2011; 25(Suppl 2): 2–11. 6 Paul C, Gallini A, Archier E et al. Evidence-based recommendations on phototherapy and topical treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists. J Eur Acad Dermatol Venereol 2012; 26(Suppl 3): 1–10. 7 Richard MA, Barnetche T, Horreau C et al. Psoriasis, cardiovascular events, cancer risk and alcohol use: evidence-based recommendations based on systematic review and expert opinion. J Eur Acad Dermatol Venereol 2013; 27(Suppl 3): 2–11. 8 Richard MA, Barnetche T, Rouzaud M et al. Evidence-based recommendations on the role of dermatologists in the diagnosis and management of psoriatic arthritis: systematic review and expert opinion. J Eur Acad Dermatol Venereol 2014; 28 (Suppl. 5): 3–12. 9 Warren RB, Helliwell PS, Chinoy H. Time for a ‘joint’ approach? Br J Dermatol 2013; 168: 683–684.
© 2014 European Academy of Dermatology and Venereology
