By Dr Irwin Lim, Rheumatologist
It was a terribly wet weekend. Perfect weather to work on a talk that I'm giving to a room of about 60 dermatologists.
My brief is to provide them a rheumatologist's perspective of psoriatic arthritis. In half an hour.
I thought I'd share with you three major points I'm trying to make.
- Psoriasis Arthritis is a clinically heterogeneous entity.
This is another way of saying that it can present in many, many ways. As such, it can present in vague and confusing ways. I wanted to make the point that this means the diagnosis is often delayed or not made.
Dermatologists will not miss a patient with hot swollen joints. The problem is the patient who presents complaining of joint pain without swelling, or the one with tendon problems, or the one with back pain that's just thought to be "non-specific". The patient may of course have all of these at the same time.
- Treatment options have improved
The lack of effectiveness of our traditional DMARDs was highlighted in the MIPA trial (read here). This trial casts doubt over Methotrexate in psoriatic arthritis, but does suffer from a variety of limitations and issues making the conclusions difficult to interpret.
Rheumatologists do believe that Methotrexate is an effective medication in psoriatic arthritis but we know it does have limitations in treating the various different manifestations of psoriatic arthritis. In particular, it's lousy at treating inflammatory spinal pain and enthesitis/tendon issues. While a useful medication, it is not nearly as useful in this disease as it is in Rheumatoid Arthritis.
TNF inhibitor medications are the only drugs which seem to be able to help all the various manifestations of psoriatic arthritis. This includes skin disease, synovitis, spondylitis, enthesitis, dactylitis.
- A Call to action.
For the situation to improve for patients suffering with psoriatic arthritis, dermatologists and rheumatologists need to form better relationships. The skin manifestations don't tend to be missed. The joint, tendon, entheseal manifestations are not so "visible" and are missed.
My talk still needs to evolve and improve, but I think I'll work around these 3 points.
Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here. Arthritis requires an integrated approach. We call this, Connected Care. Contact us.