Enthesitis in psoriatic arthritis

https://doi.org/10.1016/j.semarthrit.2013.04.005Get rights and content

Abstract

Objectives

It is increasingly recognized that enthesitis in patients with psoriatic arthritis (PsA) is of clinical importance. We review data on the detection, assessment, and treatment of enthesitis and its related dactylitis in PsA.

Methods

We searched Pubmed with the search terms psoriatic arthritis or psoriasis in combination with enthesitis, enthesopathy, and treatment, or enthesitis in combination with imaging.

Results

One hundred fifty-seven papers were selected. Enthesitis occurs frequently in PsA and may be asymptomatic or painful. It can also affect patient's function and quality of life. New imaging modalities, such as ultrasonography and magnetic resonance imaging, have revealed that enthesitis may be the initial osteoarticular inflammatory site in patients with PsA. Enthesitis indices have been developed and should be incorporated in clinical trials. Dactylitis, a characteristic and frequent manifestation of PsA can be tender or not tender and is prognostic of disease progression. Treatment of enthesitis includes non-steroidal anti-inflammatory drugs, classical DMARDs, and adjunctive local steroid injections. In inadequate response, TNFα inhibitors are used.

Conclusions

Enthesitis and dactylitis are important manifestations of PsA, and their evaluation is increasingly used in drug trials and clinical practice.

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)

  • S.W. Dandorfer et al.

    Differences in the patient's and the physician's perspective of disease in psoriatic arthritis

    Semin Arthritis Rheum

    (2012)
  • J. Braun et al.

    Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial

    Lancet

    (2002)
  • L.C. Coates et al.

    Disease measurement—enthesitis, skin, nails, spine and dactylitis

    Best Pract Res Clin Rheumatol

    (2010)
  • L. Barozzi et al.

    Seronegative spondylarthropathies: imaging of spondylitis, enthesitis and dactylitis

    Eur J Radiol

    (1998)
  • B. Godfrin et al.

    Spondyloarthropathy with entheseal pain. A prospective study in 33 patients

    Joint Bone Spine

    (2004)
  • A.L. Tan et al.

    Psoriatic arthritis: correlation between imaging and pathology

    Joint Bone Spine

    (2010)
  • L.C. Coates et al.

    MRI and ultrasonography for diagnosis and monitoring of psoriatic arthritis

    Best Pract Res Clin Rheumatol

    (2012)
  • C.Z. Erdem et al.

    MR imaging features of foot involvement in patients with psoriasis

    Eur J Radiol

    (2008)
  • M. Gutierrez et al.

    Subclinical entheseal involvement in patients with psoriasis: an ultrasound study

    Semin Arthritis Rheum

    (2011)
  • G.M. Alenius et al.

    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

    (2002)
  • K. Reich et al.

    Epidemiology and clinical pattern of psoriatic arthritis in Germany: a prospective interdisciplinary epidemiological study of 1511 patients with plaque-type psoriasis

    Br J Dermatol

    (2009)
  • M. Haroon et al.

    High prevalence of psoriatic arthritis in patients with severe psoriasis with suboptimal performance of screening questionnaires

    Ann Rheum Dis

    (2013)
  • L. Eder et al.

    Incidence of arthritis in a prospective cohort of psoriasis patients

    Arthritis Care Res (Hoboken)

    (2011)
  • R.G. Langley et al.

    Psoriasis: epidemiology, clinical features, and quality of life

    Ann Rheum Dis

    (2005)
  • D.D. Gladman et al.

    Psoriatic arthritis: epidemiology, clinical features, course, and outcome

    Ann Rheum Dis

    (2005)
  • C.J. Michet et al.

    Hip joint disease in psoriatic arthritis: risk factors and natural history

    Ann Rheum Dis

    (2005)
  • D.D. Gladman et al.

    Observational cohort studies: lessons learnt from the University of Toronto Psoriatic Arthritis Program

    Rheumatology (Oxford)

    (2011)
  • V. Dhir et al.

    Psoriatic arthritis: a critical review

    Clin Rev Allergy Immunol

    (2013)
  • C. Salvarani et al.

    Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis

    J Rheumatol

    (1997)
  • W. Taylor et al.

    Classification criteria for psoriatic arthritis: development of new criteria from a large international study

    Arthritis Rheum

    (2006)
  • L.C. Coates et al.

    Sensitivity and specificity of the classification of psoriatic arthritis criteria in early psoriatic arthritis

    Arthritis Rheum

    (2012)
  • M. Dougados et al.

    The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy

    Arthritis Rheum

    (1991)
  • M. Rudwaleit et al.

    The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection

    Ann Rheum Dis

    (2009)
  • M. Rudwaleit et al.

    The Assessment of SpondyloArthritis international Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general

    Ann Rheum Dis

    (2011)
  • R.J. Francois et al.

    Entheses and enthesitis: a histopathologic review and relevance to spondyloarthritides

    Curr Opin Rheumatol

    (2001)
  • M. Benjamin et al.

    Histopathologic changes at “synovio–entheseal complexes” suggesting a novel mechanism for synovitis in osteoarthritis and spondylarthritis

    Arthritis Rheum

    (2007)
  • D. McGonagle et al.

    The concept of a “synovio–entheseal complex” and its implications for understanding joint inflammation and damage in psoriatic arthritis and beyond

    Arthritis Rheum

    (2007)
  • J.P. Sherlock et al.

    IL-23 induces spondyloarthropathy by acting on ROR−gammat+ CD3+CD4−CD8− entheseal resident T cells

    Nat Med

    (2012)
  • P. Mandl et al.

    Ultrasound for enthesitis: handle with care!

    Ann Rheum Dis

    (2012)
  • O. Fitzgerald et al.

    Psoriatic arthritis: from pathogenesis to therapy

    Arthritis Res Ther

    (2009)
  • D. McGonagle

    Enthesitis: an autoinflammatory lesion linking nail and joint involvement in psoriatic disease

    J Eur Acad Dermatol Venereol

    (2009)
  • D. McGonagle et al.

    The biomechanical link between skin and joint disease in psoriasis and psoriatic arthritis: what every dermatologist needs to know

    Ann Rheum Dis

    (2008)
  • R.J. Lories et al.

    Ankylosing enthesitis, dactylitis, and onychoperiostitis in male DBA/1 mice: a model of psoriatic arthritis

    Ann Rheum Dis

    (2004)
  • R.J. Lories et al.

    Evidence for uncoupling of inflammation and joint remodeling in a mouse model of spondylarthritis

    Arthritis Rheum

    (2007)
  • K. Braem et al.

    Inhibition of inflammation but not ankylosis by glucocorticoids in mice: further evidence for the entheseal stress hypothesis

    Arthritis Res Ther

    (2012)
  • A.L. Tan et al.

    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)

    (2007)
  • B. Frediani et al.

    Ultrasound and clinical evaluation of quadricipital tendon enthesitis in patients with psoriatic arthritis and rheumatoid arthritis

    Clin Rheumatol

    (2002)
  • A. Marchesoni et al.

    Identification of the clinical features distinguishing psoriatic arthritis and fibromyalgia

    J Rheumatol

    (2012)
  • R. Secundini et al.

    Clinico-radiological correlation of enthesitis in seronegative spondyloarthropathies (SNSA)

    Clin Rheumatol

    (1997)
  • I. Eshed et al.

    MRI of enthesitis of the appendicular skeleton in spondyloarthritis

    Ann Rheum Dis

    (2007)
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