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[|What I would like to add to chapter 6 is
the fact that psoriatic arthritis may cause disability by permanent damage of
the joints. The dermatologist may recognise psoriatic arthritis in an early
phase and alert the patient that psoriatic arthritis may be the explanation for
her joint complaints. Adequate diagnosis and treatment in an early phase of
psoriatic arthritis is essential.|auteur197]

[|This is an area of intense interest, both personally as well as to all dermatologists, and more recently rheumatologists who appear to have “rediscovered” this spondyloarthropathy as separate from rheumatoid arthritis. Moll and Wright’s 30-year classification of Psoriatic Arthritis is clearly outmoded and has been replaced by the new CASPAR classification. Large patient surveys in Europe and the United States as mentioned by Professor Dubertret, having given an approximately 30% incidence of joint disease. However, I do believe this needs to be better elucidated. We do not have serological markers for psoriatic arthritis like we do for other arthridities, eg rheumatoid arthritis. We also, as mentioned in a previous discussion, do not have any true genetic markers for the various subtypes of psoriatic arthritis. Likewise, can we predict which patient with psoriatic arthritis will progress radiologically and clinically? Should MRIs be routine in patients with skin disease with mild clinical manifestations in an attempt to prevent further joint progression and disability? This is obviously a very expensive exercise and is currently being utilized more as an investigational tool to better understand the radiological manifestations of this form of spondyloarthritis.
 
Another question that I believe should be discussed is the use of the term “enthesitis”, ie inflammation of the tendon insertions, eg Achilles, and also possibly even smaller joints, ie hands and feet. Thus, immunopathologically speaking, psoriatic arthritis appears to be different from rheumatoid arthritis, even though there are clinical “overlaps” between these two.
 
Thus, I do believe that a list of questions should be developed by dermatologists, in concert with their rheumatology colleagues, to be evaluated at each and every clinical visit to the dermatologist so that appropriate treatments can be initiated. For too long, we as dermatologists have ignored psoriatic arthritis, when the majority of patients present to us with their skin manifestations 5-10 years before joint symptoms appear.|auteur215]

In 5 to 7% of patients suffering from psoriasis, a link is observed between the skin lesions and a particular inflammatory, enthesopathic rheumatism - psoriatic arthritis. Two recent surveys, one conducted among over 40,000 members of the US Psoriasis Association, the other among over 18,000 patients in Europe, found a 30% incidence of psoriatic arthritis. Half of these patients are being monitored by their dermatologist for skin lesions and rheumatism. Therefore, it is particularly important for dermatologists to know how to take care of this non-cutaneous aspect of psoriasis even though the best care calls, of course, for a close collaboration between dermatologist and rheumatologist.

[|The number of 5-7% may be too
low, more recent data suggest that at least one quarter of the patients may
have joint pain of joint inflammation.|auteur195]

In psoriatic arthritis the sex ratio is one. However, the forms displaying axial predominance are slightly more frequent in the male whereas the forms displaying peripheral predominance are more frequent in the female. Psoriatic arthritis seems to be more common when the psoriasis is severe and involves the nails.

The effects of rheumatism may be familial, so it is often associated with class-1 HLA antigens B36, 17, 27 and CW6. When confronted with an inflammatory rheumatism, the existence of psoriasis in the family, and especially of psoriatic arthritis, is of great diagnostic importance.

Psoriatic rheumatism usually begins around the age of forty, but it can start in childhood, particularly in girls. Early onsets are frequently more severe. In women, the postpartum and menopausal periods are common times for the onset of psoriatic arthritis. Finally, in about 8% of cases, the onset of psoriatic rheumatism is connected with some trauma. The first rheumatic lesions may appear in a very variable context: sometimes an acute onset mimicking the gout, or a very progressive appearance in the form of articular deformations virtually painless. The site of the first affected joints varies greatly.

Development proceeds by attacks, joint pains being predominant in the night and morning. They are associated with stiffness that requires a prolonged session of stretching.

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