Psoriatic Arthritis (PsA is a chronic inflammatory disease of the musculoskeletal system belonging to the family of spondyloarthritis. It presents in 30% of patients with platelet psoriasis, particularly in those with nail bed compromise and with location of the psoriasis in certain anatomical areas (e.g. scalp). It affects between .05% and .25% of the general population,1 which makes it the second most common form of chronic inflammatory arthritis after rheumatoid arthritis. PsA comprises several domains which represent the phenotypic manifestations of the disease. It usually aggravates skin psoriasis and often presents as an oligoarthritis with dactylitis, enthesitis and/or extra-articular-associated axial compromise, which included uveitis and/or inflammatory bowel disease. Its varied forms of presentation and manifestations, both musculoskeletal and cutaneous, make its therapeutic focus hugely complex, often requiring a multidisciplinary approach.2 In order to approach the therapeutic options and integrate the musculoskeletal and cutaneous phenotypes, the GRAPPA group (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) identified six disease domains (peripheral arthritis, enthesitis, dactylitis, axial compromise, psoriasis and nail bed compromise.3

Available information in the literature regarding prevalence, incidence, phenotypic presentation and response to treatment in developing countries is scarce. Management recommendations for PsA from GRAPPA3 and EULAR4 (European League Against Rheumatism), have been developed based on information from studies originating from Europe and North America. These recommendations have often been adapted to the context of the health systems and patients in the different developing countries. However, there are no recommendations which specifically focus on the treatment of PsA in countries with limited resources.

Bearing in mind the above, a group of members from the ILAR (International League of Associations for Rheumatology) worked on creating recommendations for the treatment of PsA, in regions of the world where several of the recommended treatments had access limitations or their use was conditioned by the presence of infectious diseases and/or comorbidities.5 The group called ILAR-PsA comprised rheumatologists and dermatologists from Latin American and Africa countries with clinical expertise in the treatment of PsA and Psoriasis. The Asia Pacific region was not represented in the group because the APLAR (Asia Pacific League of Associations for Rheumatology) was in the process of writing its own guidelines.

To adapt the existing GRAPPA and EULAR guidelines, the ILAR-PsA recommendation group used the ADAPTE process for the development of clinical practice guidelines. In order to generate recommendations, they identified specific areas of unmet needs and exclusive challenges pertaining to countries with limited resources. The work group discussed the relevant questions of diagnosis and treatment approach and they reviewed the EULAR and GRAPPA recommendations for clinical content in accordance with the approved questions. Following an iterative process, 10 questions were identified with under 70% agreement between committee members, and this therefore required a systematic review of the literature. Despite an exhaustive review of databases (including, among others, the African Index Medicus, and Latin American and Caribbean Healthcare Literature), no published information was found to have come from regions with limited resources. The recommendations relating to these questions were therefore adapted based on the expert opinions.

The recommendation group evaluated the need for early diagnosis and the use of disease-modifying drugs (in monotherapy or combined therapy), to obtain control of the disease in regions with limited access to biologics and with specific comorbidities which would be potentially included in clinical decisions. The importance of monitoring the efficacy and safety of the said drugs was emphasized, including follow-up of adverse events. Equally, patient access limitations were discussed by both speciality healthcare professionals, rheumatologists and dermatologists. Follow-up of comorbidities and the need for a multidisciplinary team to manage a heterogeneous and complex disease was also highlighted. Finally, the prevalence of infections was considered (including tuberculosis), which is higher in developing countries. However, there is very little information available which evaluates the prevalence of these infections in patients with PsA in these regions. This is relevant in the setting of the use of biologic therapy (e.g. anti TNF),6 as it may increase the risk of active tuberculosis. Other infections include Chagas disease, leishmaniasis, hepatitis B, hepatitis C and leprosy. In these cases, follow-up of national directives were recommended for each of these conditions prior to initiation of treatment.

Several studies have been conducted in Latin America aimed at filling in the information gaps on PsA. Studies have been published which evaluate the epidemiological profile and prevalence of patients with spondyloarthritis including PsA.7 Other studies have estimated that the incidence and prevalence may be similar to that reported in Europe and the United States,8 and usage frequency of treatment options in daily clinical practice has been estimated.9 Additional studies have also explored the levels of satisfaction given by the doctor and patient with regards to PsA treatment.10

To sum up, the recommendations of the ILAR-PsA group were specifically geared towards region of the world with limited human and economic resources. They provide additional relevant information for the specific environments of these countries and they seek to unify PsA treatment in a complementary fashion to national guidelines of these countries when they are available. We would emphasize the importance of supranational scientific societies such as PANLAR (Pan American League of Associations of Rheumatology) in creating guidelines for PsA management where the particularities of these countries are considered.

One of the main results from this adaptation exercise was the acknowledgement of the scarcity of information in the context of PsA patients in regions with limited resources, including Latin American. In this sense there is clearly a need to design and produce a research plan to provide relevant data and to identify not only epidemiological aspects — such as prevalence, extra-articular manifestations, structural damage, comorbidities-, but to also calculate delay in diagnosis, patient perspective, medical outcomes, response to treatment and the safety of pharmacological interventions in patients with PsA. The need also arises for the evaluation of these recommendations, in the light of the recent new evidence arising. We hope this document serves as a wake-up call to rheumatologists, researchers and financial entities in Latin American to recognise these shortcomings and to provide evidence through a research plan so that by fortifying these and future recommendations in PsA any unmet needs may be resolved.