Enthesitis in psoriatic arthritis
Introduction
Psoriatic arthritis (PsA) develops in 8%–48% of patients with psoriasis [1], [2], [3]. The incidence of PsA in patients with psoriasis is 1.87 cases/100 patients per year [4]. Psoriasis itself is a common disease affecting 2% of the general population [5]. PsA has been defined for many years as an inflammatory arthritis in individuals with psoriasis and no serum rheumatoid factor [6]. However, arthritis develops before psoriasis in 6%–18% of cases, with an average 7 years before psoriasis [7], [8]. In addition, PsA is a heterogeneous disease affecting, apart from skin and nails, peripheral joints, the axial skeleton, entheses, synovial sheaths of tendons, and eyes [9], [10]. Each clinical manifestation can occur for a long time in isolation [11].
Inflammation of enthesis, called enthesitis, is an inflammatory osteoarticular component of the classification criteria for PsA and spondyloarthritis (SpA) in general. The CASPAR (Classification Criteria for Psoriatic Arthritis) criteria, the most widely used criteria with the highest sensitivity, classified PsA as the presence of an inflammatory articular disease (joint, spine, or entheseal) plus a score of at least 3 of the following categories (each with a score 1, except current psoriasis that scores 2): current psoriasis, a history of psoriasis, a family history of psoriasis, dactylitis (swelling of an entire digit, present or past), radiographic evidence of juxta-articular bone formation, and typical nail dystrophy [12], [13]. The European Spondyloarthropathy Study Group preliminary criteria for SpA [14] and the new Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial SpA and peripheral SpA also include enthesitis [15], [16]. In fact, enthesitis is one of three entry criteria for peripheral SpA.
Enthesitis is characteristic of SpA and can affect the quality of life of patients negatively [17]. Some investigators suggest that enthesis is the initial site of inflammation in SpA in general and PsA in particular [18]. Therefore, enthesitis is an important inflammatory osteoarticular manifestation of PsA. The aim of this review is to describe clinical manifestations, assessment, and treatment of enthesitis and its related dactylitis in PsA. We also include recent existing development on pathogenesis.
Section snippets
Materials and methods
We searched for original articles and review articles in Pubmed using the term psoriatic arthritis or psoriasis in combination with enthesitis, enthesopathy, or treatment. We also searched using the terms enthesitis and imaging. In addition, we had a large collection of original articles on PsA, ankylosing spondylitis (AS), and SpA.
Results
We reviewed over 250 articles. Non-English language articles, meeting reports, opinion articles, and articles on treatment with no reference to enthesitis or dactylitis were excluded. In the final list, we included 112 original articles, 28 reviews, 9 guidelines, 4 editorials, 3 letters to the editor, and 1 case series.
Conclusion
Enthesitis and its related dactylitis occur frequently in PsA and may be the initial rheumatic inflammatory involvement. They may be painful or asymptomatic. They can also affect the quality of life causing physical disability. Assessment methods and imaging methods for enthesitis have been developed and may improve patient management. Treatment of enthesitis includes NSAIDs, classical DMARDs, and in case of inadequate response, TNFα inhibitors.
References (157)
- et al.
Psoriatic arthritis
Semin Arthritis Rheum
(1973) - et al.
Relationship between enthesitis, clinical parameters and quality of life in spondyloarthritis
Joint Bone Spine
(2009) - et al.
Classification of inflammatory arthritis by enthesitis
Lancet
(1998) - et al.
HLA-DR17 is associated with enthesitis in psoriatic arthritis
Joint Bone Spine
(2011) - et al.
Varied presentations of enthesopathy
Semin Arthritis Rheum
(2007) - et al.
Whole-body M.R. imaging in psoriatic arthritis: additional value for therapeutic decision making
Eur J Radiol
(2011) - et al.
Acitretin-induced enthesitis in a patient with psoriatic arthritis
Joint Bone Spine
(2005) - et al.
The use of Achilles tendon ultrasonography for the diagnosis of familial hypercholesterolemia
Atherosclerosis
(2001) - et al.
Dactylitis: implications for clinical practice
Semin Arthritis Rheum
(1998) - et al.
Enthesitis
Best Pract Res Clin Rheumatol
(2006)
Differences in the patient's and the physician's perspective of disease in psoriatic arthritis
Semin Arthritis Rheum
Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial
Lancet
Disease measurement—enthesitis, skin, nails, spine and dactylitis
Best Pract Res Clin Rheumatol
Seronegative spondylarthropathies: imaging of spondylitis, enthesitis and dactylitis
Eur J Radiol
Spondyloarthropathy with entheseal pain. A prospective study in 33 patients
Joint Bone Spine
Psoriatic arthritis: correlation between imaging and pathology
Joint Bone Spine
MRI and ultrasonography for diagnosis and monitoring of psoriatic arthritis
Best Pract Res Clin Rheumatol
MR imaging features of foot involvement in patients with psoriasis
Eur J Radiol
Subclinical entheseal involvement in patients with psoriasis: an ultrasound study
Semin Arthritis Rheum
Inflammatory joint manifestations are prevalent in psoriasis: prevalence study of joint and axial involvement in psoriatic patients, and evaluation of a psoriatic and arthritic questionnaire
J Rheumatol
Epidemiology and clinical pattern of psoriatic arthritis in Germany: a prospective interdisciplinary epidemiological study of 1511 patients with plaque-type psoriasis
Br J Dermatol
High prevalence of psoriatic arthritis in patients with severe psoriasis with suboptimal performance of screening questionnaires
Ann Rheum Dis
Incidence of arthritis in a prospective cohort of psoriasis patients
Arthritis Care Res (Hoboken)
Psoriasis: epidemiology, clinical features, and quality of life
Ann Rheum Dis
Psoriatic arthritis: epidemiology, clinical features, course, and outcome
Ann Rheum Dis
Hip joint disease in psoriatic arthritis: risk factors and natural history
Ann Rheum Dis
Observational cohort studies: lessons learnt from the University of Toronto Psoriatic Arthritis Program
Rheumatology (Oxford)
Psoriatic arthritis: a critical review
Clin Rev Allergy Immunol
Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis
J Rheumatol
Classification criteria for psoriatic arthritis: development of new criteria from a large international study
Arthritis Rheum
Sensitivity and specificity of the classification of psoriatic arthritis criteria in early psoriatic arthritis
Arthritis Rheum
The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy
Arthritis Rheum
The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection
Ann Rheum Dis
The Assessment of SpondyloArthritis international Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general
Ann Rheum Dis
Entheses and enthesitis: a histopathologic review and relevance to spondyloarthritides
Curr Opin Rheumatol
Histopathologic changes at “synovio–entheseal complexes” suggesting a novel mechanism for synovitis in osteoarthritis and spondylarthritis
Arthritis Rheum
The concept of a “synovio–entheseal complex” and its implications for understanding joint inflammation and damage in psoriatic arthritis and beyond
Arthritis Rheum
IL-23 induces spondyloarthropathy by acting on ROR−gammat+ CD3+CD4−CD8− entheseal resident T cells
Nat Med
Ultrasound for enthesitis: handle with care!
Ann Rheum Dis
Psoriatic arthritis: from pathogenesis to therapy
Arthritis Res Ther
Enthesitis: an autoinflammatory lesion linking nail and joint involvement in psoriatic disease
J Eur Acad Dermatol Venereol
The biomechanical link between skin and joint disease in psoriasis and psoriatic arthritis: what every dermatologist needs to know
Ann Rheum Dis
Ankylosing enthesitis, dactylitis, and onychoperiostitis in male DBA/1 mice: a model of psoriatic arthritis
Ann Rheum Dis
Evidence for uncoupling of inflammation and joint remodeling in a mouse model of spondylarthritis
Arthritis Rheum
Inhibition of inflammation but not ankylosis by glucocorticoids in mice: further evidence for the entheseal stress hypothesis
Arthritis Res Ther
The relationship between the extensor tendon enthesis and the nail in distal interphalangeal joint disease in psoriatic arthritis—a high-resolution MRI and histological study
Rheumatology (Oxford)
Ultrasound and clinical evaluation of quadricipital tendon enthesitis in patients with psoriatic arthritis and rheumatoid arthritis
Clin Rheumatol
Identification of the clinical features distinguishing psoriatic arthritis and fibromyalgia
J Rheumatol
Clinico-radiological correlation of enthesitis in seronegative spondyloarthropathies (SNSA)
Clin Rheumatol
MRI of enthesitis of the appendicular skeleton in spondyloarthritis
Ann Rheum Dis
Cited by (58)
DKK-1 in psoriatic arthritis: Correlation with disease activity and enthesopathy
2024, Reumatologia ClinicaClinical practice guideline for the treatment of psoriatic arthritis in Colombia
2023, Revista Colombiana de ReumatologiaEarly detection of subclinical lower limb enthesopathy by ultrasonography in patients with psoriasis: Relation to disease severity
2021, Egyptian RheumatologistCitation Excerpt :Clinically identifying enthesitis in patients with PsA can be challenging. Enthesitis may be asymptomatic or mimic symptoms of other conditions such as mechanical injury and tendinitis [12]. Knee enthesitis and synovitis have been reported on magnetic resonance imaging (MRI) in patients with psoriasis without arthritic symptoms [13].
Psoriatic arthritis: From pathogenesis to pharmacologic management
2019, Pharmacological ResearchMicroorganisms in Pathogenesis and Management of Psoriasis Arthritis (PsA)
2022, Role of Microorganisms in Pathogenesis and Management of Autoimmune Diseases: Volume I: Liver, Skin, Thyroid, Rheumatic and Myopathic Diseases
Source of support: ELKE University of Thessaly.