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Questions and Answers

Which of the following DMARDs is specifically mentioned as a treatment option?

  • Acetaminophen
  • Ibuprofen
  • Aspirin
  • Methotrexate (correct)

What treatment option is recommended for patients with severe skin inflammation?

  • Physical therapy alone
  • Methotrexate and retinoic-acid derivatives (correct)
  • Over-the-counter analgesics
  • Intra-articular corticosteroids

In cases of persistent arthritis, what is the recommended first-line treatment?

  • Physical therapy only
  • Corticosteroid injections
  • Use of DMARDs (correct)
  • Surgical intervention

What surgical procedure has been noted to be effective for treating chronic monoarticular synovitis?

<p>Arthroscopic synovectomy (A)</p> Signup and view all the answers

Which of the following is NOT a component of a rehabilitation treatment program for psoriatic arthritis?

<p>Demanding high-impact exercise (C)</p> Signup and view all the answers

What is an expected outcome after surgical release of joint contractures in patients?

<p>High rates of recurrence of joint contractures (D)</p> Signup and view all the answers

Which of the following treatments is surfacing for patients suffering from arthritis mutilans?

<p>Combination of arthrodesis, arthroplasty, and bone grafts (C)</p> Signup and view all the answers

What is a potential benefit of wrist spontaneous fusion in patients?

<p>Relief of pain without surgical intervention (C)</p> Signup and view all the answers

Which loci has the strongest association with psoriasis according to genome scans?

<p>6p (A)</p> Signup and view all the answers

What is true regarding serum immunoglobulin levels in psoriatic arthritis patients?

<p>IgM levels may be normal or diminished. (B)</p> Signup and view all the answers

Which pathway is NOT mentioned as part of the important pathways in psoriasis pathogenesis?

<p>Apoptosis pathway (D)</p> Signup and view all the answers

What role do ERAP1 variants play in psoriasis susceptibility?

<p>They influence susceptibility only in those with the HLA-C risk allele. (A)</p> Signup and view all the answers

Which proinflammatory cytokine is NOT identified to have increased levels in psoriatic arthritis patients?

<p>IL-4 (A)</p> Signup and view all the answers

What cytokine profile reflects the immune dysregulation seen in psoriatic arthritis?

<p>Type 1 helper T-cell cytokines are more prevalent. (D)</p> Signup and view all the answers

Compared to rheumatoid arthritis (RA), psoriatic arthritis patients produce which of the following to a lesser extent?

<p>IL-5 (B)</p> Signup and view all the answers

What is a notable difference between the inflammatory processes in psoriatic arthritis and rheumatoid arthritis?

<p>Psoriatic arthritis lacks intracellular citrullinated proteins. (B)</p> Signup and view all the answers

What is the percentage of patients with uveitis who have sacroiliitis?

<p>43% (C)</p> Signup and view all the answers

Which ocular finding is most commonly associated with uveitis?

<p>Iritis (B)</p> Signup and view all the answers

What is a potential cardiac complication in patients with psoriatic arthritis?

<p>Aortic valve root insufficiency (A)</p> Signup and view all the answers

What is a characteristic laboratory finding in patients with psoriatic arthritis?

<p>Elevated erythrocyte sedimentation rate (D)</p> Signup and view all the answers

In which conditions might psoriasiform skin lesions be observed?

<p>Inflammatory bowel disease and secondary syphilis (C)</p> Signup and view all the answers

Which arthritis condition is least likely to present with deforming arthritis compared to psoriatic arthritis?

<p>Lupus erythematosus (B)</p> Signup and view all the answers

What distinguishes psoriatic arthritis from rheumatoid arthritis on a radiologic examination?

<p>Sparing of the distal joints (C)</p> Signup and view all the answers

What is a common misconception about the association of psoriatic arthritis and secondary syphilis?

<p>It occurs simultaneously with the skin lesions (A)</p> Signup and view all the answers

What is one potential benefit of weight loss for patients with psoriatic arthritis?

<p>Reducing mechanical stress on joints (D)</p> Signup and view all the answers

Which type of exercises should be included in a rehabilitation treatment program for psoriatic arthritis?

<p>A mix of passive, active, stretching, and strengthening exercises (B)</p> Signup and view all the answers

Why should prolonged rest be avoided in psoriatic arthritis patients?

<p>It may cause adverse effects from immobility (A)</p> Signup and view all the answers

Which treatment modality can temporarily relieve pain and reduce joint swelling?

<p>Soaking in a warm tub (A)</p> Signup and view all the answers

What role does education play in the rehabilitation of psoriatic arthritis patients?

<p>It informs patients on energy conservation and joint protection (C)</p> Signup and view all the answers

What is an appropriate approach to isometric exercises during the subacute and long-term phase of treatment?

<p>Progressing gradually to active movement from isometric exercises (B)</p> Signup and view all the answers

What should patients be educated about during the acute phase of psoriatic arthritis treatment?

<p>The importance of rest and joint protection (C)</p> Signup and view all the answers

Which statement about splints in psoriatic arthritis is correct?

<p>They can provide rest and pain relief for affected joints. (A)</p> Signup and view all the answers

What is the recommended approach if a joint is swollen?

<p>Avoid resistive exercises through full ROM. (B)</p> Signup and view all the answers

When should heat therapy be administered in relation to ROM exercises?

<p>Just prior to the performance of ROM exercises. (A)</p> Signup and view all the answers

Which treatment is suggested for patients experiencing persistent pain after therapy?

<p>Decrease the intensity of the therapy. (B)</p> Signup and view all the answers

What modification should be made to shoes for patients with painful toes?

<p>Incorporate rocker-bottom modifications. (C)</p> Signup and view all the answers

What treatment may be necessary for patients with severe chronic monoarticular synovitis?

<p>Arthroscopic synovectomy. (A)</p> Signup and view all the answers

Which exercise type is particularly beneficial for patients with axial spine involvement?

<p>Spine extension exercises. (D)</p> Signup and view all the answers

What is a common consequence of surgical release for psoriatic arthritis patients?

<p>High rates of recurrence of joint contractures. (B)</p> Signup and view all the answers

What should be considered if a patient has plantar fasciitis?

<p>Arch supports may be beneficial. (A)</p> Signup and view all the answers

What is the recommended annual examination for patients with juvenile psoriatic arthritis?

<p>Ophthalmologist check-up (D)</p> Signup and view all the answers

Which medication is known to potentially exacerbate psoriasis?

<p>Lithium (B)</p> Signup and view all the answers

For patients with joint deformities, which specialist may be necessary for consultation?

<p>Orthopedic surgeon (C)</p> Signup and view all the answers

What should be prioritized in the care of a patient with psoriatic arthritis to manage multiple active domains of the disease?

<p>Multidisciplinary team care (B)</p> Signup and view all the answers

Which of the following is a common comorbidity associated with psoriatic arthritis?

<p>Cardiovascular disease (D)</p> Signup and view all the answers

What type of joint protection may be helpful for patients with psoriatic arthritis?

<p>Splints and braces (A)</p> Signup and view all the answers

What is the effect of lithium withdrawal on patients with psoriatic arthritis?

<p>It causes disease flare-ups (C)</p> Signup and view all the answers

What primary goal should be maintained for finger function in patients with psoriatic arthritis?

<p>Maintenance of the pinch mechanism (C)</p> Signup and view all the answers

Flashcards

DMARDs for Arthritis

Disease-modifying antirheumatic drugs (DMARDs) are medications used to treat arthritis by slowing or stopping the progression of the disease.

Methotrexate

A DMARD used to treat arthritis, often severe skin inflammation.

Sulfasalazine

A DMARD used to treat arthritis.

Biologic agents

Biological response modifiers used to treat arthritis. These agents target specific inflammatory pathways.

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Corticosteroids for arthritis

Corticosteroids can be injected into inflamed joints to reduce inflammation quickly.

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Arthroscopic synovectomy

A surgical procedure used to remove inflamed synovial tissue from a joint.

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Joint replacement

A surgical procedure to replace a damaged joint with an artificial one.

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Arthrodesis/Arthroplasty

Surgical procedures to fuse or replace a joint.

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Physical therapy for arthritis

A rehabilitation program to improve mobility, function, and reduce pain and disability in patients with arthritis.

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Rest in Arthritis

Essential for reducing inflammation, pain, and joint stress. Local or systemic

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Exercise in Arthritis

Crucial for improving joint mobility, strength, and endurance.

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Modalities in Arthritis

Heat or cold therapies used to manage pain and inflammation.

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Education for Arthritis patients

Important for patients to understand their condition and manage it effectively

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Psoriasis Genetic Loci

Studies show genetic links on chromosomes 17q, 4q, and 6p, with strongest evidence on 6p, suggesting genes influence psoriasis.

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Immunoglobulin Genes (PsA)

Certain immunoglobulin genes may be linked with psoriatic arthritis (PsA).

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IgA and IgG in PsA

Serum levels of immunoglobulin A (IgA) and IgG are higher in PsA patients compared to others.

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Psoriasis Susceptibility Genes

Finding specific genes related to psoriasis can help understand the disease's cause, potentially leading to new treatments.

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Psoriasis Pathogenesis Pathways

Several biological pathways are involved in psoriasis development, including skin barrier function, the Th17 pathway, innate immunity with interferon signaling, beta-defensin and Th2 immune responses.

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ERAP1 and HLA-C Interaction

ERAP1 gene variants show increased psoriasis susceptibility only in people with a particular HLA-C gene variant suggesting an interplay between these immune system genes.

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Psoriatic Arthritis Inflammation

Psoriatic arthritis inflammation involves similar inflammatory processes as rheumatoid arthritis (RA), but with key differences in cytokine profiles.

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Psoriatic vs. Rheumatoid Arthritis Cytokines

Psoriatic arthritis demonstrates different cytokine levels (types of immune signaling proteins) compared to RA, particularly regarding Th1 helper cells and their associated factors like TNF-alpha and IL-10.

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Skin Barrier Genes (Psoriasis)

Genes like LCE3B and LCE3C are associated with the integrity of the skin barrier, an important component in psoriasis.

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Th17 pathway (Psoriasis)

The Th17 pathway, a type of immune response, plays a part in psoriasis through genes such as IL12B, IL23A, and IL23R.

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Uveitis

Inflammation of the uvea, the middle layer of the eye.

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Sacroiliitis

Inflammation of the sacroiliac joints.

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HLA-B27

A specific human leukocyte antigen.

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Psoriatic Arthritis

A type of arthritis that causes joint pain and inflammation, often associated with psoriasis.

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Scleritis

Inflammation of the sclera (white part of the eye).

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Keratoconjunctivitis sicca

Dry eyes and cornea.

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Iritis

Inflammation of the iris, a colored part of the eye.

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Aortic Valve Root Insufficiency

Damage to the root of the aortic valve, leading to leakage.

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Secondary Amyloidosis

Amyloid build up that results from another medical condition.

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Enteropathic Arthritis

Arthritis related to inflammatory bowel disease.

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Erythrocyte Sedimentation Rate (ESR)

A blood test measuring how quickly red blood cells settle.

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C-Reactive Protein (CRP)

A blood protein produced in response to inflammation.

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Psoriatic Arthritis Rehabilitation

Personalized treatment programs starting early in the disease that target various aspects of the condition.

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Rest in Psoriatic Arthritis

Important for pain management; however, prolonged rest should be avoided to prevent immobility.

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Exercise in Psoriatic Arthritis

Crucial, encompassing passive, active, stretching, strengthening, and endurance exercises.

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Heat/Cold Therapy

Temporary pain and swelling relief through warm tubs, compresses, or cold packs.

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Orthotics

Support devices for upper/lower extremities and spinal care.

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Assistive Devices

Tools for activities of daily living and movement, including home/vehicle modifications.

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Disease Education

Teaching patients about psoriatic arthritis, its management, and self-care strategies.

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Weight Loss in Psoriatic Arthritis

Can reduce stress on joints, improve mobility, and may enhance medication effectiveness.

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Smoking Cessation

Clinicians should recommend smoking cessation strategies to patients.

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Acute Phase Exercise

Rest is prioritized, with controlled passive movements.

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Subacute/Long-term Phase Exercises

Gradual progression of exercises including isometric exercises and range-of-motion exercises, avoiding forced movements.

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Heat Therapy Timing

Heat therapy should be administered just before range-of-motion (ROM) exercises to improve the effectiveness of the therapy.

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Gait Activities

Gait activities involving weight-bearing (with or without assistive devices) are important for patients to maintain mobility.

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Pain Management

If pain persists more than 2 hours after therapies, reduce the intensity.

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Resistive Exercises in Swelling

Avoid full range of motion (ROM) resistive exercises if a joint is swollen.

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Axial Spine Involvement

Spine extension exercises enhance flexibility and strength for patients with axial spine issues.

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Pain and ROM Exercises

Avoid ROM exercises if pain increases during the exercises.

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Foot Protection in Toe Issues

Extra-depth shoes with a high toe box are crucial for patients with sausage-toes; rocker-bottom shoes support toes with pain.

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Arch Supports & Plantar Fasciitis

Arch supports can be helpful in managing plantar fasciitis.

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Synovectomy

Arthroscopic synovectomy is used to treat severe, chronic, monoarticular synovitis, but can cause fibrosis.

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Post-Synovectomy Care

Anti-inflammatory measures and physical therapy are crucial adjuncts to improve range-of-motion (ROM) after synovectomy to reduce fibrosis.

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Joint Replacement

Joint replacement surgery, like hip and knee replacements, is often successful for patients with psoriatic arthritis.

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Arthrodesis/Arthroplasty

Arthrodesis and arthroplasty can be used in various joints to treat different joint issues.

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Wrist Fusion

Wrist fusion can spontaneously occur, sometimes easing pain without surgery.

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Psoriatic Arthritis Recurrence

Psoriatic arthritis often results in joint contractures, particularly in the hand, after surgical releases.

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Arthritis Mutilans Treatment

For arthritis mutilans, surgery targets saving the hand, usually by combining arthrodesis, arthroplasty, and bone grafts to reconstruct the affected digits.

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Psoriatic Arthritis Referral

If a doctor isn't comfortable prescribing medication for psoriatic arthritis, a rheumatologist with more experience is recommended.

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Physiatrist's Role

Physiatrists focus on restoring the patient's functionality.

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Juvenile PsA Eye Exams

Annual eye exams are crucial for patients with juvenile psoriatic arthritis to check for eye inflammation.

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Multidisciplinary Care

Patients with psoriatic arthritis need care from multiple specialists, especially if more than one part of the disease is active.

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Orthopedic Consultation

Patients with joint deformities in psoriatic arthritis need an orthopedic specialist for potential procedures like joint replacement or contracture release.

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Medication Exacerbations

Some medications can worsen psoriasis by causing flares.

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Lithium and Corticosteroids

Lithium and withdrawal from systemic corticosteroids are known to cause psoriasis flare-ups.

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Other Triggering Drugs

Beta-blockers, antimalarials (except hydroxychloroquine), and NSAIDs may also worsen psoriasis in some cases.

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NSAID Switching

If skin lesions worsen with one NSAID, try a different type of NSAID.

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Psoriatic Arthritis Prevention

Rest, exercise, and joint supports are key for prevention, but a definite prevention isn't possible due to the chronic nature of the disease.

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Psoriatic Arthritis Comorbidities

Psoriatic arthritis is often linked with other health problems such as cardiovascular disease, metabolic syndrome, inflammatory bowel disease, osteoporosis, malignancy, ophthalmic disease, and liver disease.

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Bone Mineral Density in PsA

Psoriatic arthritis can lead to reduced bone density and deterioration of bone structure, particularly over time.

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Study Notes

Psoriatic Arthritis Overview

  • Psoriatic arthritis is a seronegative oligoarthritis most commonly found in patients with psoriasis.
  • Distal joint involvement and arthritis mutilans are less common but characteristic features.
  • One in five patients with psoriasis has psoriatic arthritis.

Signs and Symptoms

  • Psoriasis often precedes psoriatic arthritis, but occasionally onset may occur simultaneously, or even 20 years beforehand, up to 10 years.

  • Sometimes, arthritis appears before the psoriasis.

  • Patients may experience only pain and stiffness, with few objective findings.

  • Acute onset is reported in one third of patients.

  • Physical Examination Findings:

    • Enthesopathy/enthesitis: Inflammation at tendon/ligament insertions; frequent in Achilles tendon and plantar fascia.
    • Dactylitis: Sausage digits (35% of patients).
    • Skin lesions: Scaly, erythematous plaques; guttate lesions; pus-filled lesions (lakes of pus); erythroderma
  • Psoriatic Nail Changes:

    • Beau lines
    • Leukonychia
    • Onycholysis
    • Oil spots
    • Subungual hyperkeratosis
    • Splinter hemorrhages
    • Spotted lunulae
    • Transverse ridging
    • Cracking of the nail's free edge
    • Uniform nail pitting
    • Important: Psoriasis can occur in hidden areas (e.g., scalp, perineum)

Diagnosis

  • Classification Criteria for Psoriatic Arthritis (CASPAR):

    • Presence of current psoriasis (score 2).
    • History of psoriasis in absence of current psoriasis (score 1).
    • Family history of psoriasis in absence of current/past psoriasis (score 1).
    • Juxta-articular new bone formation (score 1).
    • Dactylitis (score 1).
    • Negative rheumatoid factor (score 1).
    • Nail dystrophy (score 1)
    • Required: At least 3 criteria.
  • Laboratory Findings:

    • Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
    • Negative rheumatoid factor in most patients.
    • Increased serum uric acid in some.
    • Elevated serum immunoglobulin A levels in ~2/3 of patients.
    • Inflammatory synovial fluid.

Radiographic Abnormalities

  • Pencil-in-cup deformity: Erosion of distal phalanx into a sharpened pencil shape.
  • Arthritis mutilans: Joint-space narrowing, ankylosis.
  • Increased joint space.
  • Fluffy periostitis.
  • Bilateral, asymmetrical, fusiform soft-tissue swelling.
  • Unilateral or symmetrical sacroiliitis
  • Large, nonmarginal, unilateral, asymmetrical syndesmophytes (intervertebral bony bridges)

Management

  • Medical treatments include NSAIDs, JAK inhibitors, and DMARDs (methotrexate, sulfasalazine, etc.).
  • In severe skin inflammation, methotrexate, retinoids, psoralen plus UVA are considered.
  • Intra-articular steroid injections may be helpful.
  • Surgical treatments (arthroscopic synovectomy, joint replacement, etc.) can be an option in severe cases.
  • Physical therapy and rehabilitation are important components of management.
  • Patient education is vital in managing symptoms and lifestyle accommodations.

Pathophysiology and Etiology

  • Precise pathogenesis is not known, but genetics, environment, and immune-mediated inflammation likely play a significant role.
  • Psoriasis and psoriatic arthritis share some similarities in pathogenesis but also have differences, as indicated by treatment responses.
  • Genetic factors play a role in susceptibility, with correlations to specific HLA alleles found.

Epidemiology

  • Psoriatic arthritis affects approximately 30% of people with psoriasis.
  • Worldwide, approximately one in four people with psoriasis is estimated to have psoriatic arthritis.
  • Incidence rates vary by population.
  • The prevalence seems to have increased in recent decades.

Prognosis

  • Psoriatic arthritis can range from mild to severe, potentially leading to significant joint damage and disability in some individuals.

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