|Year : 2016 | Volume
| Issue : 2 | Page : 91-95
Clinical and radiological findings in psoriatic arthritis: A hospital-based cross-sectional study
Neetha Vijayakumaran1, Neelakandhan Asokan1, Jijith Krishnan2, Beena Narayanan1
1 Department of Dermatology, Government Medical College, Thrissur, Kerala, India
2 Department of Medicine, Government Medical College, Thrissur, Kerala, India
|Date of Web Publication||30-Jun-2016|
Prashanthi, KRA-11, PO - Kanattukara, Thrissur - 680 011, Kerala
Source of Support: None, Conflict of Interest: None
Context: There is limited published data on psoriatic arthritis (PsA) from India. Aims: To analyze the clinical and radiological findings of patients with PsA attending a tertiary care teaching hospital. Settings and Design: Cross-sectional descriptive study in a dermatology department of a tertiary care teaching hospital over a 1- year period. Materials and Methods: Demographic profile, clinical profile, and radiological changes of patients with PsA were studied. Statistical Analysis Used: Qualitative data were analyzed using means, percentages, and chi-square test and quantitative data were analyzed using Spearman's rank correlation and Z-test. Results: There were 53 patients (35 males). The most common age group was 40-59 years. The age of onset was earlier among females. The most common type of PsA was asymmetric oligoarthritis (35/53; 66%). Overlapping types were seen in 19 (35.8%) patients. The knee was the most common joint involved (21/53; 39.6%) followed by the distal interphalangeal (DIP) joint and shoulder joint (18/53 each; 34%). Enthesitis and dactylitis were present in 3 (6%) and 7 (13.2%) patients, respectively. Nails were affected in 47 (88.7%) patients; the most common finding was pitting of the nail plates. There was no correlation between clinical type of PsA and the severity of disease as assessed by Psoriasis Area and Severity Index (PASI) and body surface area of involvement (BSA). Twenty-five (47.2%) patients were either overweight or obese. A majority of the patients (41/53), particularly females (17/18), had central obesity. 34% of the patients had systemic hypertension (HT), diabetes mellitus, or both. The most common (24.5%) radiological change was marginal erosion of the phalanges. Conclusions: Asymmetric oligoarthritis was the most common clinical type of PsA. The knees, shoulders, and DIP joints were the more commonly affected joints. Severity of psoriasis was not associated with any particular type of PsA. A majority of patients, particularly females, had central obesity. The most common radiological finding was marginal erosion.
Keywords: Obesity, oligoarthritis, psoriatic arthritis (PsA), psoriasis, radiological findings
|How to cite this article:|
Vijayakumaran N, Asokan N, Krishnan J, Narayanan B. Clinical and radiological findings in psoriatic arthritis: A hospital-based cross-sectional study. Muller J Med Sci Res 2016;7:91-5
|How to cite this URL:|
Vijayakumaran N, Asokan N, Krishnan J, Narayanan B. Clinical and radiological findings in psoriatic arthritis: A hospital-based cross-sectional study. Muller J Med Sci Res [serial online] 2016 [cited 2017 Apr 29];7:91-5. Available from: http://www.mjmsr.net/text.asp?2016/7/2/91/185002
| Introduction|| |
Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis of the skin and/or nails. It is grouped under seronegative spondyloarthropathies, a group that includes ankylosing spondylitis (AS), enteropathic arthritis, and Reiter's syndrome.  Reported prevalence of PsA among patients with psoriasis has varied between 6-42% in various studies across the world.  The disease can lead to significant morbidity in affected patients. In spite of its frequency and significance, there are only a few published studies on PsA from India. ,,, Hence, we thought it will be useful to analyze the clinical and radiological findings of patients with PsA attending our hospital and compare the findings with previous studies from India and abroad.
| Materials and Methods|| |
This was a prospective cross-sectional descriptive study on patients with PsA attending the department of dermatology of a Government-run medical college in Thrissur, Kerala, over a 1-year period. All patients with definite clinical diagnosis of PsA were selected for the study. We recorded their history, and findings on physical and dermatological examinations in a pro forma. The data included demographic profile, duration of disease of the skin and joints, any predisposing factor for PsA, type of joint disease, correlation between PsA and the severity of skin lesions assessed using Psoriasis Area and Severity Index (PASI) and body surface area of involvement (BSA), relationship of PsA with body mass index (BMI) and central obesity, nail changes, and radiological changes of affected joints. Qualitative data were analyzed using means, percentages, and chi-square test and quantitative data were analyzed using Spearman's rank correlation and Z-test.
| Results|| |
Fifty-three patients with PsA (including 35 males; M:F = 1.94:1) with PsA participated in the study [Table 1]. The mean age of the patients was 48 years (SD 11.1). The youngest patient was 20 years and the oldest was 70 years of age. The most common age group of patients was 40-59 years.
The mean age of onset of skin lesions among males was 40.4 [standard deviation (SD) 15.1] years and among females, 30.8 (SD 10.5) years. The mean age of onset of joint symptoms among males was 48.4 (SD 11.00) years and among females, 38 (SD 11.00) years. Forty-seven (88.7%) patients manifested skin lesions before arthritis. Two patients (3.8%) developed joint disease before skin lesions and four patients (7.5%) had a concurrent onset of disease in the skin and joints. There was a positive correlation between the duration of psoriatic skin lesions and joint involvement (Spearman's rank correlation; r = 0.388; P < 0.01).
Only four patients noted any precipitating factor for PsA. One of them reported upper respiratory tract infection while the other three patients noted strenuous physical exertion. Eight patients (15.4%) gave history of psoriasis in another family member (first-degree relative of seven patients; and second-degree relative of the other) while two (3.8%) patients had another family member (first-degree relative of one patient; and second-degree relative of the other) with PsA.
Fifty-one patients (96.2%) had chronic plaque psoriasis while two (3.8%) had erythrodermic psoriasis. Thirty-four (64.2%) patients had a single clinical type of PsA. Among them, 23 (43.4%) had asymmetric oligoarthritis, 10 (18.9%) had rheumatoid arthritis (RA)-like symmetrical polyarthritis, and one (1.9%) had arthritis limited to the axial joints. Nineteen patients (35.8%) had overlapping clinical types of arthritis, out of whom 10 (18.9%) had oligoarthritis with axial involvement, seven (13.2%) had RA-like symmetrical polyarthritis with axial involvement, and two (3.8%) had asymmetric oligoarthritis with distal interphalangeal (DIP) joint involvement. Overall, 35 patients (66%) had asymmetric oligoarthritis, 17 (32.1%) had RA-like symmetrical polyarthritis, 18 (34%) had axial involvement, and two (3.8%) had DIP joint arthritis. None had arthritis mutilans.
The knee was the most common joint involved (21/53; 39.6%) followed by DIP joint and shoulder joint (18/53 each; 34%). The cervical spine was involved in 11 patients (20.8%). Enthesitis and dactylitis were present in three (5.7%) and seven (13.2%) patients, respectively.
Twenty-two (41.5%) patients had less than 10% skin involvement while two (3.8%) had more than 90% skin involvement. PASI of patients ranged 0.1-45.5 (mean = 9.2; SD = 10.4). There was no association between PASI and the type of PsA. (χ2 = 3.43; P = 0.633). Twenty-six patients (49.1%) had normal (18.5-24.99) BMI [Table 2]. Eighteen (33.4%) patients were overweight (BMI >25), seven (13.2%) were obese (BMI >30), and two (3.8%) were underweight (BMI <18.4). There was no association between BMI and the type of PsA (χ2 = 12.11; P = 0.67).
Forty-one patients (77.4%) had waist circumference (WC) above population- and sex-specific cutoff values (males = WC >90 cm; females >80 cm) for central obesity [Table 3]. Central obesity was more frequent among females (17/18; 94.4%), compared to males (24/35; 68.6%) (z = 2.72; P = 0.003).
Nails were affected in 47 (88.7%) patients. The most common finding was pitting (34/53; 64.2%) [Table 4]. Subungual hyperkeratosis and onycholysis were seen in 30 patients (56.6%) each. Nails were normal in six (11.3%) patients.
Out of 53 patients, 10 (18.9%) patients had systemic hypertension (HT) and 5 (9.43%) had diabetes mellitus (DM). Three (5.7%) patients had both DM and HT. Two patients had a history of coronary artery disease. One patient had human immunodeficiency virus (HIV)/acquired immune deficienct syndrome (AIDS) and was on antiretroviral therapy. Three (5.7%) patients had anemia while 18 (34%) had raised erythrocyte sedimentation rate (ESR).
The most common radiological change was marginal erosion, as seen in 13 (24.5%) patients [Table 5]. Nine (17%) patients had soft tissue inflammation while bony ankylosis and pencil-in-cup deformity were present in one patient each. Periosteal reaction was present in six (11.3%) patients. X-rays were normal in 22 patients, eleven (50%) of whom had arthropathy of less than 2 years duration.
|Table 5: Findings on x-ray examination of affected joints in patients with psoriatic arthritis|
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| Discussion|| |
The mean age of patients in the present series was 48 years. It was higher than 40.9 years as reported by Prasad et al. (2006)  but lower than 53.2 years as reported by Gladman et al. (2012).  The most common age group affected in our series was 41-60 years, comparable to the findings by Prasad et al. (2006) who reported that 40% of patients were between 51 years and 60 years of age.  The male to female ratio in the present study was 1.94:1. The male to female ratio was as high as 5.6:1 in the study by Prasad et al. (2006).  Most other studies also report a higher prevalence among males. ,,,,, While selection bias is a possible explanation for the differences with respect to age and gender in different studies, the role of biological factors also needs to be explored.
The mean age of onset of PsA of 44.9 years in this study was comparable to the findings of Ray et al. (1990),  Prasad et al. (2006),  and Scarpa et al. (1984).  The onset of PsA was earlier in females compared to males. Alonso et al. (1991) also reported an earlier age of onset of PsA among females.  Females had an earlier age of onset of skin lesions too, compared to males. This was consistent with a previous study from our institution, which reported that the mean age of onset of psoriasis was lower among females compared to males. 
Our finding that skin lesions had preceded arthritis in the majority of patients was consistent with several previous studies. ,, In the present study, there was a positive correlation between the duration of skin and joint disease. This was similar to the findings by Prasad et al. (2006). 
A comparison of the clinical types of PsA in our series with several previous studies is given in [Table 6]. Asymmetric oligoarthritis was the most common type (66%) of PsA in the present series. This was similar to the findings of Prasad et al. (2006)  but higher compared to many other reports. Ray et al. (1990),  Rajendran et al. (2003),  Gladman et al. (1987),  and Helliwell et al. (1991)  reported symmetrical polyarthritis to be the most common type. The prevalence of symmetrical polyarthritis in our series was only 32.1%. The frequency of enthesitis and dactylitis in the present series (6 and 13.2%, respectively) was much lower than reported by Kane et al. (2003)  (38% and 29%, respectively) but comparable to 7.8% and 19%, respectively, reported by Rajendran et al. (2003).  In our series, there was a considerable overlap of the various clinical types of PsA. Such a finding was first described by Moll and Wright (1973). Prasad et al. (2006)  reported a marked overlap between peripheral and axial involvements. Differences in the clinical patterns in various studies could be due to differences in the setting of study (dermatology or rheumatology) or due to differences in the geographical or ethnic characteristics of the study population.
|Table 6: Frequency of important clinical and radiological findings in this study compared with selected previous studies|
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In the present series, 34% of the patients had symptoms suggestive of axial involvement though only 15.1% had associated radiological changes. This was higher than that reported by Ray et al. (1990)  and Rajendran et al. (2003).  Among previous Indian studies, only Pandya et al. (2010)  had reported a higher figure (71%). Scarpa et al. (1984)  noted axial involvement in 20.9% and Alonso et al. (1991)  in 23% of the patients in their series. Most patients in the present series had psoriatic nail changes. A high frequency of nail changes among patients with PsA was noted in several previous studies. ,,
BSA and PASI showed no association with any particular type of arthropathy in this study. This was consistent with most of the previous studies ,, except by Prasad et al. (2006)  who noted that arthropathy was associated with a higher PASI.
A majority of the patients, especially females, in this series had central obesity. A large prospective study from Canada (2007) indicated that increasing adiposity and weight gain were strong risk factors for the increased incidence of psoriasis among women.  A general population study in the UK suggested that obesity was associated with an increased risk of PsA. 
Infection can be a precipitating factor in both psoriasis and arthritis.  Strenuous physical exertion causing precipitation of PsA could be explained by the Koebner phenomenon.  34% of the patients in this study had either systemic HT, DM, or both. Previous studies have reported an increased prevalence of atherosclerosis and metabolic syndrome in patients with PsA.  Association of PsA with HIV/AIDS in one patient in this study is interesting. Rajendran et al. (2003) also had one patient with HIV/AIDS in his series.
One-third of our patients had raised ESR. ESR was elevated in 50% of the patients in the series by Rajendran et al. (2003).  There is no laboratory test, which is specific for the diagnosis of PsA. Anemia, raised ESR, and raised C-reactive protein (CRP) are commonly found in the active phase of the disease. , Elevation of ESR and CRP are less frequent than in RA, AS, and reactive arthritis.  While not diagnostic for PsA arthritis, acute phase reactants have a prognostic value regarding joint destruction.
The most common radiological change noted in our series was marginal erosion as compared to the narrowing of joint space noted by Prasad et al. (2006).  Alonso et al. (1991) observed erosion and new bone formation as the more frequent radiological changes. 
Genetic predisposition is more important in the pathogenesis of PsA compared to other rheumatological diseases.  MHC class 1 genes, particularly those belonging to B and C loci, are more important in PsA. Patients with PsA associated with marked psoriatic skin disease are found to have a higher frequency of human leukocyte antigen (HLA)-C*06:02:01. Patients with early onset and severe presentations of PsA have been found to have an association with HLA B* 27:05:02, B* 39:01, B*38:0, and B*08:01. 
The cross-sectional nature of this study has a limitation - It may fail to pick up changes in the disease pattern over a period of time and as a result of treatment. However, it provides important information about the clinical presentation of PsA from this part of the country. Considering the impact of PsA on affected patients, such information is scarce. More focused studies on specific aspects of the disease may be conducted in the future.
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| References|| |
Winchester R. Psoriatic arthritis. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick′s Dermatology in General Medicine. 7 th
ed. New York: The McGraw-Hill Companies Inc.; 2008. p. 194-206.
Chandran V. Epidemiology of psoriatic arthritis. J Rheumatol 2009;36:213-5.
Prasad PV, Bikku B, Kaviarasan PK, Senthilnathan A. A clinical study of psoriatic arthropathy. Indian J Dermatol Venereol Leprol 2007;73:166-70.
Ray SC, Singh T, Kaur I, Suri S, Sehgal S, Kaur S. Clinical profile of psoriatic arthropathy. Indian J Dermatol Venereol Leprol 1990;56:200-3.
Rajendran CP, Ledge SG, Rani KP, Madhavan R. Psoriatic arthritis. J Assoc Physicians India 2003;51:1065-8.
Pandya SC, Solanki R, Patel J. Demographic and clinical features of consecutive patients of psoriatic arthritis presenting to a rheumatology OPD in the western part of India. Indian J Rheumatol 2010;5(Suppl):S6-7.
Gladman DD, Chandran V, Thavaneswaran A, Zummer M. Psoriatic arthritis in Canadian clinical practice: The PsA assessment in rheumatology. J Rheumatol 2012;39:1850-3.
Scarpa R, Oriente P, Pucino A, Jorella M, Vignone L, Riccio A, et al
. Psoriatic arthritis in psoriatic patients. Br J Rheumatol 1984;23:246-50.
Torre Alonso JC, Rodriguez Perez A, Arribas Castrillo JM, Ballina Garcia J, Riestra Noriega JL, Lopez Larrea C. Psoriatic arthritis (PA): A clinical, immunological and radiological study of 180 patients. Br J Rheumatol 1991;30:245-50.
Gladman DD, Shuckett R, Russel ML, Thome JC, Schachter RK. Psoriatic arthritis (PSA) - an analysis of 220 patients. Q J Med 1987;62:127-41.
Asokan N, Prathap P, Ajithkumar K, Betsy A, Binesh VG. Pattern of psoriasis in a tertiary care teaching hospital in south India. Indian J Dermatol 2011;56:118-9.
Helliwell PS, Wright V. Spondyloarthropathies: Psoriatic arthritis: Clinical features. In: Klippel JH, Dieppe PA, editors. Rheumatology. London: Mosby-Yearbook Europe Limited 1994;3:31-3.
Kane D, Stafford L, Bresnihan B, FitzGerald O. A prospective, clinical and radiological study of early psoriatic arthritis: An early synovitis clinic experience. Rheumatology (Oxford) 2003;42: 1460-8.
Fitzgerald O. Psoriatic arthritis. In: Firestein GS, Budd RC, Harris ED, McInus IB, Ruddy S, Sergeant JS, editors. Kelley′s Textbook of Rheumatology. 8 th
ed. Philadelphia: WB Saunders; 2009. p. 1201-8.
Lloyd P, Ryan C, Menter A. Psoriatic arthritis: An update. Arthritis 2012;2012:176298.
McHugh NJ, Balachrishnan C, Jones SM. Progression of peripheral joint disease in psoriatic arthritis: A 5-yr prospective study. Rheumatology (Oxford) 2003;42:778-83.
Setty AR, Curhan G, Choi HK. Smoking and the risk of psoriasis in women: Nurses′ Health Study II. Am J Med 2007;120:953-9.
Love TJ, Zhu Y, Zhang Y, Wall-Burns L, Ogdie A, Gelfand JM, et al
. Obesity and the risk of psoriatic arthritis: A population-based study. Ann Rheum Dis 2012;71:1273-7.
Finzi AF, Gibelli E. Psoriatic arthritis. Int J Dermatol 1991;30:1-7.
Farber EM, Bright RD, Nall ML. Psoriasis. A questionnaire survey of 2,144 patients. Arch Dermatol 1968;98:248-59.
Raychaudhari SP. Comorbidities of psoriatic arthritis - Metabolic syndrome and prevention: A report from the GRAPPA 2010 annual meeting. J Rheumatol 2012;39:437-40.
Nigam P, Singh D, Matreja VS, Saxena HN. Psoriatic arthritis: A clinico-radiological study. J Dermatol 1980;7:55-9.
Cuchacovich R, Perez-Alamino R, Garcia-Valladares I, Espinoza LR. Steps in the management of psoriatic arthritis: A guide for clinicians. Ther Adv Chronic Dis 2012;3:259-69.
Fitzgerald O, Winchester R. Psoriatic arthritis: From pathogenesis to therapy. Arthritis Res Ther 2009;11:214.
FitzGerald O, Haroon M, Giles JT, Winchester R. Concepts of pathogenesis in psoriatic arthritis: Genotype determines clinical phenotype. Arthritis Res Ther 2015;17:115.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]