By Alice B. Gottlieb, MD, PhD, Dermatologist, as told by Kristen Fischer
Certain things, like your genes, can increase your risk of psoriatic arthritis. If you have a first-degree relative with psoriatic arthritis, you are 39 times more likely to get it.
Other risks of psoriatic arthritis include psoriasis on the scalp and nails. Inverse psoriasis, or intertriginous psoriasis, also increases your risk of psoriatic arthritis. (Inverse psoriasis occurs in body folds, such as the armpits or groin.)
A common misconception is that only people with moderate to severe psoriasis get psoriatic arthritis. You can get psoriatic arthritis even if you have mild psoriasis. Early detection is key. Getting psoriasis under control may help prevent psoriatic arthritis from getting worse—perhaps prevent it altogether.
Primary care physicians—especially dermatologists—need to recognize psoriasis so they can prevent disability from psoriatic arthritis. Once discovered, we can do something about it.
This is a paradigm shift since I was a rheumatologist at the Hospital for Special Surgery. At that time we had nothing that could prevent the disease from getting worse. The doctors didn’t even control the signs and symptoms that well.
There are now several medications on the market to treat psoriatic arthritis. Some are Tumor Necrosis Factor (TNF)-alpha Inhibitors blockers, interleukin inhibitors and JAK inhibitors.
There is also research that found that people who took medication suffered less damage than those who didn’t. This suggests that you can even prevent psoriatic arthritis.
Dermatologists may not realize the importance of their role in detecting psoriatic arthritis. They don’t have to be experts in diagnosis, but they do have to look for it. Then they can refer you to a rheumatologist. They must ask you about joint pain. Many people don’t realize that pain can be an illness. It needs to be raised.
The lack of a diagnosis can be serious. Research tells us that a delay in diagnosis and treatment leads to increased joint erosion, deformity, and arthritis mutilans (a form of psoriatic arthritis in which bone degeneration shortens your fingers and toes).
In dermatological practices, people usually have signs of enthesitis before they have psoriatic disease. Enthesitis is inflammation where tendons and ligaments invade the bone. It can cause joint pain, stiffness, and mobility problems. Some ultrasound evidence shows that enthesitis increases the risk of a future psoriatic arthritis diagnosis five-fold.
Doctors have simple, quick screening methods to detect psoriasis disease. We need to get them into the hands of GPs and dermatologists – and they need to use them.
I’m working with a team to encourage more doctors to use these screening tools. Mount Sinai recently launched a new program that integrates psoriasis screening tools with our Electronic Medical Records (EMRs).
How it works: People who come to us answer the Psoriasis Epidemiology Screening Tool (PEST) five questions while they are in the waiting room. When they visit their doctor, their PEST results will appear on the EMR. If they answer three or more questions positively, the EMR application alerts the doctor that the score indicates possible psoriatic arthritis. It prompts the doctor to refer the patient to a rheumatologist. It couldn’t be easier.
They also integrate the industry-standard Psoriatic Arthritis Impact of Disease (PsAID) questionnaire into EMR. People with an existing psoriasis disease or people who are PEST positive have to answer 12 questions. If they have a certain score, the doctor will be alerted that the case will not be controlled. It will then prompt the doctor to make an appointment with a rheumatologist. The EMR will also suggest medications.
These screening tools are available in some other EMR systems, but my project is different because I will measure how well it works.
At the end of the 18 months I will see if the percentage of cases increases. The system will be able to determine if people are managing their psoriasis and we will be able to assess how treatments are working.
If all goes well, it will make it easy for doctors to better care for patients. It will help them be more aware of the diagnosis of psoriasis disease and know if patients have their disease under control.
The screening tools are available in the GRAPPA app produced by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.
There are some advances in medications used to treat psoriatic arthritis. TNF blockers are the gold standard for treating psoriasis. But they don’t work for everyone.
Deucravacitinib is a newer FDA-approved drug for psoriasis — but not psoriatic arthritis. There is evidence that it can improve psoriatic arthritis. Clinical trials are looking good for bimekizumab, an oral drug that clears the skin for three years but isn’t yet approved in the US
In 2023, adalimumab (Humira) will be available in generic form. I don’t think the price will go down much.
I prefer treatments that prevent psoriatic arthritis from getting worse, even in patients who only have psoriasis. That’s because there’s evidence that the drugs can prevent psoriatic arthritis.
Right now, combining effective treatments — and getting more people diagnosed so we can prevent disability from psoriasis — is a priority.
We have great treatments for psoriasis, but many are expensive. Many people cannot afford this, even those with supplementary insurance.
Overall, people need to know that psoriasis is much more than something affecting their skin. It can cause permanent damage and complications.
This is why screening for psoriasis and psoriatic arthritis is so important, and why I am committed to getting everyone screened.