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Ribeiro AL, Eder L. From Psoriasis to Psoriatic Arthritis: Ultrasound Insights Connecting Psoriasis with Subclinical Musculoskeletal Inflammation and the Path to Psoriatic Arthritis. Curr Rheumatol Rep 2024:10.1007/s11926-024-01146-9. [PMID: 38512585 DOI: 10.1007/s11926-024-01146-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE OF REVIEW This review summarizes the literature about the transition from psoriasis to psoriatic arthritis (PsA), focusing on musculoskeletal ultrasound (MSUS) for detecting subclinical inflammation and its role in diagnosis and triage of high-risk patients. RECENT FINDINGS MSUS effectively detects subclinical musculoskeletal inflammation in patients with psoriasis; however, some of these lesions are non-specific and can be found in healthy individuals. Preliminary evidence suggest that subclinical sonographic findings may predict progression to PsA in psoriasis patients. MSUS can also improve referrals' accuracy and its integration in the PsA classification criteria may improve early PsA detection. MSUS is a valuable tool for detecting subclinical abnormalities in psoriasis patients, which indicate an increased likelihood of progressing to PsA. Its integration into referral protocols and clinical use could improve PsA diagnosis. We propose an MSUS-inclusive algorithm for PsA referrals and triage, which requires validation. The potential of early intervention in reducing PsA progression in psoriasis patients with subclinical inflammation remains to be established.
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Affiliation(s)
- A L Ribeiro
- Department of Medicine, Women's College Research Institute, Women's College Hospital, University of Toronto, 76 Grenville Street Room 6326, Toronto, Ontario, M5S 1B2, Canada
| | - L Eder
- Department of Medicine, Women's College Research Institute, Women's College Hospital, University of Toronto, 76 Grenville Street Room 6326, Toronto, Ontario, M5S 1B2, Canada.
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Silte Karamanlioglu D, Unlu Ozkan F, Ceren Arıkan EE, Pirdal BZ, Ozturk G, Aktas I. Detection of subclinical enthesitis by ultrasonography in patients with psoriasis and controls. ARP RHEUMATOLOGY 2024; 3:29-39. [PMID: 38368555 DOI: 10.63032/unbm9076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Psoriasis is a widespread chronic inflammatory skin disease; enthesitis is inflammation of the tendon, ligament, and joint capsule insertion, prevalent in patients with psoriatic arthritis. OBJECTIVES The aim of study to evaluate the utility of the Madrid Sonography Enthesitis Index scoring system for accurate detection of subclinical enthesitis in patients with Psoriasis compared with healthy controls. Another objective was to assess increase in enthesis area and Psoriatic arthritis incidence, in a prospective 1-year follow-up. METHOD Patients aged ≥18 years who were diagnosed with Psoriasis, without musculoskeletal complaints, and who did not have any clinical sign and/or symptom of enthesitis and synovitis were included in the study. The patients and healthy controls were evaluated with ultrasonography. Ultrasonography evaluation consisted of the detection of gray-scale enthesitis and power Doppler signal in the enthesis areas. The Madrid Sonography Enthesitis Index scoring system was used to quantify the extent of the sonographic enthesis abnormalities. RESULTS The mean MASEI score, structure, thickness, erosion, and calcification were significantly higher in the Psoriasis group than in the control group. The mean MASEI score, structure, erosion, and calcification measurements were significantly higher at the last examination when compared to the first examination. The triceps was the most commonly affected tendon in both groups. CONCLUSION Ultrasonography is an important tool for diagnosis and follow-up of subclinical enthesitis in patients with psoriasis. Regardless of disease duration and severity, patients should be screened using ultrasonography at yearly intervals.
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Affiliation(s)
| | | | | | | | | | - Ilknur Aktas
- Fatih Sultan Mehmet Training and Research Hospital
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Sharifaskari A, Goodarzi A, Davoody N, Kianmehr N, Sepyani A, Haghighi A. Sonographic assessment of Achilles tendon in patients with cutaneous psoriasis. CASPIAN JOURNAL OF INTERNAL MEDICINE 2024; 15:313-317. [PMID: 38807726 PMCID: PMC11129060 DOI: 10.22088/cjim.15.2.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 07/08/2023] [Accepted: 08/16/2023] [Indexed: 05/30/2024]
Abstract
Background Psoriasis is a common, chronic, immune-mediated inflammatory disease with a variety of skin manifestations. The aim of this study was to determine the prevalence of subclinical Achilles tendon disorder in cutaneous psoriasis patients and compare it with healthy controls. Methods This was a cross-sectional case-control study conducted on psoriasis patients that were referred to dermatology clinic. Thirty patients in the case group and 30 healthy controls were included in the study. Thickness of Achilles tendon enthesis was scanned by an expert rheumatologist using ultrasound equipped with a 5-14 MHz linear prob bilaterally. Results The mean age of the patient and control groups was 43.97±16.82 years and 38.87±12.71 years, respectively (P=0.190). The mean thickness of the Achilles tendon enthesis in the dominant limb was 4.31±0.86 mm in the patient group and 4.10±0.54 mm in the control group. There was no significant difference between the two groups in terms of thickness of the Achilles tendon enthesis in the dominant limb (P=0.276). The mean thickness of the Achilles tendon enthesis in the non-dominant limb was 4.44±0.91 mm in the patient group and 4.14±0.59 mm in the control group. There was no significant difference between the two groups in terms of thickness of Achilles tendon enthesis in the non-dominant limb (P = 0.134). Conclusion Although ultrasonography may be utilized for assessment of both structural and inflammatory changes, we revealed no difference in the mean thickness of Achilles tendon enthesis in patients with cutaneous psoriasis. Contradiction between clinical and ultrasonography features required further research.
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Affiliation(s)
- Anwar Sharifaskari
- Department of Internal Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Goodarzi
- Department of Dermatology, Rasoul Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Navid Davoody
- Department of Internal Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nahid Kianmehr
- Department of Internal Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Anousheh Haghighi
- Department of Internal Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Boussaid S, Ben Aissa R, Rekik S, Rahmouni S, Jammali S, Zouaoui K, Sahli H, Elleuch M. Ultrasonography Enthesitis and Synovitis Screening in Psoriatic Patients: A Case Control Study. Mediterr J Rheumatol 2023; 34:495-505. [PMID: 38282930 PMCID: PMC10815525 DOI: 10.31138/mjr.180923.ues] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 01/30/2024] Open
Abstract
Background The clinical screening of enthesitis and synovitis in patients with psoriasis lacks specificity and sensitivity during the preclinical phase. Aims to assess US subclinical synovitis and enthesitis in psoriatic patients compared with healthy controls. Methods A cross-sectional study on 40 psoriatic patients and 40 healthy sex- and age-matched controls. US examination of 18 joints was performed along with 22 entheseal sites on the upper and lower limbs. US subscores were established according to the US abnormalities: inflammatory score (tendon thickening, hypoechogenicity, bursitis, Doppler signal), damage score (calcification, enthesophytes, bone erosion) and total score (the sum of inflammatory and damage scores). Results US synovitis were more frequent in psoriatic patients (0.68%) than in controls (0.29%), but the difference was not significant. Patients with psoriasis had more US enthesitis (92,5%) compared to controls (40%)(p<0.001). The total number of enthesitis was higher in the psoriatic group (20.90%) compared to controls (4,78%)(p<0.001). There were more US abnormalities in the psoriatic group compared to controls for calcaneal tendon enthesis(p<0.001), distal patellar tendon enthesis(p<0.001) and deep flexor tendons of the finger enthesis(p<0.001). Compared to controls, psoriatic patients had a significantly higher inflammatory score (Mean±SD) (2.85±3.34 versus 0.58±1.17), damage score (3±2.57 versus 0.60±1.41), and total score (5.85±5.20 versus 1.18±2.07) (p < 0.001 each). Patients with scalp psoriasis had more US enthesitis (p=0.020). Conclusion Our results indicate that US enthesitis and synovitis are more frequent in patients with psoriasis. Prospective studies with larger sample size are needed to define the contribution of US in predicting the clinical onset of PsA.
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Affiliation(s)
- Soumaya Boussaid
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia
- Research Unit LR 05 SP 01, La Rabta Hospital, Tunis, Tunisia
| | - Rania Ben Aissa
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia
| | - Sonia Rekik
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia
- Research Unit LR 05 SP 01, La Rabta Hospital, Tunis, Tunisia
| | - Safa Rahmouni
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia
- Research Unit LR 05 SP 01, La Rabta Hospital, Tunis, Tunisia
| | - Samia Jammali
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia
- Research Unit LR 05 SP 01, La Rabta Hospital, Tunis, Tunisia
| | - Khaoula Zouaoui
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia
- Research Unit LR 05 SP 01, La Rabta Hospital, Tunis, Tunisia
| | - Hela Sahli
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia
- Research Unit LR 05 SP 01, La Rabta Hospital, Tunis, Tunisia
| | - Mohamed Elleuch
- Rheumatology Department, Rabta Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, Tunisia
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Bieber T. Disease modification in inflammatory skin disorders: opportunities and challenges. Nat Rev Drug Discov 2023; 22:662-680. [PMID: 37443275 DOI: 10.1038/s41573-023-00735-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/15/2023]
Abstract
Progress in understanding of the mechanisms underlying chronic inflammatory skin disorders, such as atopic dermatitis and psoriasis vulgaris, has led to new treatment options with the primary goal of alleviating symptoms. In addition, this knowledge has the potential to inform on new strategies aimed at inducing deep and therapy-free remission, that is, disease modification, potentially impacting on associated comorbidities. However, to reach this goal, key areas require further exploration, including the definitions of disease modification and disease activity index, further understanding of disease mechanisms and systemic spillover effects, potential windows of opportunity, biomarkers for patient stratification and successful intervention, as well as appropriate study design. This Perspective article assesses the opportunities and challenges in the discovery and development of disease-modifying therapies for chronic inflammatory skin disorders.
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Affiliation(s)
- Thomas Bieber
- Department of Dermatology and Allergy, University Hospital, Bonn, Germany.
- Christine Kühne - Center for Allergy Research and Education, Davos, Switzerland.
- Davos Biosciences, Davos, Switzerland.
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The role of ultrasound in screening subclinical psoriatic arthritis in patients with moderate to severe psoriasis. Eur Radiol 2023; 33:3943-3953. [PMID: 36853346 DOI: 10.1007/s00330-023-09493-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/29/2022] [Accepted: 02/02/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVE To identify patients in the subclinical psoriatic arthritis (Sub-PsA) phase by ultrasound (US) and provide a solution to screen them. METHODS A total of 490 participants with moderate-to-severe psoriasis were evaluated. Among them, 384 participants without arthritis symptoms were enrolled into the silent psoriasis group and 106 participants with arthritis symptoms, called prodromal/active PsA phase, were enrolled into the clinical PsA group. Another 80 non-psoriasis participants were enrolled into the control group. Each participant received clinical assessments and US examinations of 60 joints, 38 tendons, and 40 entheses. We compared the incidences of synovio-enthesitis, synovitis, tenosynovitis, erosion, and dactylitis detected on US among the three groups. Subsequently, on the basis of significant US findings, we distinguished Sub-PsA from psoriasis alone (PsO) in the silent psoriasis group and analyzed the clinical characteristics, mainly including basic clinical characteristics, body surface area (BSA), and Psoriasis Area and Severity Index (PASI) score. RESULTS Only synovio-enthesitis significantly differed between the control group and the silent psoriasis group (1.3% vs. 16.1%, p < 0.001). The knee was the most commonly involved site of synovio-enthesitis (79.0%). Taking synovio-enthesitis as the standard, 16.1% of silent psoriasis participants and 12.7% of all psoriasis participants were in the Sub-PsA phase. Furthermore, there were no differences in BSA and PASI among the three phases of PsO, Sub-PsA, and prodromal/active PsA. CONCLUSIONS Since the psoriasis patients in Sub-PsA phase was as high as 12.7% in all patients with moderate-to-severe psoriasis, US-detected synovio-enthesitis was recommended routinely for screening them regardless of arthritis symptoms, especially in the lower limbs. KEY POINTS • Synovio-enthesitis on ultrasound was significantly associated with subclinical psoriatic arthritis, especially in the lower limbs. • Routine ultrasound evaluation could help screen psoriasis patients in the subclinical psoriatic arthritis phase, which was as high as 12.7% in all psoriasis patients.
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Sabry R, Tharwat S, Nassar MK, Eltoraby EE. Ultrasonographic assessment of entheseal sites of upper and lower extremities in hemodialysis patients using Madrid Sonography Enthesitis Index. BMC Musculoskelet Disord 2022; 23:606. [PMID: 35739500 PMCID: PMC9219154 DOI: 10.1186/s12891-022-05512-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 06/01/2022] [Indexed: 12/27/2022] Open
Abstract
Background There is no much information about the entheseal involvement among hemodialysis (HD) patients. The aim of this study was to assess the frequency and distribution of ultrasonographic (US) entheseal alterations in HD patients and to evaluate the association between US abnormalities and both clinical and laboratory data. Methods This study was conducted on 41 HD patients and 23 sex- and age- matched controls. All participants were evaluated clinically for any signs of enthesopathy. Six entheses sites were scanned bilaterally using grey scale (GS) and power Doppler (PD) US and were scored using Madrid Sonography Enthesitis Index (MASEI) scoring system. Results In HD patients, at least one clinical sign suggestive of enthesopathy was found in 69 (14%) of 492 entheses. HD patients had statistically significant higher scores of structural tendon abnormalities (p < 0.001), enthesis thickening (p < 0.001), bone erosions (p < 0.001) and calcification (p = 0.037) than the healthy controls. Total MASEI score was higher in HD patients than healthy controls (median;18 vs 8, p < 0.001), also, MASEI-inflammatory (median;11 vs 3, p < 0.001) and damage scores (median;6 vs 0, p < 0.001). There was a statistically significant positive association between total MASEI score and both age (p = 0.032) and duration of HD (p = 0.037). Duration of HD was predictive for both MASEI-damage component (p = 0.004) and total MASEI score (p = 0.014). Conclusion There is a high prevalence of subclinical enthesopathy in HD patients. The entheseal US alterations is much higher in HD patients than in healthy subjects. The duration of HD is the significant predictor of enthesopathy in HD patients.
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Affiliation(s)
- Reham Sabry
- Nephrology unit, Internal Medicine Department, Mansoura New General Hospital, Mansoura University, Mansoura, Egypt.
| | - Samar Tharwat
- Rheumatology & Immunology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, El Gomhouria St, Mansoura, Dakahlia Governorate, 35511, Egypt
| | - Mohammed Kamal Nassar
- Mansoura Nephrology & Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ehab E Eltoraby
- Rheumatology & Immunology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, El Gomhouria St, Mansoura, Dakahlia Governorate, 35511, Egypt
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Mascarenhas S, Couette N. A Systematic Review of the Inclusion of Non-Inflammatory Ultrasonographic Enthesopathy Findings in Enthesitis Scoring Indices. Diagnostics (Basel) 2021; 11:diagnostics11040669. [PMID: 33917826 PMCID: PMC8068272 DOI: 10.3390/diagnostics11040669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 11/16/2022] Open
Abstract
Ultrasound has advanced the diagnosis and management of patients with inflammatory rheumatic conditions. It can be used to identify and monitor enthesitis, a cardinal feature of spondyloarthropthies. Several enthesitis scoring systems utilizing ultrasound to determine entheseal involvement have been developed. These scoring systems generally rely on determining the presence or absence of erosions, tendon enlargement, power Doppler signal, or enthesophytes. This systematic review identified ultrasound scoring systems that have been utilized for evaluating enthesitis and what key components derive the score. Review of these scoring systems, however, demonstrated confounding as some of the score components including enthesophytes may be seen in non-inflammatory conditions and some components including erosions can be seen from chronic damage, but not necessarily indicate active inflammatory disease. What is furthermore limiting is that currently there is not an agreed upon term to describe non-inflammatory enthesopathies, further complicating these scoring systems. This review highlights the need for a more comprehensive ultrasound enthesopathy scoring index.
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Narcisi A, Valenti M, De Simone C, Esposito M, Richetta A, Teoli M, Argento G, Costanzo A. Effects of TNF-α inhibition on pre-clinical enthesitis: observational study on 49 psoriatic patients. J DERMATOL TREAT 2021; 33:1703-1706. [PMID: 33691568 DOI: 10.1080/09546634.2021.1899112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Enthesitis is a hallmark of psoriatic arthritis (PsA) and echographic ultrasounds (US) represent a support for diagnosis of pre-clinical signs of enthesitis in asymptomatic patients at high risk for advanced forms. Early treatment with anti-TNFα could prevent permanent damage contrasting the degenerative course of the disease. OBJECTIVES To evaluate the effects of adalimumab on echographic and preclinical enthesitis signs in patients affected by plaque psoriasis. METHODS 49 psoriatic patients undergoing adalimumab treatment for plaque-type psoriasis were subjected to echographic screening for identifying pre-clinical signs of enthesitis. Patients underwent clinical and ultrasonographic examination of hands, elbows and knees before starting adalimumab and after 24 and 48 weeks of treatment. RESULTS We observed a reduction of the total number of echographic abnormalities and a significant decrease of the thickness of quadriceps tendons at week 24 and week 48. Furthermore, there was no evidence of significant articular damage progression during the entire study duration. CONCLUSIONS Entheseal ultrasonography may be used for preclinical diagnosis of PsA.Our study demonstrates that early detection and management with adalimumab leads to a block of articular damage progression. On quadriceps tendon, adalimumab has shown to be effective with a significant thickening reduction at week 24 and 48.
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Affiliation(s)
- Alessandra Narcisi
- Department of Dermatology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy
| | - Mario Valenti
- Department of Dermatology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Clara De Simone
- Institute of Dermatology, Catholic University, Rome, Italy.,Dermatology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Esposito
- Department of Dermatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.,Department of Dermatology, University of Rome Tor Vergata, Rome, Italy
| | - Antonio Richetta
- Clinic of Dermatology Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Miriam Teoli
- Department of Dermatology, University of Rome Tor Vergata, Rome, Italy
| | | | - Antonio Costanzo
- Department of Dermatology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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