Preventing psoriatic arthritis: focusing on patients with psoriasis at increased risk of transition

Psoriatic arthritis: A comprehensive review for the dermatologist part I: Epidemiology, comorbidities, pathogenesis, and diagnosis

Psoriatic arthritis (PsA) is an inflammatory seronegative arthritis strongly associated with psoriasis. Recognition of the clinical features of PsA is critical, as delayed detection and untreated disease may result in irreparable joint damage, impaired physical function, and a significantly reduced quality of life. Dermatologists are poised for the early detection of PsA, as psoriasis predates its development in as many as 80% of patients. In an effort to further acquaint dermatologists with PsA, this review provides a detailed overview, emphasizing its epidemiology, comorbidities, etiopathogenesis, and diagnostic features.

Multimorbidity in psoriasis as a risk factor for psoriatic arthritis: a population-based study

OBJECTIVES

To examine multimorbidity in psoriasis and its association with the development of psoriatic arthritis (PsA).

METHODS

A retrospective cohort study was performed using the Rochester Epidemiology Project. Population-based incidence (2000-09) and prevalence (1 January 2010) cohorts of psoriasis were identified by manual chart review. A cohort of individuals without psoriasis (comparators) were identified (1:1 matched on age, sex and county). Morbidities were defined using two or more Clinical Classification Software codes ≥30 days apart within prior 5 years. PsA was defined using ClASsification of Psoriatic ARthritis (CASPAR) criteria. χ2 and rank-sum tests were used to compare morbidities, and age-, sex- and race-adjusted Cox models to examine the association of baseline morbidities in psoriasis with development of PsA.

RESULTS

Among 817 incident psoriasis patients, the mean age was 45.2 years with 52.0% females, and 82.0% moderate/severe psoriasis. No multimorbidity differences were found between incident psoriasis patients and comparators. However, in the 1088 prevalent psoriasis patients, multimorbidity was significantly more common compared with 1086 comparators (odds ratio 1.35 and 1.48 for two or more and five or more morbidities, respectively). Over a median 13.3-year follow-up, 23 patients (cumulative incidence: 2.9% by 15 years) developed PsA. Multimorbidity (two or more morbidities) was associated with a 3-fold higher risk of developing PsA.

CONCLUSION

Multimorbidity was more common in the prevalent but not incident cohort of psoriasis compared with the general population, suggesting that patients with psoriasis may experience accelerated development of multimorbidity. Moreover, multimorbidity at psoriasis onset significantly increased the risk of developing PsA, highlighting the importance of monitoring multimorbid psoriasis patients for the development of PsA.

Comparative analysis of disease outcomes: Early vs. late transition from psoriasis to psoriatic arthritis

OBJECTIVES

Psoriasis typically precedes psoriatic arthritis (PsA). We explored whether the interval between the two diagnoses is associated with PsA phenotype and outcomes.

METHODS

We constructed an inception (PsA duration ≤2 years) cohort of patients who developed PsA after psoriasis from a prospective observational cohort. All patients were diagnosed with PsA prior to or at their presentation to the clinic (baseline). We divided the cohort into early and late transition groups based on the median transition period between the diagnoses of psoriasis and PsA of nine years. Features associated with early and late transition at baseline were studied using logistic regression. The impact of early versus late transition on disease activity was assessed using multivariate linear regression, with the 5-year adjusted mean swollen joint count (SJC) as the outcome. The influence on damage was evaluated using Cox regression, with time to radiographic progression as the outcome.

RESULTS

We included 702 patients. Late transition patients were observed to have a younger age at diagnosis of psoriasis and older age at diagnosis of PsA. At baseline, they had higher BMI and PASI and less frequent use of conventional synthetic DMARDs. There was a trend for lower disease activity over time in the late transition group. Radiographic progression was not significantly different.

CONCLUSION

There were no significant differences in the PsA features at baseline between the two groups. However, on follow-up, there was a trend for lower cumulative disease activity but not in the rate of radiographic progression in the late transition group.

An interpretable machine learning approach for detecting psoriatic arthritis in a UK primary care psoriasis cohort using electronic health records from the Clinical Practice Research Datalink

OBJECTIVES

Develop an interpretable machine learning model to detect patients with newly diagnosed psoriatic arthritis (PsA) in a cohort of psoriasis patients and identify important clinical indicators of PsA in primary care.

METHODS

We developed models using UK primary care electronic health records from the Clinical Practice Research Datalink (CPRD). The study population consisted of a cohort of (PsA free) patients with incident psoriasis who were followed prospectively. We used Bayesian networks (BNs) to identify patients who developed PsA using primary care variables measured prior to diagnosis and compared the results to a random forest (RF). Variables included patient demographics, musculoskeletal symptoms, blood tests, and prescriptions. The importance of each variable used in the models was evaluated using permutation variable importance. Model discrimination was measured using the area under the receiver operating characteristic curve (AUC) and the area under the precision-recall curve (PRAUC).

RESULTS

We identified a cohort of 122,330 patients with an incident psoriasis diagnosis between 1998 and 2019 in the CPRD, of whom 2460 patients went on to develop PsA. Our best BN achieved an AUC of 0.823, and PRAUC of 0.221, compared to the AUC of 0.851 and PRAUC of 0.261 of the RF. Psoriasis duration, nonsteroidal anti-inflammatory drug prescriptions, nonspecific arthritis, nonspecific arthralgia, and C-reactive protein blood tests were all important variables in our models.

CONCLUSIONS

We were able to identify psoriasis patients at higher risk, and important indicators, of PsA in UK primary care. Further work is required to evaluate our model's usefulness in assisting PsA screening.

Fatigue and the Impact of Musculoskeletal Pain on Quality of Life in Pediatric Patients With Psoriasis

Background and aims

Musculoskeletal pain associated to psoriasis without the presence of psoriatic arthritis is a poor explored issue in pediatric population. The aim of this study was to compare the health-related quality of life (HRQoL) and fatigue scores of pediatric patients with psoriasis and healthy peers and estimate the impact of musculoskeletal pain.

Methods

The pediatric Gait Arms Legs and Spine (pGALS) questions were used to screen for musculoskeletal pain. General HRQoL was measured using the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL 4.0) and fatigue was assessed using the PedsQL-Multidimensional Fatigue Scale (PedsQL-MFS).

Results

Fifty psoriatic patients (12.1years old; IQR 9-15) and 50 controls (12.3 years old; IQR 8.8-15.9) were evaluated. Patients with psoriasis had long disease duration of 6.9 years (IQR 3.7-9.5) and predominantly low disease activity (PASI 3.2, IQR 0.8-6; BSA 3.0, IQR 1-8), mainly treated with topical therapy. The PedsQL 4.0 total score of psoriatic patients with musculoskeletal pain was poorer than controls with pain. Fatigue by PedsQL-MFS was also worse in patients with psoriasis and pain. The risk of impaired HRQoL was 7.7 times higher in the presence of musculoskeletal pain (OR = 7.71, 95%CI 1.66-35.78); other variables such as age, sex and severity of psoriasis did not increase the risk of HRQoL impairment.

Conclusions

Musculoskeletal pain and fatigue may provide clues for systemic impairment in pediatric psoriatic disease and calls for effective systemic treatment to reduce disease burden and accumulated damage.

Precision Medicine in Rheumatology: The Role of Biomarkers in Diagnosis and Treatment Optimization

Rheumatic diseases encompass a wide range of autoimmune and inflammatory disorders, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriatic arthritis (PsA), and systemic sclerosis (SSc). These conditions often result in chronic pain, disability, and reduced quality of life, with unpredictable disease courses that may lead to joint destruction, organ damage, or systemic complications. Biomarkers, defined as measurable indicators of biological processes or conditions, have the potential to transform clinical practice by improving disease diagnosis, monitoring, prognosis, and treatment decisions. While significant strides have been made in identifying and validating biomarkers in rheumatic diseases, challenges remain in their standardization, clinical utility, and integration into routine practice. This review provides an overview of the current state of biomarkers in rheumatic diseases, their roles in clinical settings, and the emerging advancements in the field.

Treatment of psoriasis with different classes of biologics reduces the likelihood of peripheral and axial psoriatic arthritis development

OBJECTIVE

To assess the potential role of biologic treatment for psoriasis (PsO) in reducing the likelihood of psoriatic arthritis (PsA) development, through a detailed analysis that considered the different historical phases in PsA management, the different biologic classes and the different patterns of articular involvement.

METHODS

A monocentric cohort of 1023 PsO patients underwent a rheumatological assessment in which clinical and therapeutic data were recorded. A chi-squared test and multivariate logistic regression analysis (adjusted for the main PsA risk factors) were performed to compare the likelihood of PsA development in different treatment groups.

RESULTS

The PsA prevalence in PsO patients treated at least once with biologics was significantly lower than in patients never treated with biologics (8.9% vs 26.1%, P < 0.001). In multivariate analysis, a significantly (P < 0.01) lower likelihood of PsA development in biologic-treated patients was confirmed in the whole cohort (adjusted odds ratio [adjOR] 0.228), as well as in the subgroups of patients with PsO onset after 2005 (adjOR 0.264) and after 2014 (adjOR 0.179). Separately analysing the different biologic classes, the TNF (adjOR 0.206), IL-17 (adjOR 0.051) and IL-23 or 12/23 (adjOR 0.167) inhibitors were significantly (P < 0.01) associated with a lower likelihood of PsA development. Finally, patients treated with biologics had a significantly (P < 0.04) lower prevalence of both pure peripheral PsA (adjOR 0.182) and peripheral PsA with axial involvement (adjOR 0.115).

CONCLUSIONS

This study provides meaningful and concordant evidence supporting the significant role of different classes of biologics in reducing the likelihood of peripheral and axial PsA development.

Early methotrexate treatment for psoriatic arthritis prevention in psoriasis patients - A retrospective cohort study

OBJECTIVES

Early initiation of biologic therapies for psoriasis has been explored to prevent or delay the onset of psoriatic arthritis (PsA). This has renewed interest in the potential role of methotrexate (MTX) in mitigating PsA risk in newly diagnosed psoriasis patients. The aim of this study was to evaluate the impact of early MTX initiation on PsA incidence in individuals with psoriasis.

METHODS

A retrospective, longitudinal cohort study of psoriasis patients treated at a tertiary center from 2014 to 2024 was conducted. Patients were categorized into early MTX (MTX initiation within 2 years of psoriasis onset), late MTX (> 2 years after onset), and a control group (non-DMARD treatment). PsA incidence was calculated as events per 100 patient years, and a time-dependent Cox proportional hazard model was used to compare PsA risk across groups. Sensitivity analyses were performed to validate results.

RESULTS

A total of 629 patients were followed for a mean of 13.03 years, accumulating 8498.5 person-years. The overall PsA risk was 3.51 events per 100 patient years. The early MTX group had a significantly lower PsA incidence (1.07 events/100 patient years) compared to both the control (4.45 events/100 patient years, adjusted HR: 0.24, P<0.001) and late MTX groups (2.66 events/100 patient years, adjusted HR: 0.36, P<0.01). This effect persisted in patients naïve to biologics and with a minimum follow-up of 10 years.

CONCLUSIONS

Early initiation of methotrexate in patients with moderate to severe psoriasis may reduce the risk of developing PsA.

Understanding the spectrum from preclinical psoriatic arthritis to early diagnosis of the disease

Psoriasis is a chronic inflammatory skin disease that often precedes the development of psoriatic arthritis. Advances over the past 10 years have deepened our understanding of the transition from skin inflammation to joint inflammation, revealing various phases during which genetic, environmental, and immunological factors can affect this transition. In 2023, a European Alliance of Associations for Rheumatology task force outlined key considerations for identifying individuals with subclinical disease from those with clinically stabilised disease. Discerning between subclinical psoriatic arthritis and very early disease is crucial and raises doubts and questions about when an individual transitions from being at risk to having established psoriatic arthritis. Labelling this stage as very early psoriatic arthritis rather than subclinical disease might have substantial clinical and therapeutic implications. This Viewpoint highlights the importance of precisely identifying the different stages of progression of psoriatic arthritis for timely interventions and better outcomes for patients.

Risk of developing psoriatic arthritis in patients with psoriasis initiating treatment with different classes of biologics

OBJECTIVES

To investigate the risk of psoriatic arthritis (PsA) in plaque psoriasis (PsO) patients receiving different classes of biologics.

METHODS

A retrospective observational study involving consecutive bionaïve PsO patients starting biologic treatment was performed. We compared the occurrence of PsA by the class of the biologic (tumour necrosis factor [TNF], interleukin [IL]-17, or IL-23 inhibitors) using inverse probability of treatment weighting (IPTW) in the setting of multiple treatments to balance pretreatment covariates across cohorts and thus adjust for potential confounders. An IPTW Cox regression model was used to estimate hazard ratios (HRs) of PsA for IL-17 and IL-23 inhibitors versus TNF inhibitors.

RESULTS

In total, 622 patients, 430 (62.4%) males, mean ± SD age 46.9 ± 12.9 years, were included. They have been treated with TNF (n = 317, 50.9%), IL-17 (n = 164, 26.4%) or IL-23 inhibitors (n = 141, 22.7%) and followed for 2510 person-years (a mean of 4.1 ± 2.1 years per person). TNF, IL-17, and IL-23 inhibitor cohorts had a total of 1569, 486, and 455 person-years of follow-up. A total of 60 (10%) out of 622 patients on biologic therapy developed incident PsA during the observation period: 45 (14.2%) in the TNF, 9 (5.5%) in the IL-17, and 6 (4.3%) in the IL-23 inhibitor cohorts. After IPTW, the 3 treatment cohorts were well-balanced, and the HRs of PsA were 0.63 (95% CI, 0.38-1.05) for IL-17 and 0.57 (95% CI, 0.34-0.96) for IL-23 compared with the TNF treatment group.

CONCLUSIONS

The risk of developing PsA appeared slightly different in patients receiving diverse classes of biologics.

An integrated multi-omics analysis identifies protein biomarkers and potential drug targets for psoriatic arthritis

Psoriatic arthritis (PsA) is a complex, chronic immune-mediated inflammatory arthropathy that currently lacks definitive biomarkers and treatment targets. Identifying biomarkers and treatment targets is urgently needed for effectively managing PsA. Here, we conducted a multi-omics approach to identify protein biomarkers and potential drug targets for psoriatic arthritis. Proteome-wide Mendelian randomization (MR) analysis revealed seven plasma protein biomarkers significantly associated with PsA. Specifically, genetically predicted lower levels of NEO1 were linked to an increased PsA risk, whereas the remaining six proteins (IL23R, ERAP2, IFNLR1, KIR2DL3, CLSTN3, and POLR2F) exhibited a positive association with PsA risk. PPI analysis further supported these findings. Notably, druggability assessment revealed that scopoletin and esculetin were the two most significant drugs associated with ERAP2. Single-cell RNA-seq analysis revealed expression of IL23R, ERAP2, CLSTN3, and POLR2F in distinct T-cell subgroups of PBMCs derived from PsA patients. Furthermore, phenome-wide association studies (PheWAS) analysis assessed the potential side effects and safety as potential drug targets. Interestingly, experimental evidence showed that IFNLR1 expression is significantly upregulated under simulated inflammatory conditions. This study employed proteome-wide mendelian randomization to identify seven plasma proteins associated with PsA, including IL23R, ERAP2 and IFNLR1, offering potential insights for personalized PsA treatment strategies.

Value of ultrasound-assessed dactylitis in the early diagnosis of psoriatic arthritis

PURPOSE

The primary objective of this prospective, longitudinal, observational, single-centre study was to evaluate the association between ultrasound-assessed lesions of dactylitis and the diagnosis of psoriatic arthritis (PsA) in patients with psoriasis (PsO) and hand arthralgia.

METHODS

We included adult patients diagnosed with PsO with hand arthralgia, with or without other musculoskeletal complaints. They were clinically assessed at baseline, 6 and 12 months by a rheumatologist blinded to the ultrasound findings. At baseline, patients underwent a B-mode (BM) and power Doppler (PD) ultrasound assessment by other rheumatologist blinded to clinical data. The ultrasound evaluation included bilateral detection and scoring of synovitis (3 joints, 0-3), tenosynovitis (flexor tendons, 0-3), enthesitis (9 sites, 0-1), peri‑extensor tendon inflammation (PETI) (0-3), and subcutaneous tissue inflammation (SCTI) (0-3) in the 2nd-5th fingers.

RESULTS

Seventy patients [44 women; mean (SD) age 51 (12.4) years] were included, of whom 64 completed the study. Of these, 15 (23.4 %) were diagnosed with PsA during the 12-month follow-up period. At finger level, the presence and amount of baseline BM and PD synovitis, BM tenosynovitis, BM and PD enthesitis, and BM and PD PETI were associated with PsA diagnosis (p < .05). A predictive model including two variables, presence of PD synovitis and BM enthesitis, was found to predict PsA diagnosis (χ2 = 35.38; p < .001) with an accuracy of 89.1 %, a sensitivity of 86.7 % and a specificity of 89.8 %.

CONCLUSIONS

Ultrasound-assessed lesions of dactylitis were associated with a diagnosis of PsA and the short-term development of PsA in patients with PsO and hand arthralgia.

Arthralgia and Extraintestinal Manifestations in Crohn's Disease Elevate the Risk of IBD-Related Arthritis over Sacroiliitis

INTRODUCTION

Inflammatory bowel disease (IBD) related arthritis is the most prevalent extraintestinal manifestation (EIM) of IBD, ranging between 10 and 39%. Magnetic resonance enterography (MRE) is used to assess small bowel disease involvement in Crohn's disease (CD) and can detect signs of sacroiliitis in up to 23.5% of patients. The predicting role of sacroiliitis detected on MRE is still unknown. The aim of this study is to evaluate the predictive role of sacroiliitis at MRE and other clinical features for IBD-related arthritis development in a cohort of adult patients with CD.

METHODS

Between December 2012 and May 2020, consecutive patients with CD who performed MRE were enrolled in the study. Patients with a previous diagnosis of IBD-related arthritis were excluded. A baseline demographics and clinical characteristics of the patients were retrospectively collected. The identification of new-onset IBD-related arthritis events during the follow-up was based on rheumatological clinical diagnosis and fulfillment of the ASAS classification criteria.

RESULTS

Ninety-five patients, mean age 43.9 years (standard deviation [SD] ± 16.6), 52.6% female were enrolled in the study with a median follow-up of 83 months (Q25:75 25:143). Six out 95 (6.3%) developed IBD-related arthritis with a mean time of 11 months (SD ± 16.8). Sacroiliitis detected on MRE was not associated with an increased risk of IBD-related arthritis (odds ratio [OR] = 2.12 [95% confidence interval (CI) 0.36, 12.53, p = 0.408]). In contrast, the presence of arthralgia and EIMs were found to be a predictor for IBD-related arthritis development (OR = 84.0 [95% CI 8.18, 862.39, p < 0.0001] and OR = 7.37 [95% CI 1.25, 43.32, p = 0.027], respectively).

CONCLUSIONS

This study highlights that sacroiliitis, as assessed by MRE, was not associated with the development of IBD-related arthritis, whereas extraintestinal manifestations and arthralgia were significantly associated with later IBD-related arthritis development in patients with CD.

Evaluation of the "Multivariable Psoriatic Arthritis Risk Estimation Tool" in a Cohort of Patients with Psoriasis: Preliminary Results of a Prospective Observational Study

INTRODUCTION

An intriguing aspect that emerged in recent years is the transition phase from psoriasis (PsO) to psoriatic arthritis (PsA). The PRESTO instrument allows estimating a patient's risk of developing PsA based on a few clinical items. The aim of this study was to apply and evaluate the performance of the PRESTO tool in a cohort of patients with PsO.

METHODS

Consecutive patients with PsO were enrolled. Dermatological and rheumatological assessment was carried out in order to evaluate clinical features of PsO, to exclude the diagnosis of PsA, and to administer the PRESTO tool.

RESULTS

Between January 1, 2024 and April 1, 2024, 100 patients were assessed. Eight-four patients found the questionnaire to be very useful and easy. The estimated risk (median/IQR) of 1-year progression to PsA found in our group was 2.45% at 1 year (1.1-4).

CONCLUSIONS

The PRESTO instrument was feasible and well accepted by patients. The 1-year risk assessed by PRESTO tools is consistent with other reports in the literature.

IL-22-mediated microRNA-124-3p/GRB2 axis regulates hyperproliferation and inflammatory response of keratinocytes in psoriasis

Psoriasis is an inflammatory dermatosis that features overproliferation and inflammatory reaction of keratinocytes. A study reported that IL-22 is involved in the pathogenesis of psoriasis by mediating miR-124 to regulate the expression of fibroblast growth factor receptor 2 in keratinocytes. A microRNA may target multiple target genes. Therefore, we speculate that miR-124-3p may also target other downstream genes to affect IL -22-induced keratinocyte function. A possible target gene of miR-124-3p, growth factor receptor-bound protein 2 (GRB2), was screened by analyzing the target gene databases. GRB2 expression was elevated and miR-124-3p expression was decreased in psoriatic lesions compared to psoriatic adjacent normal skins and healthy controls. We performed the following cell experiments in the IL-22-stimulated HaCaT cell model. In keratinocytes transfected with the miR-124-3p mimics, GRB2 expression was significantly lower. We analyzed the regulation of keratinocyte proliferation by GRB2 and miR-124-3p. High levels of GRB2 promoted keratinocyte proliferation and expression of Ki67, PCNA, and K16, which were inhibited by low expression of GRB2. In addition, we found that the effect of GRB2 inhibitors on the proliferation and inflammatory response of keratinocytes was dose-dependent. Finally, we investigated the influence of GRB2 on inflammatory mediators in keratinocytes with the ELISA. After low expression of GRB2, the mRNA expression and secretion of the pro-inflammatory factor were suppressed. When both GRB2 and miR-124-3p were overexpressed, the cellular overproliferation and inflammation caused by GRB2 overexpression were significantly reversed by miR-124-3p. In summary, IL-22-mediated miR-124-3p regulates keratinocyte hyperproliferation and inflammatory response by suppressing GRB2 expression in psoriasis.

Risk prediction model for psoriatic arthritis: NHANES data and multi-algorithm approach

OBJECTIVE

To develop a simplified predictive model for identifying psoriatic arthritis (PsA) in psoriasis patients.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) database were analyzed, including patients with psoriasis without arthritis (PsC) or PsA. The least absolute shrinkage and selection operator, Boruta algorithm, random forest, and stepwise regression were employed to select key variables from 38 potential predictors. Logistic regression models were constructed for each combination of selected variables and evaluated using receiver operating characteristic (ROC) curves, precision-recall (PR) curves, calibration plots, Brier scores, and decision curve analysis (DCA).

RESULTS

The study included 587 patients with psoriasis, 238 of whom had PsA. The variable combinations proposed by the Boruta algorithm exhibited the best overall performance. Key predictors in the Borutamodel included age, fasting glucose, education level, thyroid disease, hypertension, and chronic bronchitis. This model achieved area under the curve (AUC) of 0.781 (95% CI, 0.737-0.826) for the training set and 0.780 (95% CI, 0.712-0.848) for the testing set in the ROC curve analyses. The AUC values in the PR curves were 0.687 (95% CI, 0.611-0.757) and 0.653 (95% CI, 0.535-0.770), respectively. The Brier scores of 0.186 and 0.191 for the testing and training sets indicated a good fit, further supported by the calibration curves. DCA showed a net clinical benefit for decision thresholds ranging from 0.2 to 0.8 in both datasets.

CONCLUSION

The Borutamodel represents a promising tool for early risk assessment of PsA. Key Points • National Database Utilization: This study leverages the NHANES database to predict psoriatic arthritis risk, addressing previous limitations tied to regional or ethnic constraints. • Comprehensive Variable Analyses: The research examines 38 variables, including demographics, health conditions, laboratory results, and lifestyle factors, using four distinct screening methods and thorough evaluations of model performance. • Innovative Risk Model: The study introduces a novel risk assessment model that integrates age, fasting glucose, education, and comorbidities including hypertension, thyroid disease, and chronic bronchitis, thus moving beyond traditional focus on skin lesions and joint symptoms.

Subclinical psoriatic arthritis and disease interception-where are we in 2024?

Psoriatic arthritis (PsA) is a chronic rheumatic disease that usually appears in patients with skin psoriasis, making it a model for detection of joint disease in the pre-clinical phases in a setting where therapy for cutaneous disease may ameliorate or prevent arthritis development. Such PsA prevention appears credible due to the increasingly recognized closely shared immunopathology between the skin and joints, especially the entheses. Recently, several initiatives have explored the concept of pre-clinical PsA, and nomenclatures have been developed with the recent EULAR nomenclature proposing a simplified three stages from psoriasis to clinical PsA development, namely at risk of PsA, subclinical PsA and early PsA. A better comprehension of early PsA and the identification of individuals predisposed to its development could enable interventions to 'prevent' the appearance of PsA. Several recent retrospective observational studies have demonstrated disease interception feasibility, i.e. treatment of people with psoriasis may prevent the appearance of PsA, in particular using biologic disease-modifying drugs. However, further data are urgently required due to unexpected findings in some studies where TNF inhibition for psoriasis does not reduce the rate of PsA development. In this review we address the current challenges in early PsA, including comparisons of pre-PsA nomenclature sets, its risk factors and the potential for disease interception.

Therapeutic interception in individuals at risk of rheumatoid arthritis to prevent clinically impactful disease

Multiple clinical trials for rheumatoid arthritis (RA) prevention have been completed. Here, we set out to report on the lessons learnt from these studies. Researchers who conducted RA prevention trials shared the background, rationale, approach and outcomes and evaluated the lessons learnt to inform the next generation of RA prevention trials. Individuals at risk of RA can be identified through population screening, referrals to musculoskeletal programmes and by recognition of arthralgia suspicious for RA. Clinical trials in individuals at risk for future clinical RA have demonstrated that limited courses of corticosteroids, atorvastatin and hydroxychloroquine do not alter incidence rates of clinical RA; however, rituximab delays clinical RA onset, and methotrexate has transient effects in individuals who are anticitrullinated protein antibody-positive with subclinical joint inflammation identified by imaging. Abatacept delays clinical RA onset but does not fully prevent onset of RA after treatment cessation. Additionally, subclinical joint inflammation and symptoms appear responsive to interventions such as methotrexate and abatacept. To advance prevention, next steps include building networks of individuals at risk for RA, to improve risk stratification for future RA and to understand the biological mechanisms of RA development, including potential endotypes of disease, which can be targeted for prevention, thus adopting a more precision-based approach. Future trials should focus on interceptions aimed at preventing clinical RA onset and which treat existing symptoms and imaging-defined subclinical inflammation. These trials may include advanced designs (eg, adaptive) and should be combined with mechanistic studies to further define pathophysiological drivers of disease development.

Clinical, genetic and omics-based biomarkers that might support the identification of the development of psoriatic arthritis in individuals with psoriasis: a narrative review of the literature

It is known that 25%-30% of individuals with cutaneous psoriasis (PsC) will develop psoriatic arthritis (PsA). To date, the reasons for the development of PsA in individuals with PsC have not been identified. Furthermore, there are considerable delays in the diagnosis and treatment of PsA, which lead to joint and bone deformation and chronic pain. It is therefore important to develop more precise diagnostic and screening tools. In this narrative review of the literature, clinical risk factors and novel molecular biomarkers (genetic markers, blood and inflammatory markers, lipid, metabolite and protein biomarkers) have been evaluated. The review included 38 publications that were reported between May 2020 and May 2024. Similar to previous reviews, nail involvement was one of the strongest clinical risk factors for the development of PsA, while molecular biomarkers did not provide a clear and robust differentiation between PsC and PsA groups. The seemingly poor performance of molecular markers may be largely attributed to small study populations and heterogeneity in study designs. Data and sample sharing in large consortia such as HIPPOCRATES (Health initiatives in Psoriasis and PsOriatic arthritis ConsoRTium European States) could help to overcome the limitations of small studies and enable the development of more robust diagnostic and screening tools for PsA.

Superior effect of adalimumab versus secukinumab on ultrasound-confirmed synovitis in psoriatic arthritis: comprehensive evidence from musculoskeletal ultrasound and clinical assessments

Background and objectives: Psoriatic arthritis (PsA) is a chronic inflammatory musculoskeletal disorder affecting 30% of psoriatic patients. Effective treatment, especially with biologics like IL-17 and TNF inhibitors, is vital for improving patient outcomes. This study aimed to compare the efficacy of secukinumab and adalimumab in PsA patients through clinical and ultrasonographic evaluations.Materials and methods: We enrolled 116 PsA patients, with 58 patients receiving secukinumab and 58 receiving adalimumab. Regular follow-ups were conducted at weeks 4, 12, 24, and 52. The primary outcome was the proportion of patients achieving at least a 20% improvement in the ACR response (ACR20) at week 12, with additional evaluations for axial arthritis, enthesitis, skin involvement, minimal disease activity, health assessment questionnaire, and ultrasound changes.Results: There was no significant difference in ACR20 response between the two groups at week 12 (OR: 0.59, 95% CI: 0.26-1.37, p = 0.22). However, secukinumab demonstrated superior efficacy in achieving Psoriasis Area and Severity Index (PASI)90 (OR: 2.25, 95%CI: 1.07-4.74, p = 0.03), while adalimumab showed better improvement in ultrasound synovitis count (β: 0.94, 95%CI: 0.09-1.79, p = 0.03) and synovitis PD signal (β: 0.20, 95%CI: 0.03-0.36, p = 0.02).Conclusions: In conclusion, both treatments were highly effective for PsA, with secukinumab being more suitable for severe skin involvement and adalimumab for significant ultrasound-confirmed synovitis.

Bimekizumab Efficacy in High-Impact Areas: Pooled 2-Year Analysis in Scalp, Nail, and Palmoplantar Psoriasis from Phase 3/3b Randomized Controlled Trials

INTRODUCTION

Psoriasis in high-impact areas, including the scalp, nails, palms, and soles, can disproportionately impair patient quality of life. Here, we evaluate the 2-year efficacy of bimekizumab treatment in patients with moderate to severe plaque psoriasis in post hoc analyses of five phase 3/3b trials.

METHODS

High-impact area efficacy data were pooled through 2 years across five phase 3/3b trials: BE VIVID, BE READY, BE SURE, their ongoing open-label extension (OLE) BE BRIGHT, and BE RADIANT (including its double-blinded treatment period and the first year of its OLE). Complete clearance of psoriasis in high-impact areas is reported over 2 years using the scalp Investigator's Global Assessment (IGA), palmoplantar IGA, and modified Nail Psoriasis Severity Index (mNAPSI). Patients included in these analyses had baseline moderate to severe scalp or palmoplantar involvement (scalp or palmoplantar IGA score ≥ 3) or mNAPSI score > 10.

RESULTS

A total of 1107 patients were randomized to bimekizumab and entered the OLEs. Subsets of 821 patients had scalp IGA ≥ 3 at baseline, 377 had mNAPSI > 10, and 193 had palmoplantar IGA ≥ 3. Complete scalp clearance in patients with baseline scalp IGA ≥ 3 randomized to bimekizumab was achieved rapidly, with high responses sustained from first (86.4%) to second year (85.9%). Nail clearance responses in patients with baseline mNAPSI > 10 increased from 63.4% to 68.5% from first to second year. Palmoplantar clearance in patients with baseline palmoplantar IGA ≥ 3 was sustained from first (88.3%) to second year (89.8%). Similar trends were seen in the 374 patients who received bimekizumab 320 mg every 4 weeks (Q4W)/every 8 weeks (Q8W) initial/maintenance dosing.

CONCLUSION

In these analyses pooled across 2 years, bimekizumab showed sustained efficacy in psoriasis in high-impact areas.

CLINICALTRIALS

GOV TRIAL REGISTRATION NUMBERS

NCT03370133, NCT03410992, NCT03412747, NCT03598790, NCT03536884.

Biological therapy for psoriatic arthritis: current state and future perspectives

Psoriatic arthritis is a medical condition that lies at the intersection of various fields of medicine, and its therapy always requires a comprehensive, holistic approach. Biological disease-modifying antirheumatic drugs (bDMARDs) constitute an extremely effective treatment method for PsA, provided that appropriate principles for patient qualification for the drug are followed, along with subsequent monitoring of the response to treatment. Based on their mechanisms of action, four main groups of bDMARDs used in PsA can be distinguished (TNF inhibitors, IL-12/23 and IL-23 inhibitors, IL-17 inhibitors, CTLA4 agonists). Clinical trials are ongoing in search of registration for additional bDMARDs, and the tasks for doctors and scientists worldwide include patient education, increasing treatment accessibility, and optimizing its costs.

Recent advances in nuclear medicine and their role in inflammatory arthritis: focus on the emerging role of FAPI PET/CT

Imaging molecular processes associated with inflammatory disease has been revolutionized by hybrid imaging using positron emission tomography/computed tomography (PET/CT). PET/CT visualizes metabolic activity as well as protein expression and provides a comprehensive whole-body evaluation. It has the potential to reveal inflammation prior to detection of structural changes in inflammatory joint diseases. FAP is a type II transmembrane glycoprotein overexpressed not only in the stroma of tumors but also in the fibrotic processes of certain immune-mediated disorders. The recent introduction of fibroblast activation protein inhibitors (FAPI) labeled by positron emitters and thus suitable for PET/CT allows to investigate FAP expression in vivo. This review will focus on the use of FAPI-PET/CT for the diagnosis and evaluation of treatment response in inflammatory joint diseases.

Liquid-liquid Phase Separation in Aging: Novel Insights in the Pathogenesis and Therapeutics

The intricate organization of distinct cellular compartments is paramount for the maintenance of normal biological functions and the orchestration of complex biochemical reactions. These compartments, whether membrane-bound organelles or membraneless structures like Cajal bodies and RNA transport granules, play crucial roles in cellular function. Liquid-liquid phase separation (LLPS) serves as a reversible process that elucidates the genesis of membranelles structures through the self-assembly of biomolecules. LLPS has been implicated in a myriad of physiological and pathological processes, encompassing immune response and tumor genesis. But the association between LLPS and aging has not been clearly clarified. A recent advancement in the realm of aging research involves the introduction of a new edition outlining the twelve hallmarks of aging, categorized into three distinct groups. By delving into the role and mechanism of LLPS in the formation of membraneless structures at a molecular level, this review encapsulates an exploration of the interaction between LLPS and these aging hallmarks, aiming to offer novel perspectives of the intricate mechanisms underlying the aging process and deeper insights into aging therapeutics.

Association Between Non-HDL to HDL Cholesterol Ratio (NHHR) and Psoriasis in Adults: A Cross-Sectional Study Using 2009-2014 Data

Background

Because of its possible significance in metabolic diseases, the non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) has garnered attention as a novel and trustworthy lipid biomarker. Psoriasis may be linked to metabolic problems and obesity, according earlier research. Uncertainty surrounds the relationship between NHHR and the onset of psoriasis, though. The primary aim of this investigation was to examine the relationship between NHHR and psoriasis.

Patients and methods

This cross-sectional analysis used data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2009 and 2014. The association between psoriasis and NHHR was examined using multivariate logistic regression, and smoothed curve fitting was done to explore the non-linear relationship. Furthermore, Subgroup and sensitivity studies were performed in order to confirm the robustness of the findings.

Results

Psoriasis and NHHR were shown to be positively correlated in 15,951 adult individuals who were at least 20 years old. Psoriasis risk rose by 7% for each unit increase in NHHR [1.07 (1.01, 1.14)]. Individuals in the highest NHHR tertile were 39% more likely compared to those in the bottom tertile to have psoriasis [1.39 (1.09, 1.78)]. Across subgroups, this favorable connection remained consistent.

Conclusion

Elevated NHHR levels are positively correlated with an upsurge chance of psoriasis in the adult population in the United States. The significance of NHHR as an indication for early psoriasis risk assessment is shown by this study.

A novel nomogram to predict psoriatic arthritis in patients with plaque psoriasis

OBJECTIVE

To construct a predictive model for Psoriatic Arthritis (PsA) based on clinical and ultrasonic characteristics in patients with plaque psoriasis (PsP).

PATIENTS AND METHODS

Demographic, clinical, and ultrasound data were collected from patients with PsP and PsA between May 2019 and December 2022.

RESULTS

A total of 212 patients with PsP and 123 with PsA in the training cohort, whereas the validation cohort comprised 91 patients with PsP and 49 with PsA. The multivariate logistic regression identified nail psoriasis (odds ratio [OR] 1.88, 95% CI: 1.07-3.29), synovitis (OR 18.23, 95% CI: 4.04-82.33), enthesitis (OR 3.71, 95% CI: 1.05-13.14), and bone erosion (OR 11.39, 95% CI: 3.05-42.63) as effective predictors for PsA. The area under the curve was 0.750 (95% CI, 0.691-0.806) and 0.804 (95% CI, 0.723-0.886) for the training and validation cohorts, respectively. The Hosmer-Lemeshow goodness-of-fit test showed good consistency for both the training cohort (p  =  0.970) and the validation cohort (p  =  0.967). Calibration curves also indicated good calibration for both cohorts. The DCA revealed that the predictive model had good clinical utility.

CONCLUSIONS

We have developed a quantitative, intuitive, and convenient predictive model based on nail psoriasis, synovitis, enthesitis, and bone erosion to assess the risk of PsA in patients with plaque psoriasis.

Secukinumab in the Treatment of Psoriasis: A Narrative Review on Early Treatment and Real-World Evidence

Psoriasis is a chronic, immune-mediated, inflammatory skin disease, associated with multiple comorbidities and psychological and psychiatric disorders. The quality of life of patients with this disease is severely compromised, especially in moderate-to-severe plaque psoriasis. Secukinumab, a fully humanized monoclonal antibody, was the first anti-interleukin (IL)-17 biologic approved for treating psoriasis. Secukinumab demonstrated long-lasting efficacy and a good safety profile in individuals with plaque psoriasis, and it is associated with an improvement in health-related quality of life. While there is evidence that early treatment with systemic therapy can affect disease progression and improve long-term outcomes in other autoimmune diseases, evidence is limited in psoriasis, especially in real-world settings. This review provides an overview of studies describing the effectiveness of secukinumab in the treatment of psoriasis summarizing the literature and focusing on real-world evidence and early intervention.

Ultrasound-based detection of inflammatory changes for early diagnosis and risk model construction of psoriatic arthritis

OBJECTIVES

PsA is the most prevalent coexisting condition associated with psoriasis. Early-stage PsA patients always present unspecific and subtle clinical manifestations causing delayed diagnosis and leading to unfavourable health outcomes. The application of US enables precise identification of inflammatory changes in musculoskeletal structures. Hence, we constructed US models to aid early diagnosis of PsA.

METHODS

This was a cross-sectional study carried out in the Department of Dermatology at West China Hospital (October 2018-April 2021). All participants underwent thorough US examinations. Participants were classified into the under 45 group (18 ≤ age ≤ 45 years) and over 45 (age >45 years) group and then randomly grouped into derivation and test cohort (7:3). Univariable logistic regression, least absolute shrinkage and selection operator, and multivariable logistic regression visualized by nomogram were conducted in order. Receiver operating characteristic (ROC), calibration curve, decision curve analysis (DCA) and clinical impact curve analysis (CICA) were performed for model verification.

RESULTS

A total of 1256 participants were included, with 767 participants in the under 45 group and 489 in the over 45 group. Eleven and 16 independent ultrasonic variables were finally selected to construct the under 45 and over 45 model with the area under the ROC of 0.83 (95% CI 0.78-0.87) and 0.83 (95% CI 0.78-0.88) in derivation cohort, respectively. The DCA and CICA analyses showed good clinical utility of the two models.

CONCLUSION

The implementation of the US models could streamline the diagnostic process for PsA in psoriasis patients, leading to expedited evaluations while maintaining diagnostic accuracy.

GRAPPA 2023 Debate: Is Psoriatic Disease Really a Primary Enthesitis That Drives Joint Synovitis? The Enthesitis Hypothesis 25 Years On

The enthesitis hypothesis posits that enthesitis is a primary lesion and that inflammation at the enthesis initiates the musculoskeletal symptoms of psoriatic arthritis (PsA) and spondyloarthropathies (SpA). The hypothesis suggested that inflamed entheseal tissue near the synovium could trigger cytokine-mediated synovitis, that enthesis bone anchorage could explain osteitis, and that the location of entheses at the soft tissue interface could explain dactylitis. Advances in imaging techniques that allow better visualization of enthesitis lesions and the development of animal models have allowed evolution of the concept of enthesitis as a central mechanistic driver of musculoskeletal symptoms in PsA and SpA. A debate between Drs. Dennis McGonagle and Bruce Kirkham at the Group for Research on Psoriasis and Psoriatic Arthritis (GRAPPA) 2023 annual meeting discussed the data supporting and refuting this hypothesis in PsA and SpA, respectively. The major points of this debate are summarized in this article.

GRAPPA 2023 Basic Science Workshop: What to Expect From Animal Models for Psoriatic Arthritis and Psoriasis

Animal models help to drive research into psoriasis and psoriatic arthritis (PsA), particularly when studies in humans are not feasible. There are no animal models that perfectly mimic psoriatic disease (PsD) and so the pros and cons of each existing model must be considered for appropriate experimental design. Roughly, the existing animal models for PsD can be divided into 4 categories: (1) spontaneous models, (2) transgenic models, (3) inducible models, and (4) xenotransplantation models. Animal models in PsD are extremely important for dissecting and understanding molecular mechanisms of the disease process and for developing novel drugs. Animal models remain highly valuable for research in PsD in 2 scenarios. The first scenario is when complex interventions or analyses are required that are not feasible in humans due to technical, safety, or economic reasons. The second is when well-controlled study environments are required, such as dietary modifications, that would be challenging in humans. This topic was presented as part of the basic science workshops during the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2023 annual meeting.

A Simple Score Scale Composed of Serum Inflammatory Factors Assists in Psoriasis Arthritis Prediction among Patients with Psoriasis Vulgaris

Aim: To compare the levels of serum inflammatory indicators in psoriasis vulgaris patients who progress to PsA and those not, as well as to establish and validate a simple score scale for predicting PsA for psoriasis vulgaris patients. Methods: A cross-sectional study was performed at a university hospital in China to recruit five hundred and seventy-seven patients who had been diagnosed with psoriasis vulgaris for at least 10 years. After evaluation, 86 were enrolled in the PsA group, and the others were selected as the control group. Eight serum inflammatory factors were detected and compared between the two groups. A simple score scale for PsA prediction was established and validated. Results: Serum CRP, IL-6, and TNF-α levels were significantly higher in the PsA group than in the control group. A simple score scale composed of CRP, IL-6, and TNF-α was established. The sensitivity was 59.30% and the specificity was 83.50% for predicting PsA among all psoriasis vulgaris patients when the cut-off value of the total score was set as 1.8 points. The simple score scale presented a predictive value for progressing to PsA among all psoriasis vulgaris patients internally (AUC = 0.788), and the performance was also conformed in psoriasis vulgaris patients receiving topical treatment (AUC = 0.746), systemic treatment (AUC = 0.747) and biological treatment (AUC = 0.808), respectively. The predictive performance of this scale was also validated by an external retrospective cohort (AUC = 0.686). Conclusions: CRP, IL-6, and TNF-α were potential indicators to recognize PsA risk in patients with psoriasis vulgaris. A simple score scale may provide new insights for early prediction of PsA among psoriasis vulgaris patients.

Sappanone A ameliorated imiquimod-induced psoriasis-like dermatitis in BALB/c mice via suppressing Mmp8 expression and IL-17 signaling pathway

Psoriasis is a prevalent immune-mediated inflammatory skin disease characterized by excessive abnormal proliferation of keratinocytes and infiltration of immune cells, which have significant impact on the life quality of individuals. Although biological agents and small molecule targeted drugs have brought significant clinical benefits to psoriasis patients, adverse reactions and high prices remains key issues in clinical medication of psoriasis, while natural product monomers possess high efficiency, low toxicity, anti-inflammatory and immunomodulatory properties, and bring new hope for the clinical treatment of psoriasis. Sappanone A (SA), a small molecule compound isolated from Caesalpinia sappan L, exhibits significant anti-inflammatory properties in various models, such as kidney inflammation and LPS-induced mice inflammation. Among these effects, the anti-inflammatory property of SA has received significant attention. In our study, we found that SA exhibited anti-proliferation and anti-inflammatory effects in HaCaT cells, and significantly alleviated imiquimod-induced psoriasis-like skin lesions via the inhibition of the excessive proliferation of keratinocytes and the infiltration of lymphocytes. Furthermore, the combinational analysis of network pharmacology and transcriptome sequencing revealed that SA exerted anti-psoriasis effects by inhibiting the matrix metalloproteinase 8 (Mmp8) expression and IL-17 pathway activation. In summary, we have first demonstrated that SA can be used as a novel anti-psoriasis drug, which may provide a novel strategy for the clinical treatment of psoriasis.

Early psoriatic arthritis: clinical and therapeutic challenges

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic immunoinflammatory disease of the enthesis and adjacent synovium, skin, and nail, which early diagnosis may be crucial for starting a prompt therapeutic intervention. Theoretically, early treatment offers the advantage of acting on the reduction of the articular damage progression since initial phases of the disease.

AREAS COVERED

This review explores the challenges of clinical-diagnostic aspects and the underlying pathophysiology of early PsA phases, as well as the evidence evaluating the impact of early intervention on disease outcomes.

EXPERT OPINION

Main instruments for early PsA diagnosis include recognizing synovial-entheseal inflammatory signs at onset, improving screening PsA high-risk subjects, and increasing disease knowledge of physicians and patients with psoriasis or familial history. PsA continues to significantly impact on the Quality of Life of patients affected by the disease, making necessary to deeply study clinical manifestations, risk factors, and underlying immunoinflammatory mechanisms, as well as to identify biomarkers for early identification. Additionally, it remains a need to increase more evidence on understanding how early treatment of PsA and of psoriasis might influence the course of the disease.

Application of a natural language processing artificial intelligence tool in psoriasis: A cross-sectional comparative study on identifying affected areas in patients' data

Psoriasis is an immune-mediated skin disease affecting approximately 3% of the global population. Proper management of this condition necessitates the assessment of the body surface area and the involvement of nails and joints. The integration of natural language processing with electronic medical records (EMRs) has recently shown promise in advancing disease classification and research. This study evaluates the performance of ChatGPT-4, a commercial artificial intelligence platform, in analyzing unstructured EMR data of psoriasis patients, particularly in identifying affected body areas. The study analyzed EMR data from 94 patients treated at the Dermatology Department and Psoriasis Outpatient Clinic of Sheba Medical Center between 2008 and 2022. The data were processed using the ChatGPT-4 interface to identify and report the body areas affected by psoriasis. These identified areas were then categorized, and the accuracy of ChatGPT-4's analysis was compared with that of a senior dermatologist. The results revealed that the dermatologist identified 477 psoriasis-affected body areas. ChatGPT-4 accurately recognized 443 (92.8%) of these areas, missed 34, and incorrectly identified 30 areas as affected. From 94 cases, nail involvement was detected in 32 cases (34.0%), with ChatGPT-4 correctly identifying 29 cases. Joint involvement was noted in 25 cases (26.6%), with 24 correctly identified using ChatGPT-4. Complete accuracy was achieved in 54 cases (57.4%), although inaccuracies were observed in 40 cases (42.6%). We found that cases with more characters, words, or identified body areas were more prone to errors, suggesting that increased data complexity heightens the likelihood of inaccuracies in artificial intelligence analysis. ChatGPT-4 demonstrated high performance in analyzing detailed and complex unstructured EMR data from patients with psoriasis, effectively identifying involved body areas, including nails and joints. This highlights the potential of NLP algorithms to enhance the analysis of unstructured EMR data for both clinical follow-up and research purposes.

Subclinical Enthesopathy in Psoriasis-An Ultrasonographic Study

The present study is aimed at assessing the presence and prevalence of subclinical entheseal changes in Psoriasis (PsO) patients using musculoskeletal ultrasonography (US), conjoined with the analysis of possible differences in terms of demographic, clinical, or biological features. We carried out an observational study on 54 patients with PsO and 40 controls. Subclinical enthesopathy, according to OMERACT definitions, was identified in 20 of the psoriasis patients (37.03%), a significantly difference compared to the controls (5 patients; 10.20%). A comparison between US examinations for psoriasis patients and controls indicates that all the examined areas manifested changes in a significantly higher percentage of patients than the controls. The most common structural changes were represented by thickened tendon (85%), calcification (65%), erosions (35%), power Doppler (PD) signal (20%), and bursitis (5%). The difference in mean MASEI (Madrid Sonographic Enthesitis Index) score between the psoriasis and control groups was statistically significant (10.56 + 2.96 vs. 2.9 + 2.20; p < 0.0001). In conclusion, ultrasound is an easily accessible and vital follow-up method for psoriasis patients to enable an early, subclinical detection of entheseal involvement, i.e., the first red-flag sign for a future transition to psoriatic arthritis (PsA).

Oral microbiota diversity in moderate to severe plaque psoriasis, nail psoriasis and psoriatic arthritis

Gaining a comprehensive understanding of the role played by the oral microbiome in moderate to severe plaque psoriasis and its potential implications for disease management and development holds significant importance. With the objective of exploring correlations between the oral microbiota and severe psoriasis, this study involved 72 severe psoriasis patients and 16 healthy individuals, whose clinical manifestations and living habits were carefully recorded. Cutting-edge techniques such as 16S rRNA gene sequencing and bioinformatics analysis were employed to compare the microbial flora, investigating dynamic changes among severe plaque psoriasis patients, psoriatic arthritis patients and healthy individuals. The findings revealed noteworthy patterns including increased levels of Aggregatibacter in the psoriatic arthritis group, accompanied by a decrease in the level of Prevotella. Moreover, the enrichment o Capnocytandophaga (P = 0.009), Campylobacter (P = 0.0022), and Acetobacter (P = 0.0292) was notably more substantial in the psoriasis group compared to the control group, whereas certain bacterial species such as Bacteroides (P = 0.0049), Muribaculaceae (P = 0.0048) demonstrated decreased enrichment. Additionally, the psoriatic arthritis group exhibited significantly higher levels of Ralstonia, Bifidobacterium and Micromonospora. Based on these findings, it can be inferred that individuals with lower levels of Prevotella and higher levels of Corynebacterium may be more susceptible to psoriasis exacerbation.

Targeting cytokines in psoriatic arthritis

Psoriatic arthritis (PsA) is part of the psoriatic disease spectrum and is characterized by a chronic inflammatory process that affects entheses, tendons and joints. Cytokines produced by immune and non-immune cells play a central role in the pathogenesis of PsA by orchestrating key aspects of the inflammatory response. Pro-inflammatory cytokines such as TNF, IL-23 and IL-17 have been shown to regulate the initiation and progression of PsA, ultimately leading to the destruction of the architecture of the local tissues such as soft tissue, cartilage and bone. The important role of cytokines in PsA has been underscored by the clinical success of antibodies that neutralize their function. In addition to biologic agents targeting individual pro-inflammatory cytokines, signaling inhibitors that block multiple cytokines simultaneously such as JAK inhibitors have been approved for PsA therapy. In this review, we will focus on our current understanding of the role of cytokines in the disease process of PsA and discuss potential new treatment options based on modulation of cytokine function.

Advantages of ultrasound imaging for the early diagnosis of psoriatic arthritis in patients with moderate to severe psoriasis

Background

Psoriatic arthritis (PsA) is an immune-mediated form of chronic inflammatory arthritis associated with psoriasis (PsO). It constitutes a significant comorbidity of PsO and is distinguished by the presence of widespread musculoskeletal inflammation.

Objective

The aim of this study is to precisely detect asymptomatic PsA using ultrasound (US) examinations and to distinguish between various stages of PsO.

Methods

All patients with moderate-to-severe PsO, who consented to undergo musculoskeletal US examinations during their hospitalization between September 2020 and January 2022, were enrolled in the study. We compared patients' demographic characteristics, comorbidities, disease duration, relevant laboratory parameters, and musculoskeletal US findings.

Results

A total of 547 patients with PsO were included in the study, and 114 of them received a diagnosis of PsA. Furthermore, 16.45 % of patients with moderate to severe PsO displayed subclinical PsA. We observed a significantly higher frequency of abnormal US findings in patients with PsA compared to those without PsA, with a sensitivity of 95.61 % and a specificity of 79.22 %. Additionally, the incidence of enthesitis and synovitis varied significantly between PsA and non-PsA patients, and they were identified as independent variables predicting the presence of PsA. Furthermore, the interphalangeal joint, knee joint, and calcaneal tendon were the most frequently affected areas in PsA, as indicated by the observed US changes.

Conclusion

Ultrasound examination proves to be a valuable tool for detecting subclinical PsA, facilitating early screening of the condition. Particular attention should be directed towards changes in the interphalangeal joint, knee joint, and calcaneal tendon when reviewing ultrasound images of asymptomatic patients.

Defining the Minimal Important Change and Meaningful Change Value of the Disease Activity Index for Psoriatic Arthritis: A Chinese Longitudinal Study

OBJECTIVE

To determine the minimal important change (MIC) and meaningful change value (MCV) of the Disease Activity Index for Psoriatic Arthritis (DAPSA) and the effect size (ES) of DAPSA.

METHODS

This was a retrospective cohort study, recruiting 106 patients who agreed to participate in the research from the Department of Dermatology, Xiangya Hospital, between November 1, 2019, and April 1, 2023. An anchor-based method using linear regression analyses was used to determine the MICs and MCVs of the DAPSA. The anchor question assessed whether the patient's well-being had changed since their previous visit, employing a 5-point Likert scale that ranged from "much improved" to "much deteriorated."

RESULTS

The overall MIC value was 8.4 (95% CI 0.01-16.75). The MIC improvement was 9.5 (95% CI 0.89-18.14) and MIC deterioration was 1.1 (95% CI -9.81 to 12.05). The overall MCV was 10.5 (95% CI 4.34-16.72). MCV improvement was 11.4 (95% CI 5.95-16.95) and MCV deterioration was 1.1 (95% CI -9.81 to 12.05). The ES was 0.6.

CONCLUSION

A change in DAPSA of 8.4 is indicative of an MIC, offering physicians an additional means to contextualize the patient's perception of disease activity during treatment, and a change in DAPSA of 10.5 is likely to be regarded as MCV. These values can enhance the utility of DAPSA in psoriatic arthritis clinical trials.

Prevention of Psoriatic Arthritis: The Need for Prospective Studies

Psoriatic arthritis (PsA) is a systemic chronic inflammatory disease that develops in up to 30% of patients with psoriasis. Mixed data variably support the potential ability to "prevent" and/or delay PsA through use of systemic therapies in psoriasis patients. Though intriguing, almost all of these studies are retrospective in nature, and hold substantial limitations and potential biases that challenge the ability to meaningfully interpretation their results. Thus, the authors believe prospective observational and interventional studies are crucial to understanding our ability to truly modify the transition from psoriasis to psoriatic arthritis and delay or prevent PsA onset.

Differential risks of psoriatic arthritis development in patients with varied psoriasis manifestations: a sex- and ethnicity-specific analysis

Objectives

This study investigated psoriatic arthritis (PsA) risk across varied psoriasis manifestations, considering sex and ethnicity.

Methods

Using TriNetX, a federated database encompassing over 120 million electronic health records (EHRs), we performed global retrospective cohort studies. Psoriasis vulgaris (Pso), pustulosis palmoplantaris (PPP), and generalized pustular psoriasis (GPP) cohorts were retrieved using ICD-10 codes. Propensity score matching, incorporating age, sex, and ethnicity, was employed. An alternative propensity matching model additionally included established PsA risk factors.

Results

We retrieved data from 486 (Black or African American-stratified, GPP) to 35,281 (Pso) EHRs from the US Collaborative Network. Significant PsA risk variations emerged: Pso carried the highest risk [hazard ratio (HR) 87.7, confidence interval (CI) 63.4-121.1, p < 0.001], followed by GPP (HR 26.8, CI 6.5-110.1, p < 0.0001), and PPP (HR 15.3, CI 7.9-29.5, p < 0.0001). Moreover, we identified significant sex- and ethnicity-specific disparities in PsA development. For instance, compared to male Pso patients, female Pso patients had an elevated PsA risk (HR 1.1, CI 1.1-1.2, p = 0.002). Furthermore, White Pso patients had a higher likelihood of developing PsA compared to their Black or African American counterparts (HR 1.3, CI 1.04-1.7, p = 0.0244). We validated key findings using alternative propensity matching strategies and independent databases.

Conclusion

This study delineates nuanced PsA risk profiles across psoriasis forms, highlighting the pivotal roles of sex and ethnicity. Integrating these factors into PsA risk assessments enables tailored monitoring and interventions, potentially impacting psoriasis patient care quality.

Anatomical pattern of entheseal and synovial fibroblast activation in patients with psoriasis and its risk of developing psoriatic arthritis

OBJECTIVES

To assess the presence and anatomical distribution of activated fibroblasts in the joints and entheses of patients with psoriasis with arthralgia and to test how fibroblast activation visualised by 68gallium-labelled fibroblast activation protein inhibitor-04 (68Ga-FAPI-04)-positron emission tomography (PET)/CT correlates with clinical tenderness, musculoskeletal ultrasound findings and progression to psoriatic arthritis (PsA).

METHODS

We conducted a prospective cohort study in patients with psoriasis and arthralgia who underwent clinical and ultrasound evaluation and whole-body PET/CT imaging with 68Ga-FAPI-04. 68Ga-FAPI-04 uptake at synovial and entheseal sites was assessed by maximal standardised uptake values (SUVmax) and PET/CT Joint Index (JI); logistic regression models were used to investigate its correlation with clinical and ultrasound findings. Survival analyses were performed on patients with at least 6 months of follow-up.

RESULTS

36 patients with psoriasis were enrolled. 68Ga-FAPI-04 uptake was found in 318 (7.9%) joints and 369 (7.3%) entheses in 29 (80.6%) participants, with a mean SUVmax (SD) of 3.2 (1.8) for joints and 2.9 (1.6) for entheses. Large joints and the lower limbs were predominantly affected. A significant positive relationship was found between 68Ga-FAPI-04-PET/CT signal intensity and the 68 tender joint count (SUVmax: p<0.001; PET/CT-JI: p<0.001) and tender entheses count (SUVmax: p<0.001; PET/CT-JI: p=0.002). No correlations were found with ultrasound findings (SUVmax: p=0.969; PET/CT-JI: p=0.720). Patients with relevant synovio-entheseal 68Ga-FAPI-04 uptake showed a statistically significant higher risk of developing PsA (p=0.02), independent of ultrasound findings.

CONCLUSIONS

Patients with psoriasis presenting with arthralgia show localised signs of resident tissue activation in joints and entheses, which are associated with higher risk of developing PsA.

Single-cell analysis and machine learning identify psoriasis-associated CD8+ T cells serve as biomarker for psoriasis

Psoriasis is a chronic inflammatory skin disease, the etiology of which has not been fully elucidated, in which CD8+ T cells play an important role in the pathogenesis of psoriasis. However, there is a lack of in-depth studies on the molecular characterization of different CD8+ T cell subtypes and their role in the pathogenesis of psoriasis. This study aims to further expound the pathogenesy of psoriasis at the single-cell level and to explore new ideas for clinical diagnosis and new therapeutic targets. Our study identified a unique subpopulation of CD8+ T cells highly infiltrated in psoriasis lesions. Subsequently, we analyzed the hub genes of the psoriasis-specific CD8+ T cell subpopulation using hdWGCNA and constructed a machine-learning prediction model, which demonstrated good efficacy. The model interpretation showed the influence of each independent variable in the model decision. Finally, we deployed the machine learning model to an online website to facilitate its clinical transformation.

Psoriatic arthritis risk in psoriasis patients prescribed acitretin versus disease-modifying antirheumatic drugs: a nationwide cohort study

OBJECTIVES

To compare the risk of PsA in psoriasis (PsO) patients treated with acitretin vs DMARDs.

METHODS

This retrospective study used Taiwan's National Health Insurance Research Database from 1997 to 2013. Adult PsO patients without PsA prescribed acitretin or DMARDs for ≥30 days within a year were assigned to the acitretin cohort or DMARDs cohort, respectively. Patients in the acitretin cohort prescribed DMARDs for >7 days, or in the DMARDs cohort prescribed acitretin for >7 days, were excluded. Cumulative incidence of PsA were determined within both cohorts using the Kaplan-Meier method. The hazard ratio (HR) comparing acitretin to DMARDs was calculated with Cox regression models, adjusting for demographic and clinical covariates including the use of NSAIDs and comorbidities.

RESULTS

The study included 1948 patients in each cohort. The 5-year cumulative incidence of PsA in the acitretin cohort was lower than that in the reference cohort (7.52% vs 9.93%; P = 0.005), with a more pronounced difference in the subpopulation receiving NSAIDs treatment. However, in subpopulations without NSAIDs treatment, the 5-year cumulative incidence of PsA in the acitretin cohort was comparable to the DMARDs cohort (5.26% vs 6.98%; P = 0.106). Acitretin was not associated with PsA development in PsO (HR 0.83, 95% confidence interval 0.65-1.05). This risk remained consistent regardless of adjustments for NSAID treatment and comorbidities. Other independent risk factors for PsA included female and NSAIDs treatment.

CONCLUSION

Compared with DMARDs, acitretin was not associated with increased PsA risk in PsO patients.

Global and regional epidemiology of psoriatic arthritis in patients with psoriasis: A comprehensive systematic analysis and modelling study

OBJECTIVES

To provide a comprehensive analysis and modelling of the global epidemiology of psoriatic arthritis (PsA) in patients with psoriasis.

METHODS

We reviewed and analysed PsA epidemiology studies over the past 45 years. A Bayesian hierarchical linear mixed model was developed to provide comprehensive age- and sex-specific epidemiologic estimates in different countries and regions.

RESULTS

Three hundred and sixty-three studies were systematically reviewed. The incidence of PsA in patients with psoriasis varied from 2.31 per 1000 person-years in the United Kingdom to 74.00 per 1000 person-years in several Western European countries. The global prevalence of PsA in patients with psoriasis is estimated to be 17.58% (3.33%, 43.69%). Regionally, the overall prevalence of PsA in patients with psoriasis varies from 7.62% (4.18%, 12.28%) in Australasia to 26.59% (18.89%, 35.76%) in North America. The Caribbean and Central Latin America also have relatively high prevalence and are estimated at 23.14% (14.06%, 35.17%) and 22.81% (14.36%, 32.25%), respectively. The prevalence of PsA is higher in adults than children (23.93% vs 8.59%) and also slightly higher in females than males (19.14% vs 16.01%).

CONCLUSIONS

This study provides valuable insights into the global epidemiology of PsA. It also serves as a useful resource for researchers in areas lacking relevant studies. These findings have important implications for clinicians managing the course of PsA and for health policymakers in resource allocation.

Upadacitinib for the treatment of adult patients with active psoriatic arthritis

INTRODUCTION

Psoriatic arthritis (PsA) is a rheumatic disorder that may be responsible for relevant articular impairment. The recently licensed Janus Kinase (JaK) inhibitors represent a new opportunity to improve PsA treatment. This review deals with the clinical usefulness of the selective JaK-1 inhibitor upadacitinib (UPA) in patients with PsA.

COVERED AREAS

Two phase-III studies are available: SELECT-PsA 1, performed in patients with an inadequate response to non-biological therapies, and SELECT-PsA 2, conducted in biologic-experienced patients. Long-term extension results and post-hoc analysis data of these two trials are also available.

EXPERT OPINION

The results provided by the trials indicate that UPA may be used to treat all of the clinical manifestations of PsA. Venous thromboembolism, cardiovascular events, and malignancy, the most feared adverse events associated with JaK inhibitor use, were not increased in the trial populations, yet long-term observational studies are needed to make sure that UPA is safe in this respect.

[Treatment of psoriasis vulgaris : Therapy strategies for optimal patient-centered care]

Psoriasis is a chronic inflammatory systemic disease that requires optimal long-term management due to its high prevalence in the population and the numerous comorbidities that severely impair quality of life. A variety of treatment options are now available. In addition to objective skin findings and a specific location such as nails or genital area, the presence of psoriatic arthritis and other comorbidities as well as the disease burden of the affected person play a decisive role in individualized treatment decision-making. Good communication with the patient is fundamental to understand the individual needs and expectations of the patient. Shared decision-making can positively influence adherence and thus also the clinical outcome and patient satisfaction. In addition, interdisciplinary collaboration is crucial and often necessary for a comprehensive therapy strategy.