A Multidisciplinary Team for the Diagnosis and Management of Psoriatic Arthritis

A Multidisciplinary Team for the Diagnosis and Management of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a complex and multifaceted condition that represents a unique subtype of psoriasis, significantly impacting the quality of life of those affected. The clinical manifestations of PsA are diverse, encompassing not only skin lesions but also musculoskeletal symptoms, nail changes, and ophthalmological features that may occur simultaneously or sequentially with the skin lesions. Given the heterogeneity of its symptoms, the diagnosis and treatment of PsA present considerable challenges. In recent years, the importance of a multidisciplinary approach to managing PsA has gained recognition, as early screening, diagnosis, and treatment can effectively control the signs and symptoms of the disease, improve patients’ quality of life, and slow disease progression.

The multidisciplinary management of PsA involves the collaboration of dermatologists and rheumatologists, as the condition presents with both dermatological and rheumatological manifestations. Dermatologists play a crucial role in the early diagnosis of PsA, as most patients develop skin lesions before joint symptoms. Therefore, dermatologists must be well-versed in the early manifestations of PsA and make timely referrals to rheumatologists when necessary. Conversely, rheumatologists are responsible for managing the musculoskeletal symptoms and reducing the impact of skin manifestations on the patient’s quality of life. Current multidisciplinary management strategies include combined rheumatology-dermatology (R-D) clinics and virtual clinics, with telemedicine gaining prominence, especially in the context of the COVID-19 pandemic.

One of the significant challenges in the pre-diagnosis phase of PsA is the cognitive gap regarding the risk of musculoskeletal lesions in psoriasis patients among non-rheumatologists. The lack of clear referral recommendations for psoriasis patients to rheumatology departments often results in delayed diagnoses. Even for rheumatologists, diagnosing PsA can be challenging, particularly in patients with psoriasis who also have osteoarthritis or gout. To address these challenges, detailed medical history and physical examinations are essential, along with the use of screening questionnaires, laboratory tests, and diagnostic imaging.

Several screening tools have been developed and validated for their efficacy in the early diagnosis of PsA, including the Psoriatic Arthritis Screening Evaluation (PASE), the Psoriasis Epidemiology Screening Tool (PEST), and the Psoriatic Arthritis Screening Questionnaire. However, the sensitivity and specificity of these tools remain relatively low. In China, dermatology and rheumatology departments have begun collaborating online to identify suitable screening tools for the early diagnosis of PsA. One such tool is the Early Arthritis for Psoriatic Patients (EARP) questionnaire, which has shown higher sensitivity than PASE and PEST and has been validated in Italy, Spain, Japan, Australia, Korea, and China.

Biomarkers also play a crucial role in assisting the diagnosis of PsA. Commonly detected blood indexes in clinical practice include erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), which are often elevated in PsA patients. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies are usually seronegative in PsA patients, although 5% to 20% of PsA patients may have positive RF. Experts recommend that dermatologists test for RF, CRP, and human leukocyte antigen B27 (HLA-B27) in patients with axial pain before referring them to rheumatologists. Recent advancements in PsA treatment have highlighted the potential of interleukin-17 (IL-17) antagonists, suggesting that IL-17 may be an effective biomarker for PsA. Additionally, serum chemokine C-X-C ligand 10 (CXCL10) levels have been found to be significantly elevated in psoriasis patients who progress to PsA, making CXCL10 a potential diagnostic marker.

Imaging techniques are also critical in the early detection of PsA. While X-ray examination alone is insufficient for detecting early signs of enthesitis and articular disease, ultrasound and magnetic resonance imaging (MRI) are more sensitive. Ultrasound is particularly useful for detecting early lesions such as synovitis and enthesitis, while MRI can differentiate PsA from rheumatoid arthritis and osteoarthritis by identifying enthesitis and extracapsular inflammation.

Given that most PsA patients develop skin lesions before joint symptoms, dermatologists must prioritize screening for joint involvement in the management of psoriatic diseases. Dermatologists should actively diagnose signs or symptoms of PsA at least once a year, preferably every six months, by inquiring about joint pain, stiffness, swelling, and fatigue. Specific conditions of joint pain and stiffness, such as the time of onset, duration, and relationship with exercise, should be highlighted. Patients with psoriasis should be referred to a rheumatologist when joint symptoms do not respond to disease-modifying antirheumatic drugs (DMARDs). Before referral, dermatologists can prescribe non-steroidal anti-inflammatory drugs (NSAIDs) to alleviate joint pain.

According to 2020 recommendations, patients with psoriasis and suspected PsA who exhibit at least one of the following signs and symptoms should be referred to the rheumatology department: inflammatory axial pain (including night pain), inflammatory peripheral pain or swelling, enthesitis or signs of enthesitis (especially in the Achilles tendon and plantar fascia), and dactylitis or signs of dactylitis. Ultrasound is a useful tool for identifying musculoskeletal signs of PsA, while MRI is recommended for identifying axial PsA manifestations.

PsA is a complex disease that requires multidisciplinary care involving dermatologists, rheumatologists, and gastroenterologists. Additionally, comorbidities of PsA must be considered, as they significantly influence treatment choices. NSAIDs and other conservative strategies are typically used for PsA patients with mild clinical manifestations, although many patients do not respond well to these treatments. DMARDs, along with biological treatments such as tumor necrosis factor inhibitors (TNFi), IL-17 inhibitors, IL-23/12 inhibitors, and novel targeted small molecule oral agents like phosphodiesterase-4 inhibitors and Janus kinase (JAK)/signal transducer and activator of transcription (STAT) inhibitors, have shown efficacy in treating PsA in recent years. However, medications such as TNFi and systemic glucocorticoids can lead to cutaneous complications, necessitating consultation with dermatologists to minimize flares and provide optimal management.

Several dermatology-rheumatology joint organizations have been established worldwide to improve the multidisciplinary management of PsA. The Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network, for example, focuses on establishing novel polyclinics or optimizing existing ones. Studies have shown that the multidisciplinary model can improve the quality of care by raising awareness of psoriatic disease, promoting educational activities for both physicians and patients, and comprehensively evaluating and managing patients through improved interdisciplinary communication.

A five-year retrospective study conducted by the Interdisciplinary Rheumatology-Dermatology (R-D) Clinic at Massachusetts General Hospital in the United States demonstrated that interdisciplinary clinics provide more comprehensive evaluations and better drug use. Similarly, a retrospective study at the Center for Skin and Related Musculoskeletal Diseases (SARM) at Brigham and Women’s Hospital in Boston found that systemic drugs and biological agents are more likely to be prescribed after assessment by SARM. A two-year study in an Italian R-D clinic showed that using specific working procedures and treatment flowcharts through close cooperation between dermatologists and rheumatologists can yield significant therapeutic efficacy and improve health-related quality of life.

Despite the proven benefits of multidisciplinary management, several challenges remain. First, closer collaboration is needed among dermatologists, rheumatologists, and radiologists, as imaging examinations such as ultrasound and MRI provide accurate information for early diagnosis and treatment evaluation. In China, patients often seek medical help for joint pain in departments such as orthopedics, pain management, rehabilitation, and traditional Chinese medicine, making coordination with these specialties a considerable challenge. Second, the assessment of rheumatism and skin diseases is time-consuming and requires clinical expertise, making it difficult to arrange highly effective outpatient care involving both dermatologists and rheumatologists. Third, multidisciplinary R-D clinics in European and American countries typically operate once a month to once a week, making it challenging to coordinate schedules between patients and clinics to ensure the rational use of medical resources. Additionally, high medical costs remain a barrier to the widespread adoption of these combined clinics.

In conclusion, considering the comorbidities of PsA and the need for long-term treatment, multidisciplinary management is the most effective approach for managing PsA. Interdisciplinary care involving dermatologists, rheumatologists, and other specialists such as psychiatrists, general practitioners, cardiologists, and pain specialists can significantly contribute to preventing irreversible joint damage and reducing the high mortality risks associated with comorbidities. Multidisciplinary management also improves patient satisfaction, reduces the number of repeated inspections, and saves medical care resources.

doi.org/10.1097/CM9.0000000000001588

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