By Alice B. Gottlieb, MD, PhD, dermatologist, told to Kristen Fischer
Certain things, like your genes, can increase your risk of psoriatic arthritis. If you have a first-degree relative with psoriatic arthritis, you are 39 times more likely to develop it.
Other risks for psoriatic arthritis include psoriasis on the scalp and nails. Inverse psoriasis, or intertriginous psoriasis, also increases your risk of psoriatic arthritis. (Inverse psoriasis occurs in body folds, such as the armpits or groin.)
A common misconception is that only people with moderate to severe psoriasis get psoriatic arthritis. You can get psoriatic arthritis even if you have mild psoriasis. Early detection is essential. If you can manage psoriasis, you may be able to prevent psoriatic arthritis from getting worse – maybe even prevent it altogether.
Why is early diagnosis of psoriatic disease important?
Family physicians, especially dermatologists, need to detect psoriasis in order to prevent disability caused by psoriatic arthritis. Once detected, we can do something about it.
It’s a paradigm shift from when I was a rheumatology fellow at the Hospital for Special Surgery. At the time, we had nothing that could prevent the disease from getting worse. The doctors weren’t even controlling the signs and symptoms so well.
There are now several medications on the market to treat psoriatic arthritis. Some are tumor necrosis factor (TNF)-alpha inhibitors blockers, interleukin inhibitors and JAK inhibitors.
Research has also found that people who took medication had less damage than those who didn’t. This suggests you might even be able to prevent psoriatic arthritis.
How can dermatologists detect psoriatic disease?
Dermatologists may not realize how important their role is in detecting psoriatic arthritis. They don’t need to be experts to diagnose it, but they do need to check it out. Then they may refer you to a rheumatologist. They should ask you about joint pain. Many people don’t realize that pain can be a disease. You have to raise it.
Missing a diagnosis can be serious. Research tells us that a delay in diagnosis and treatment leads to increased joint erosion, deformity and arthritis mutilans (a form of psoriatic arthritis where bone degeneration shortens the fingers and toes) .
In dermatology offices, people usually show signs of enthesitis before they have psoriatic disease. Enthesitis is an inflammation where tendons and ligaments insert into the bone. This can cause joint pain, stiffness, and mobility issues. Some ultrasound evidence shows that enthesitis increases the risk of a future diagnosis of psoriatic arthritis fivefold.
How is the management of psoriatic diseases improving?
Doctors have simple and quick screening methods to identify psoriatic diseases. We need to get them into the hands of more GPs and dermatologists – and they need to use them.
I’m working with a team to encourage more doctors to use these screening tools. Mount Sinai recently launched a new program that integrates psoriatic disease screening tools into our electronic medical records (EMRs).
Here’s how it works: People who come to see us will answer the five Psoriasis Epidemiological Screening Tool (PEST) questions while they’re in the waiting room. When they see their doctor, their PEST results will appear on the EMR. If they answer three or more questions positively, the EMR app alerts the doctor that the score indicates possible psoriatic arthritis. It will prompt the physician to refer the patient to a rheumatologist. It couldn’t be easier.
They also incorporate the industry-standard Psoriatic Arthritis Disease Impact Questionnaire (PsAID) into the EMR. People with existing psoriatic disease, or those who test positive for PEST, will be asked 12 questions. If they have a certain score, it will alert the doctor that the case is out of control. He will then encourage the doctor to make an appointment with a rheumatologist. The DME will also offer medications.
These screening tools are available in some other EMR systems, but my project is different because I will be measuring how well it works.
After 18 months, I will see if the percentage of cases increases. The system will be able to tell if people are managing their psoriatic illnesses, and we will be able to assess how treatments are working.
If all goes well, this will allow doctors to better care for patients. This will help them to be more aware of the diagnosis of psoriatic diseases and whether people are in control of their disease.
Screening tools are available on the GRAPPA app, which is produced by the Psoriasis and Psoriatic Arthritis Research and Evaluation Group.
What’s New in Psoriasis Medications?
There are some advances in medications to treat psoriatic arthritis. TNF antagonists are the gold standard for treating psoriatic diseases. But they don’t work for everyone.
Deucravacitinib is a new drug approved by the FDA for psoriasis, but not for psoriatic arthritis. There is evidence that it can improve psoriatic arthritis. Clinical trials look good for bimekizumab, an oral drug that cleans skin for 3 years, but it’s not yet approved in the US
In 2023, adalimumab (Humira) will be available in generic form. I don’t think the price will drop much.
I favor treatments that prevent psoriatic arthritis from getting worse, even in patients who only have psoriasis. This is because there is evidence that medications can prevent psoriatic arthritis.
For now, combining effective treatments – and getting more people diagnosed to prevent disability from psoriatic disease – is a priority.
We have excellent treatments for psoriatic diseases, but many are expensive. Many people cannot afford it, even those who have supplementary insurance.
What’s next for psoriatic arthritis and psoriasis?
All in all, people need to know that psoriasis is more than just a problem that affects their skin. This can cause lasting damage and complications.
This is why screening for psoriasis and psoriatic arthritis is so important, and why I am committed to ensuring that everyone gets checked.