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Spondyloarthropathies
How to Treat Both Joint and Skin in Psoriatic Arthritis
a report by
Laure Brulhart
1
and Douglas J Veale
1,2
1. Department of Rheumatology, St Vincent’s University Hospital, Dublin; 2. The Conway Institute of Biomedical Biomolecular Research and
Dublin Academic Health Centre, University College Dublin
Psoriatic arthritis (PsA) is a chronic and disabling inflammatory alternative.
9,10
A number of reports of NSAIDs resulting in a flare or
arthritis that affects 0.2–1% of the population
1
and 6–42% of psoriasis worsening of skin psoriasis have led to some patients being reluctant
patients.
2
It may present as a symmetrical polyarthritis indistinguishable to take them continuously.
11
from rheumatoid arthritis (RA), although distal interphalangeal joints
and the small joints of the feet are more often involved. It may also Even without randomised controlled trials (RCTs), expert opinion is
present as an asymmetrical arthritis, often oligoarticular in nature.
3
PsA that steroid injection may be the most appropriate option for
is classified as spondylarthropathy with inflammatory spinal persistent monoarthritis,
11
enthesopathy
12
and dactylitis.
13
Systemic
manifestations, enthesopathy, dactylitis and uveitis occurring steroids may be useful for rapid peripheral symptom release when PsA
commonly. PsA is a progressive disorder in 11–62% of patients, patients fail to respond or do not tolerate NSAIDs; however, they
associated with erosions, deformity and reduced function.
4
Quality of should be used with caution because withdrawal may trigger acute
life evaluated with health-related EuroQol (EQ-5D) is similarly reduced flare in pustular psoriasis.
14
compared with RA patients.
5
Disease-modifying Antirheumatic Drugs
The effectiveness of DMARDs has been evaluated in only a few
RCTs, but they remain the first choice for long-term management of
Recent research on immuno- PsA. Only two small randomised, placebo-controlled studies on a
pathological mechanisms has
total of 58 patients have been conducted into methotrexate (MTX),
the most frequently used DMARD.
15
highlighted novel findings shared
between psoriasis and psoriatic
In the first study, a single parenteral dose of MTX was associated with
significant improvement in joint tenderness, range of motion, skin
arthritis, such as angiogenesis and
lesions and sedimentation rate.
16
Gastrointestinal and haematological
tumour necrosis factor α.
adverse reactions were high – gastrointestinal: 76%; leukopaenia:
33%; two deaths – which is probably due to the method of
administration. The second study showed small oral dosages of MTX
(7.5–15mg/week) to be effective in terms of physician’s global disease
Recent research on immunopathological mechanisms has highlighted assessment and psoriasis skin surface area, but other end-points – such
novel findings shared between psoriasis and PsA, such as angiogenesis as joint tenderness, swelling or duration of morning stiffness – did not
and tumour necrosis factor α (TNFα).
6
However, the management of improve;
17
however, this study used low dosages of MTX and had a
psoriasis and PsA depends on the clinical presentation and includes short follow-up (12 weeks) and small patient numbers (n=37). In
topical therapies for skin disease and non-drug therapy, physiotherapy
and rehabilitation, systemic and injectable anti-inflammatory
Laure Brulhart is a Research Fellow in Rheumatology in the
treatment and disease-modifying antirheumatic drugs (DMARDs) for
Department of Rheumatology, St Vincent’s University
PsA. In this brief review, we will focus on systemic therapies for joint Hospital, Dublin. Her specialist clinical interests are
and skin disease.
musculoskeletal ultrasound and biologic treatment of chronic
inflammatory arthritis. Dr Brulhart graduated from the
University of Geneva Medical School in 2000.
Non-steroidal Anti-inflammatory Drugs and Corticosteroids
Non-steroidal anti-inflammatory drugs (NSAIDs) are useful in the
symptomatic management of PsA patients. NSAIDs appear to be
Douglas J Veale is Adjunct Professor of Medicine in the
Department of Rheumatology, St Vincent’s University
rapidly effective at relieving axial pain and stiffness.
7
In ankylosing
Hospital, and The Conway Institute of Biomedical
spondylitis patients, continuous NSAID administration may reduce Biomolecular Research and Dublin Academic Health Centre,
radiographic progression.
8
NSAIDs may also be useful for
University College Dublin. He is also Director of Research at
The Education and Research Centre, St Vincent’s University
enthesopathy or peripheral oligoarthritis, without disability or evidence
Hospital. Professor Veale’s clinical research interests include
of progressive erosions.
9
However, gastrointestinal side effects limit
early inflammatory arthritis, psoriatic and rheumatoid
arthritis and psoriasis, focusing on immunopathogenesis,
the prescription of this medication. Selective – such as celecoxib – and
hypoxia, angiogenesis and biopharmaceuticals.
relatively selective – such as meloxicam – cyclo-oxygenase 2 (COX-2)
E:
douglas.veale@ucd.ie
are associated with a lower risk of bleeding and may be an
© TOUCH BRIEFINGS 2007 21
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