Psoriatic arthritis prognosis. Psoriatic arthritis: diagnosis and treatment

Irina Alexandrovna Zborovskaya - Doctor of Medical Sciences, Professor, Professor of the Department hospital therapy with the course of clinical rheumatology of the faculty of advanced training of doctors of the Volgograd State Medical University, director of the Federal Budgetary State Institution"Research Institute of Clinical and Experimental Rheumatology" of the Russian Academy of Medical Sciences, head of the regional Center for Osteoporosis, member of the Presidium of the Association of Rheumatologists of Russia, member of the editorial boards of the journals "Scientific and Practical Rheumatology" and "Modern Rheumatology" Etiology and pathogenesis of psoriasis and psoriatic arthritis Psoriasis is a dermatosis, a disease characterized primarily by hyperplasia (proliferation) of the epidermis, the cause of which has not been definitively established. Clinically, it appears as sharply demarcated pink papules covered with silvery scales. Less common are psoriasis of the palms and soles, pustular psoriasis, as well as skin lesions on the folds of the limbs and in the area of skin folds, localized in "favorite" places (extensor surface of large joints - knee, elbow, scalp, intergluteal fold, umbilical fossa, area of the sacrum; an analogue of skin rashes is psoriatic lesions of the nails). 1. Psoriasis of the scalp should be determined by palpation. 2. With moderately severe psoriasis of the scalp, simulating dandruff, there should be, in addition, areas of completely unchanged skin between areas covered with scales. 3. In the presence of eczema, seborrhea or seborrheic dermatitis of any localization, psoriasis can only be diagnosed by classic plaques. 4. Isolated changes in toes are not taken into account. 5. In the absence of typical psoriatic rashes or clear anamnestic indications of psoriasis, only classical changes in the nails of the fingers can be taken into account, namely: pinpoint damage to the nail plates in the form of a thimble, onycholysis, or a characteristic discoloration of the lateral section of the free edge of the nail plate. In such cases, microscopic and bacteriological examination is indicated to exclude infection. 6. An isolated skin lesion on the folds of the limbs is taken into account if the changes are classic, i.e. all affected areas around the perimeter are surrounded by a sharply demarcated edge. Candidiasis infection should be ruled out by microscopic examination of scrapings. 7. Pustular dermatosis of the palms and feet cannot be regarded as psoriasis in the absence of typical skin changes in other areas or characteristic changes in the nails. - It is believed that the proliferation of the epidermis in psoriasis is associated with a violation of biochemical processes in its cells. According to the hypothesis of some authors, these disorders are based on an imbalance between cyclic nucleotides (AMP and GMP), as well as prostaglandins, which are usually involved in the regulation of epidermal growth. – According to other authors, the factor that induces cellular methods in the epidermis is a pathological substance (epidermopoietin) produced by proliferating cells. Biochemical changes are not primary, but develop on the basis of local and general immune disorders that occur under the influence of some external influences in predisposed individuals. – Both psoriasis and psoriatic arthritis are multifactorial diseases characterized by a combination of various internal and external factors. Unfavorable heredity manifests itself phenotypically under the influence of environmental (provoking) factors. These include:

infectious agents(streptococcus, staphylococcus, mycotic infection, viruses - retroviruses, HIV). Proven more severe course of psoriatic arthritis in patients suffering from chronic tonsillitis, and a very severe course (atypical forms of psoriasis, generalized, rapidly progressive psoriatic arthritis) in patients with AIDS.
endocrine factors. The peak incidence of psoriasis occurs during puberty and menopause. Pregnancy alters the course of the disease, usually by reducing the symptoms of the disease, although in some cases it provokes a severe course of the disease.
Diseases of the gastrointestinal tract(gastritis, cholecystitis, intestinal dysbacteriosis).
Psycho-emotional stress precedes the debut of the disease in 70% and exacerbation of the process in 65% of cases of psoriasis.
Medicines(lithium preparations, beta-blockers, aminoquinoline agents, sometimes non-steroidal anti-inflammatory drugs), alpha-interferon can provoke the onset of psoriasis or its exacerbation.

At the same time, it is impossible to name a specific pathogen that can be considered as the most frequent stimulus for the development of dermatosis. With regard to the development of arthritis in psoriasis, the role of trauma cannot be ruled out. There is an appearance of arthritis after a bruised joint. A significant number of patients associate the onset of a skin disease with acute neuropsychic overstrain or prolonged negative emotions. In patients with psoriasis, violations of thermoregulation, sweating, skin sensitivity, irritability, and functional vascular disorders are often found. They also find various metabolic disorders - protein, carbohydrate, lipid, uric acid, etc. So: Psoriasis is a systemic disease that, depending on the severity of the pathological process, can manifest itself as either skin or skin-articular and visceral symptoms. Histochemical studies carried out posthumously in persons who suffered from psoriasis during their lifetime "reveal changes in the connective tissue (and, above all, collagen fibers) in many internal organs - the development of sclerotic processes that were not clinically manifested during the life of patients. When radioactive technetium was administered to patients with psoriasis, it was found that it accumulates in the tissues of many joints, which did not seem to be affected, which confirms the asymptomatic development of the pathological process in them. The clinician, when analyzing the likelihood of a diagnosis in a patient with peripheral arthritis, may take into account the history of psoriasis (even in the absence of changes in the skin and nails at the time of examination) or the presence of psoriasis in a close relative. These criteria are of diagnostic value and may be associated with the clinical features of typical psoriatic arthritis. So, Psoriatic arthritis is one of the main forms of inflammatory diseases of the joints and spine and is a chronic systemic progressive disease associated with psoriasis, which leads to the development of erosive arthritis, bone resorption, multiple enthesitis and spondyloarthritis. Psoriatic arthritis (Pa) As you know, there is a group of so-called seronegative spondyloarthritis - diseases characterized by frequent lesions of the ilio-sacral joints, the absence of rheumatoid factor in the blood serum and tendencies to family aggregation. This group includes psoriatic arthritis, Reiter's disease, arthritis in chronic nonspecific bowel diseases, essentially close to this group and Bechterew's disease, however, unlike the latter, in seronegative arthritis, the development of ankylosing spondylitis is not mandatory, and peripheral articular syndrome. Common signs of seronegative spondyloarthritis are the following: 1. absence of RF (test for the presence of antinuclear factor is negative); 2. absence of subcutaneous rheumatoid nodules; 3. arthritis of the peripheral joints, which is often asymmetric; four. radiological signs sacroiliitis with or without ankylosing spondylitis; 5. the presence of clinical intersections between diseases included in this group. They include two or more features - psoriasis-like lesions of the skin or nails, inflammation of the eyes, including conjunctivitis or anterior uveitis, ulcers of the oral mucosa, colon and small intestine, genital organs, inflammatory changes in the genitourinary tract (urethritis or prostatitis); erythema nodosum, pyoderma gangrenosum, thrombophlebitis; 6. tendency to family aggregation; 7. presence of HLA B 27 (HL-A antigen, association B 27). The prevalence of PA is quite high. Psoriasis occurs in 1-3% of the population. Men and women suffer from psoriasis equally often. According to most authors, psoriatic arthritis develops in 5-7% of patients with psoriasis. Although some researchers point to a significantly higher incidence of joint damage in psoriasis (15-36% - 44-61%), its population frequency is about 0.1%. The debut of the disease can develop at any age, but most often the onset of the disease occurs between the ages of 20 and 50 years. AT childhood psoriatic arthritis is rare (1.9% of all forms of psoriasis in children), more often in cases of early debut of dermatosis (up to 3-4 years of age) in combination with its severe course (erythroderma). Joint syndrome usually joins at the age of 9-12 years and is a manifestation of juvenile psoriatic arthritis.

Etiology and pathogenesis of psoriatic arthritis The etiology and pathogenesis of psoriatic arthritis remain unknown. AT last years psoriasis and psoriatic arthritis are considered as clinical manifestations of a systemic process within the framework of psoriatic disease. Most researchers believe that the etiopathogenetic mechanisms of development skin psoriasis similar to those in psoriatic arthritis. 1. Among the significant factors in the development of psoriatic disease, there are genetic predisposition in the form of an association of the disease with HLA antigens, environmental factors (or environmental) and immune disorders. The study of the system of human leukocyte antigens in patients with psoriasis revealed two subtypes of the disease I and II.

Psoriasis type I is closely related to the HLA system (about 65% of all patients with psoriasis) and usually begins in adolescence. An association of psoriasis with HLA antigens B13, B16, B17, B27, B38, B39, DR4, DR7 was found. It has been established that HLA B27 is associated with damage to the axial skeleton (spine and sacroiliac joints), and DR4 is associated with erosive arthritis of peripheral joints. Psoriasis vulgaris is characterized by association with the HLA antigen CW6. A number of works provide information on the haplotypes of HLA antigens, which characterize a more favorable (B17-A2) and unfavorable (B13-A9 and A3, B8, B27, B35, B40) course of the disease.
For type II psoriasis the disease occurs much later, there is no connection with the HLA system. Psoriasis is inherited multifactorially, presumably by an autosomal dominant type of inheritance with a genetic component of 60-70% and an environmental component of 30-40%. The structure of hereditary predisposition has not been deciphered in detail. It is known that genes not included in the HLA system are also involved in the development of this disease. Apparently, the development of psoriasis can be predetermined not only by the presence of the “psoriasis gene” in the genotype, but also by an unfavorable allelic combination of other auxiliary genes (polygenic inheritance model).

1. Some authors believe that, with the exception of genetic factors, the reasons for the association of skin and joint lesions are unknown. Typically, this communication is asynchronous. The appearance of skin and articular syndromes is separated by years, they progress independently of each other, and the treatment of one of them has little or no effect on the course of the other. However, in some cases, skin and joint syndromes still occur at the same time or there is a simultaneous aggravation of these symptoms. Therefore, they cannot be considered completely separate processes, combined in one patient by chance or due to only a genetic predisposition. Therefore, most researchers believe that the nature of dermatosis affects the formation of clinical and morphological variants of the articular syndrome and other features of joint damage, including the rate of progression of bone and cartilage destruction, disease activity, other parameters of the pathological process and, in particular, the severity of systemic manifestations. In practice, this means that a milder course of the skin process, as a rule, is combined with a favorable course of arthritis, and vice versa, atypical forms of skin psoriasis are associated with a severe, rapidly progressive generalized articular syndrome. So, focal psoriasis vulgaris is combined with a distal or mono-oligoarthritic variant of arthritis and long-term preservation of the functional ability of the joints. Exudative and atypical dermatosis (erythroderma, pustular psoriasis) are accompanied by the development of generalized arthritis, osteolytic and spondyloarthritic variants of a rapidly progressive course. The malignant form of psoriatic arthritis always develops against the background of atypical psoriasis. The stage of the skin syndrome should also be taken into account in the treatment of arthritis, since often the exacerbation of the articular syndrome coincides with the progressive stage of skin psoriasis. In these cases, successful treatment of skin manifestations favorably affects the course of the articular syndrome. It should be noted, as I have already said, that many authors are reserved about the possibility of mutual influence of skin and joint syndromes and their treatment on each other, leaving this possibility only for atypical forms of psoriasis in malignant psoriatic arthritis. 2. The association of B27 in the HLA antigen is detected in 65% of patients with a combination of psoriasis and spondylitis. This indicator varies depending on the definition of spondylitis used. The association with B27 is less pronounced in the presence of only sacroiliitis or mild spondylitis. The frequency of this antigen may exceed 65% if only patients with severe spondylitis are included in the study group. In patients with psoriatic arthritis without sacroiliitis or spondylitis, the association with B27 is weak. Overall, approximately 50% of B27 carriers with psoriasis develop rheumatic disease. Interestingly, some patients with psoriasis and sacroiliitis or spondylitis have a combination of B17 (or B13) and B27. Since only one B antigen is inherited from each parent, patients in this case receive a combination of genes responsible for predisposition from both parents. 3. Immunological disorders are of certain importance in the pathogenesis of PA: a change in the ratio of T- and B-lymphocytes, an increase in the content of IgA, IgG and Ig E in serum with a normal content of Ig M, the detection of antibodies to antigens of cells of the stratum corneum and granular layers of the epidermis, the deposition of immunoglobulins, immune complexes in the epidermis of psoriatic elements. It has been established that this disease develops lymphopenia with a relative increase in the number of CD8 lymphocytes, but with a sharply reduced functional activity, both direct and stimulated. The ratio of T- and B-lymphocytes remains normal. In the blood serum of patients, a high concentration of circulating immune complexes containing skin antigen and antibodies, mainly of classes A and G, is determined. The level of immunoglobulin M remains normal. Immune complexes are also found in skin lesions and other tissues, causing organ damage (kidneys, joints, blood vessels, heart, eyes, etc.). It also often reveals a low complement level and high phagocytic activity of neutrophils and mononuclear cells. The development of an active immunological process is always associated with the production of cytokines, increased expression of cytokine receptors on the cells of damaged tissues (the number of receptors for IL-8 significantly increases on keratinocytes) of tissues, which are also involved in the development of the pathological process. In psoriasis, repeated activation of IL-1, TNF, IL-8 occurs, which leads to a violation of cytokine regulation. cell cycle epidermal cells, causing hyperproliferation of epidermal cells, impaired keratinization, inflammation in the dermis. There is an assumption that psoriasis will soon be interpreted as a cytokine pathological disease. So: The sequence of development of the pathological process in psoriatic disease can be schematically represented as follows. Under the influence of provoking factors, defective keratinocytes appear in predisposed individuals, which are skin antigens that activate local immune defenses (phagocytes, CD4, CD8 and B-lymphocytes, natural killers with the production of pro-inflammatory cytokines - IL-1, TNF, IL-8, interferons, colony-stimulating factors and increased expression of cytokine receptors and adhesion molecules on the surface of skin cells of other types of connective tissue). During the development of the immune reaction, the antigen is partially eliminated from the body and at the same time damage to new cells occurs, autoantigens are formed, which, under certain conditions, cause the development of an autoimmune reaction as a result of a “breakdown” of natural tolerance. Sensitized lymphocytes and antibodies to the autoantigen are formed in the body. There is damage to one's own tissues by cytotoxic lymphocytes and the formation of circulating immune complexes in the blood with the antigen that has entered the bloodstream. CECs are eliminated by the phagocytic system, but when it fails, immunocomplex tissue damage develops. A vicious circle arises: antigen entry > immune response > tissue damage > antigen entry > immune response, etc. Confirmation of the concept of psoriasis as a systemic connective tissue disease is a malignant form of psoriatic arthritis, in which the relationship and interdependence of skin and articular syndromes, as well as involvement in the process of most organs and systems of the body.

Pathomorphology

1. Histological changes in the synovial membrane in PA correspond to the picture chronic synovitis with moderate exudative and proliferative reactions with a predominance of fibrotic changes: there is infiltration of the synovial layer with fibrin, polynuclear cells and lymphocytes, dystrophy and necrosis of synoviocytes, followed by cell desquamation, cypilaritis, vasculitis. Features of psoriatic synovitis is the localization of inflammatory cellular infiltrate mainly in the superficial section of the synovial membrane. The presence of destructive proliferative vasculitis, annular sclerosis of the vessel walls, and the absence of pronounced fibrosis of the subintimal layer are characteristic. In psoriatic skin plaque, basically similar changes are found. 2. The pathological process also affects the epiphyseal parts of the bones, articular cartilage, where erosive changes can occur. In the most severe cases, osteolysis is observed, extending to the metaepiphyseal zone and further along the length of the bone, so some researchers include PA among neurogenic osteoarthropathies. 3. At the same time, reparative processes are underway, manifested by the development of periostitis, which make up the affected joint of bones, the formation of coarse osteophytes, and calcification of the ligamentous apparatus of the joint. Depending on the stage of the process, the following are distinguished histological features of psoriatic synovitis: Early changes :

swelling of the subsynovial layer;
high activity of alkaline phosphatase in the capillary endothelium;
capillaritis, single vasculitis;
poor diffuse infiltrate of lymphocytes, macrophages, polynuclear cells;
hypertrophy and weak proliferation of synoviocytes.

Active progressive immuno-inflammatory process:

proliferation of synoviocytes, infiltration of the synovial layer with polynuclear cells, lymphocytes, macrophages, expressed dystrophic changes in synoviocytes with their desquamation;
masses of fibrin with a large number of decaying cells on the surface of the villi;
superficial localization of the inflammatory reaction in the subsynovial layer of the villi;
moderate diffuse infiltrate from lymphocytes, macrophages, polynuclear cells;
capillaries, vasculitis;
angiogenesis in the deep parts of the villi with annular sclerosis of the vessel walls;
- foci of hemosiderosis.

Regression of the immuno-inflammatory process:

small-focal perivascular infiltration from lymphocytes and plasmocytes;
severe sclerosis of the walls of blood vessels;
synoviocyte atrophy.

The severity of morphological changes depends on the localization of the articular process and the duration of the disease. The more pronounced synovitis, the more morphologically it differs from rheumatoid synovitis. The outcome of arthritis can be not only subluxations and contractures, but also ankylosis of the joints.

Clinic

The defeat of the distal interphalangeal joints and the spine is more common in men; familial aggregation in 30% of cases, in 75% of cases, psoriasis precedes the development of arthritis, in 15% of cases, skin and joint damage develops synchronously, in other cases, joint damage precedes the development of psoriasis. Although psoriasis-associated arthritis is not a single, well-defined disease, it must be distinguished because psoriasis (or associated genetic factors) significantly influences the pattern of joint damage, and typical signs are observed in some patients. But even in the presence of psoriasis, there is sometimes considerable uncertainty in the interpretation of symptoms in individual patients. The onset of the disease may be acute, subacute or gradual . Often there is a prodromal period in the form of weakness, malaise, fatigue, sleep disturbances, arthralgia, myalgia, sometimes fever and weight loss. A characteristic feature of PA is the unpredictability of its further course. Most often, the disease begins gradually and proceeds benignly, characterized by episodic exacerbations and a tendency to unexpected remissions. However, the onset of the disease can be acute, and in some cases its course becomes aggressive and is accompanied by destructive changes. Acute onset clinically resembles septic arthritis or an acute attack of gout. The pains are intense throughout the day, accompanied by local and general stiffness in the joints, which is indistinguishable in nature from the stiffness that develops in rheumatoid arthritis. In rare cases, joint pain and stiffness lead to immobilization of the patient. These phenomena are accompanied by subfebrile body temperature, laboratory signs of activity inflammatory process(acceleration of ESR, leukocytosis, etc.). In 1/3 of patients, the articular syndrome grows slowly, with a predominance of proliferative changes. long time movements in the joints may be limited slightly. Spontaneous remission of the disease may occur, when the articular syndrome disappears for several months or years. But most often, psoriatic arthritis is progressive character. Classification of psoriatic arthritis The nature of the flow: 1. Heavy; 2. Normal (medium-heavy and light); Clinical and anatomical variant of the articular syndrome: 1. Distal; 2. Oligoarthritic; 3. Polyarthritic; 4. Osteolytic; 5. Spondyloarthritic. Systemic manifestations: I. Without systemic manifestations; II. With systemic manifestations: trophic disorders, generalized amyotrophy, polyadenia, carditis, heart defects, pericarditis, aortitis, nonspecific reactive hepatitis, liver cirrhosis, amyloidosis internal organs, skin, and joints, diffuse glomerulonephritis, acute anterior uveitis, nonspecific urethritis, polyneuritis, Raynaud's syndrome. III. Malignant form; Phase and degree of activity: A) Active 1. Minimum, 2. Moderate, 3. Maximum. B) remission. X-ray characteristic: A) Peripheral and root joints. I. Periarticular osteoporosis; II A. The same + narrowing of the joint space, cystic enlightenment of the bone tissue; II B. The same + single surface patterns; III. The same + multiple uzura, intra-articular osteolysis; IV. The same + bone ankylosis. B) sacroiliac joints; I. Fuzziness of the joint space, mild osteoporosis; II. Narrowing or expansion of the joint space, subchondral osteosclerosis; III. The same + partial ankylosing; IV. The same + complete ankylosing; C) Ankylosing spondylitis with:

Syndesmophytes or paraspinal ossificates;
Ankylosis of the intervertebral joints.

Functional ability of the patient: A) saved B) Violated:

Professional ability is preserved;
Professional ability lost;
Lost ability to self-care.

Character and stage of psoriasis: A) character

Vulgar: focal and widespread;
Exudative
Atypical; pustular, erythrodermic, rupioid;

B) Stage

progressive;
Stationary;
Regressive

C) Nail psoriasis Based on clinical and anatomical variants:

Forms of psoriatic arthritis

1. Classic psoriatic arthritis with damage to the distal interphalangeal joints of the hands and feet (5%), as a rule, is associated with psoriatic lesions of the nails and lesions of other joints. 2. Mutilating arthritis in combination with sacroiliitis (5%), it is one of the most severe forms of articular pathology, manifested by displacement of the bones of the hands and feet, leading to shortening of the fingers (deformity of the “lorgnette” type). 3. symmetrical polyarthritis, indistinguishable from RA (15%); the symmetry of the lesion is usually not complete, the lesion of the small joints of the hands and feet, both proximal and distal (sometimes with the development of ankylosis in them), wrist, ankle, knee and elbow joints, but without characteristic rheumatoid arthritis rheumatoid nodules and rheumatoid factor (RF + sometimes). four. Asymmetric periarticular arthritis (70%); the predominant lesion of the small joints of the hands and feet, with a “sausage-like” deformity of the fingers associated with axial tenosynovitis of the interphalangeal joints. 5. Monooligoarthritic variant characterized by an inflammatory process in 1-3 joints, not so much at the beginning of the development of the disease, but in the remote period of the disease. This variant is characterized by damage to large joints (knee, shoulder, elbow). However, it is possible to involve any joint in the inflammatory process, including the temporomandibular, sternoclavicular joints, etc. This variant of psoriatic arthritis is more common than others (70-75%) and has a favorable course. 6. Ankylosing spondylitis with or without peripheral arthritis (5%), considered as a manifestation of generalized enthesopathy. Some authors also highlight: 7. Juvenile psoriatic arthritis. 8. Syndrome SAPHO (Synolitis, Aene, Pustulosis, Hyperostosis, Osteomyelitis). - Palmar-plantar pustulosis, acne, purulent hydroadenitis, sternoclavicular hyperostosis, chronic sterile multiple lymphadenitis, spinal hyperostosis. The listed variants of psoriatic arthritis are not associated with a specific type of skin lesions, with the exception of arthritis of the distal interphalangeal joints, which is often associated with nail lesions.

Clinical manifestations

1. Scattered lesion of the fingers. A very characteristic feature is an asymmetric scattered lesion of several distal interphalangeal and metatarsophalangeal joints of the hands and feet. The lesion is usually multiple, but asymmetric mono-oligoarthritis may develop early in the disease. In particular, cases of isolated arthritis of the distal joints of the big toes are described. In the majority (70%) of patients, large joints (knee, ankle, less often others) are also involved in the process. Sometimes there are subluxations of the joints of the fingers (usually the feet) and flexion contractures. 2. Palpation of the joints in PA is moderately painful, the swelling is usually dense, as a rule, extends beyond the joint. The skin over the affected joints is cyanotic or purplish-cyanotic. The change in the shape of the end joints simultaneously with the peculiar coloration of the skin creates a picture of a “radish-like” defiguration of the finger, or “thimble”. Arthritis of the distal interphalangeal joints, as a rule, is combined with trophic changes in the nails. Characteristic subungual psoriatic papules are a symptom of an oil stain, subungual hyperkeratosis, onycholysis. 2a. Arthritis of the fingers and toes. 3. “Axial” lesion is also considered characteristic for PA - simultaneous lesion of 3 joints of one finger: distal, proximal interphalangeal and metacarpophalangeal, up to the development of ankylosis of these joints. Similar changes can be observed in the joints of the toes. In this case, diffuse swelling of the joints may occur due to thickening of the soft tissues, damage to the tendon sheaths, throughout the “sausage finger”: 4. Achilles bursitis, subcalcaneal bursitis, causing pain in the heels (thalalgia); 5. Enthesopathies (pain in the area of attachment of ligaments and tendons). 6. In 5% of patients, a disfiguring form of PA is observed, when, as a result of the osteolytic process, the fingers are shortened, bent, multiple subluxations and ankylosis of the joints (mutilating form) are found. Osteolysis most often affects the small joints of the hands and feet, including the metacarpus (metatarsus), carpometacarpal, and radiocarpal joints. Osteolysis undergoes not only the epiphyses of the bones that make up the joint, but also true bone dystrophy occurs, capturing the diaphyses of the bones of the phalanges, metacarpals and metatarsals, and sometimes there is a complete osteolysis of the bones of the wrist with thinning of the diaphyses of the bones of the forearm. This form is also characterized by asymmetry and disorder (chaotic) of these changes: on the same hand, for example, flexion and extensor contractures of the fingers, displacement of their axes in different directions can be found. 7. In PA, the spine is also involved in the process, more often its lumbar region and sacroiliac joints, less often the cervical and thoracic regions. Morning stiffness, pain in the spine sometimes occur throughout the day, posture is disturbed up to the “beggar” position (the latter is noted exclusively in men, usually several years after the onset of psoriasis). Spinal involvement is not as severe as in ankylosing spondylitis and progresses slowly. In this case, the destruction of peripheral joints is uncharacteristic, but occasionally mutilating arthritis still develops. Enthesopathies are typical, for example, in the places of attachment of the Achilles tendon and plantar aponeurosis to calcaneus; while patients complain of pain in the heel. Many have onychodystrophy. Eye complications are rare. In 30% of cases, inflammatory bowel disease is observed, which does not occur in patients with arthritis of the peripheral joints. At the same time, a clinical and radiological picture of ankylosing spondylitis and sacroiliitis is detected, as in Bechterew's disease. Sometimes, however, it can be combined with arthritis of the peripheral joints. 8. Sometimes the sternoclavicular and sternocostal joints are involved in the process, pains appear in them, aggravated by coughing, deep inspiration and swelling with a typical picture of Tietze's syndrome. As I said, in 1/3 of patients there is a lesion of the temporomandibular joints with limited mobility. Despite the allocation of individual clinical and anatomical variants of the articular syndrome in psoriatic arthritis, in practice, a combination of individual symptoms inherent in one or another variant is most often observed. Therefore, the determination of the variant of the articular syndrome in each individual patient is carried out on the basis of the leading symptom in a diverse picture of psoriatic arthritis. Extra-articular manifestations of PA Systemic manifestations of PA

Weight loss
prolonged fever
Skin lesion
Lymphadenopathy
Amyotrophy
Cardiac syndrome
Hepatopathy
Kidney damage
Eye damage
Urethritis
neuromuscular syndrome
Raynaud's syndrome

Skin lesion

In general, the nature of skin rashes in psoriatic arthritis is distinguished by a number of features, in particular, a tendency to exudation, pustulization, resistance to therapy, the location of the rash in the terminal phalanges with nail damage, up to onycholysis. Cardiac syndrome (especially in severe and malignant forms) A few complaints are limited to pain or a feeling of heaviness in the precordial region, interruptions, palpitations. ECG changes are represented by signs of rhythm and conduction disturbances, symptoms of hypertrophy of the heart cavities, diffuse changes in the myocardium, and prolongation of the QT interval. Quite often there is a syndrome of early repolarization of the ventricles. X-ray examination noted an increase in the heart in diameter, while there is an increase, mainly in the left ventricle. Some patients have a mitral configuration of the heart, and pleuropericardial adhesions may be detected. From the above, it follows that the cardiac syndrome in PA is characterized by a variety of manifestations that reflect changes in various structures of the heart. The most significant stigmata of the cardiac syndrome is aortitis. Dilatation of the aorta, diffuse induration of its initial part, and focal indurations on the posterior wall are associated with lesions of the spine and are close to similar changes in seronegative spondyloarthritis (SSA). Some patients have myocarditis. It usually appears against the background of high laboratory activity of the inflammatory process and is accompanied by tachycardia, rhythm and conduction disturbances, diffuse changes on the ECG, an increase in the heart and a change in its configuration, but without symptoms of circulatory failure. Pericarditis are usually adhesive, have a blurred clinical picture and are usually established by the presence of pleuro-pericardial adhesions. With PA, there is also a defeat valvular endocardium(usually aortic valve) Based on the above, we can observe the corresponding changes in ECHOkg. Echocardiographic changes in patients with PA

Enlargement of the left ventricle;
Low ejection fraction of the left ventricle, and shortening of the diameter of the left ventricle in diastole;
Dilatation of the aorta
Focal thickening of the aortic wall;
Thickening of the wall of the left ventricle and interventricular septum;
Thickening of the pericardium;
Heart defects:

- mitral stenosis, - mitral-aortic, - aortic.

Mitral insufficiency physiological;
Tricuspid insufficiency physiological;
Mitral valve prolapse.

Hepatopathy In most cases, hepatomegaly is not accompanied by a violation of the functional state of the liver. The frequency of liver damage does not correlate with the duration of the disease and the severity of arthritis, but has a certain relationship with the activity of the disease and the severity of other visceropathies. With PA, the development of chronic hepatitis, cirrhosis and amyloidosis of the liver is possible. A feature of hepatopathy in PA is the low severity of its clinical manifestations. In the induction of liver damage, the features of the skin syndrome and the activity of the disease are important. Verification of liver damage is extremely important, especially in terms of choosing the scope of therapeutic measures and, above all, prescribing disease-modifying drugs. renal syndrome Recently, attention has been paid to the frequent damage to the kidneys in psoriasis. It is necessary to say about the possibility of developing secondary chronic glomerulonephritis and systemic amyloidosis with kidney damage in PA. K.G. Golov et al. (1995) showed that all patients with psoriasis, including psoriatic arthritis (both with clinical signs of nephropathy - proteinuria, and without them), have an increase in the activity of tubular enzymes, primarily N-acetyl-b-D-glucosaminidase (NAG) urine, coinciding with the presence of morphological signs of various variants of glomerulonephritis (with clinically pronounced nephropathy) or non-specific changes in the glomerular and tubular apparatus (without clinical signs of nephropathy). The NAG value exceeded the control values in patients without proteinuria by 5 times, and in patients with proteinuria - by 8 times. The authors believe that urinary NAG is the most sensitive indicator of early kidney damage, reflects tubulopathy and, being a lysosomal hydrolase that has a destructive effect on the glomerular basement membrane, portends damage to the kidney glomeruli. Diffuse glomerulonephritis proceeds relatively well. Rarely accompanied by extrarenal symptoms and over a long period does not lead to renal dysfunction. On the contrary, amyloidosis of the kidneys, ending in chronic renal failure, is one of the main causes of lethality in PA. The peculiarity of amyloidosis in this disease is manifested in its generalized nature with the involvement of almost all internal organs, thyroid gland, synovial membrane. Clarification of the genesis of the renal syndrome is important, as it imposes restrictions on the choice of drug therapy. Eye syndromes Other systemic manifestations include a variety of ocular symptoms ranging from psoriatic blepharitis to acute anterior uveitis with significant loss of visual acuity. According to the literature, the involvement of the organ of vision in the orbit of the pathological process in PA reaches 31%. In some patients, inflammatory eye diseases occur simultaneously with lesions of the mucous membranes of the oral cavity and urogenital tract. In these cases, the differential diagnosis between PA and reactive urogenic arthritis is very difficult. It is possible that in some cases there is a combination of two diseases from the CAS group, although with PA, both psoriatic papules and nonspecific inflammatory changes may appear on the mucous membranes. Defeat NS In PA, organic changes in the central and peripheral nervous system were revealed. In electromyographic and electroneuromyographic studies, the interest of the mononeurons of the anterior horns is observed spinal cord and anterior roots, demyelination of peripheral nerve fibers. Functional disorders of the central nervous system with neurotic reactions are associated with a long course of the disease and its severe forms. Variants of the clinical course The clinical form of psoriatic arthritis comprehensively reflects the main features of the pathological process, its severity, the degree of progression of bone and cartilage destruction, the presence and severity of systemic manifestations, the functional state of the musculoskeletal and other body systems.

Severe form characterized by generalized arthritis, ankylosing spondylitis with severe spinal deformity, multiple erosive arthritis, lysis of the epiphyses of bones in two or more joints, functional insufficiency of the II or III degree joints, severe general (fever, exhaustion) and visceral manifestations with dysfunction of the affected organs, rapidly progressing the course of exudative or atypical psoriasis, the maximum degree of activity of the inflammatory process for three consecutive months or more. Diagnosis of this form requires the presence of at least two of the above signs.
regular shape characterized by inflammatory changes in a limited number of joints, the presence of sacroiliitis and/or lesions of the overlying parts of the spine, but without its functional insufficiency, destructive changes in single joints, a moderate or minimal degree of activity of the inflammatory process, a slowly progressive course, systemic manifestations without functional organ failure, limited or common psoriasis vulgaris.
Malignant form develops exclusively in young men (up to 35 years) of age with the presence of pustular or erythrodermic psoriasis. It is characterized by a particularly severe course with prolonged hectic fever, rapid weight loss to cachexia, generalized arthritis with a pronounced exudative component, spondyloarthritis, generalized lymphadenopathy and numerous visceritis.
Psoriatic arthritis in combination with diffuse connective tissue diseases, rheumatism, Reiter's disease, gout. Combined forms of the disease are rare, but the rarest option is the combination of psoriatic arthritis with systemic lupus erythematosus.

Malignant form of PA The systemic nature of PA is most clearly seen in the example of a malignant form of the disease (MFPA), which is typically characterized by a catastrophically fast course and an extremely unfavorable prognosis. As a rule, this form is observed in young men suffering from atypical psoriasis (pustular psoriasis or universal psoriatic erythroderma). Moreover, it is interesting that in most patients, joint damage appeared before skin rashes, and this period sometimes reached 11 years! This variant is characterized by high septic-type fever with chills and excessive sweating. Articular syndrome appears as polyarthritis with a pronounced exudative component of inflammation, spondyloarthritis, excruciating pains, sometimes requiring even the appointment of drugs. At the same time, progressive weight loss, the formation of trophic ulcers, bedsores, increased hair loss, amyotrophy, generalized lymphadenopathy, especially an increase in inguinal lymph nodes. All patients present with numerous systemic manifestations. Of the internal organs, the heart is most often affected by the type of myocarditis, which is manifested by a moderate expansion of the boundaries of the heart, weakening of the first tone, systolic murmur, tachycardia that does not correspond to fever, rhythm disturbance and diffuse changes in the myocardium according to ECG data. Perhaps the development of hepatitis, hepatolienal syndrome. At the height of the disease, signs of diffuse glomerulonephritis are sometimes noted, and with its protracted course, renal amyloidosis. Sometimes there is exudative pleurisy, eye damage. In the malignant variant of PA, encephalopathies can be observed with predominant involvement of subcortical formations in the process, epileptic seizures and delirium. Sometimes peripheral neuritis and polyneuritis develop. This form of psoriatic arthritis is difficult to treat, is characterized by a paradoxical response to anti-inflammatory therapy (including glucocorticosteroids) and an extremely unfavorable prognosis, often ending in death. On the example of this form, the systemic nature of PA is most clearly traced, it is possible to demonstrate the close relationship and interdependence of skin, articular and other syndromes, as well as the decisive importance of the nature of dermatosis on the clinical picture of PA and its outcomes. The presented data allow us to interpret PA from the standpoint of systemic psoriatic disease. Degree of activity The degree of activity characterizes the inflammatory process, both in the area of the joints and from other organs and systems (skin, visceritis) and is determined according to the criteria proposed by A. I. Nesterov and M. G. Astapenko for rheumatoid arthritis. I. Minimum degree of activity - Manifested by slight pain during movement. Morning stiffness is absent or its duration does not exceed 30 minutes. ESR is not accelerated or not more than 20 mm/h, body temperature is normal. Exudative manifestations in the area of the joints are absent or slightly pronounced. Other inflammatory symptoms are not detected. II. moderate degree of activity - Pain at rest and on movement. Morning stiffness lasts up to 3 hours. Moderate, not persistent exudative symptoms are determined in the area of the joints. ESR within 20-40 mm/h, significant leukocytosis and stab shift. Body temperature is often subfebrile. III. Maximum degree of activity - Severe pain at rest and on movement. Morning stiffness lasts more than 3 hours. Severe exudative phenomena in the area of periarticular tissues. ESR above 40 mm/h. High body temperature. A significant increase in the levels of biochemical laboratory parameters (sialic acids, CRP, fibrinogen, dysproteinemia, etc.). It is possible to develop a remission of the inflammatory process, especially in the mono-oligoarthritic variant of the articular syndrome and limited psoriasis vulgaris. Radiography of the joints and spine The radiological picture of psoriatic arthritis has a number of features. Thus, osteoporosis, which is characteristic of many diseases of the joints, is clearly detected in psoriatic arthritis only at the onset of the disease and in the mutilating form. 1. Radiological manifestations of arthritis of the distal interphalangeal joints are quite typical. This is an erosive asymmetric process, in which proliferative changes are simultaneously detected in the form of bone growths at the bases and tips of the phalanges, periostitis. Erosion, having arisen along the edges of the joints, further spread to its center. In this case, the tops of the terminal and middle phalanges are grinded off with simultaneous thinning of the diaphysis of the middle phalanges, and the second articular surface is deformed in the form of concavity, which creates an x-ray symptom. "pencils in a glass" and "cup and saucer" Characterized by the growth of bone tissue around erosions, osteolysis of the distal phalanges; one bone is often pushed into another like a telescope ("telescopic" finger). 2. In polyarthritis that occurs without damage to the end joints, the radiological picture may resemble RA due to marginal erosions of the epiphyses and bone ankylosis of the joints, however, the development of an ankylosing process in several joints of the same finger is considered pathognomonic for PA. 3. The mutilating form of PA, as mentioned above, is manifested by severe osteolytic changes in the constituent bones of the joints. Not only the epiphyses are resorbed, but also the diaphyses of the bones of the joints involved in the pathological process. Sometimes the lesion affects not only all the joints of the hands and feet, but also the diaphysis of the bones of the forearm. There is evidence that PA does not begin with synovitis, but with osteitis, i.e. bone loss is primary. 4. X-ray changes in the spine in patients with PA.

Department deformation.
Vertebral osteoporosis.
Paraspinal ossifications.
Ankylosis and erosion of the intervertebral joints.
Vertebral deformity.
Syndesmophytes.
Height reduction intervertebral discs
Multiple osteophytosis (lateral, anterior, posterior corners of the vertebrae).
Sharpening and elongation of the edges of the uncovertebral joints.
Schmorl's hernia

Damage to the spine and ileosacral joints during radiographic examination can be detected in 57% of patients, most of whom have no clinical signs of sacroiliitis and spondyloarthritis. In other words, spondyloarthritis proceeds, hidden, which must be borne in mind when examining a patient. - Sacroiliitis is most often unilateral, although there is also a bilateral symmetrical process with ankylosing of the ileosacral joints, as in true Bechterew's disease. – Psoriatic spondyloarthritis is characterized by the formation of rough bone bridges between individual vertebrae, vertebral and paravertebral ossifications, usually asymmetrical, creating a “jug handle” symptom; ankylosis of the intervertebral joints. They differ from the delicate syndesmophytes in Bechterew's disease. But this sign is revealed extremely rarely and the picture of the spinal lesion practically does not differ from the classic ankylosing spondylitis in Bechterew's disease. Because the paravertebral ossifications in psoriatic arthritis are not associated with the vertebrae, the vertebrae are not square. By the way, some researchers consider paravertebral ossificates as a pathognomonic symptom of PA, they may be the only manifestation of PA and precede the appearance of skin symptoms. Laboratory research

There are no laboratory tests specific to PA.
Many cases of arthritis of the distal interphalangeal joints, monoarthritis of large joints can occur with virtually unchanged laboratory parameters.
With severe exudative phenomena in the joints, the ESR is usually accelerated to 30 mm/hour or more; especially significant in the malignant course of the disease. Sometimes, in a malignant form, specific antibodies to the cells of the horny and granular layers of the epidermis are detected.
The rheumatoid factor (RF) in blood serum is not determined.

The presence of RF in patients with PA is considered by many researchers as a random combination of RA and PA. However, the interpretation of such cases cannot be unambiguous, since RF is found not only in patients with other diseases, but also in practically healthy individuals. In seropositive patients, polyarthritic and osteolytic variants of the articular syndrome are more common. It follows that seropositivity contributes to a more severe course of PA with a predominance of destructive changes in the affected joints.

In 20% of patients, hyperuricemia is determined, which reflects the severity skin changes and is almost never accompanied by clinical symptoms of gout.
Synovial fluid is regarded as inflammatory, i.e. it reveals a high cytosis (more than 5 * 10 9 l) with a neutrophilic shift. The mucin clot is loose, decaying, the viscosity is low.

However, with mono- and oligoarticular lesions and low overall activity of the process, the synovial fluid can approach “low-inflammatory” in nature. Thus, as you can see, PA is characterized by a wide range of various extra-articular manifestations that can come to the fore in the clinical picture of the disease and determine its prognosis. In many ways, these manifestations are close to similar manifestations common to the entire group of seronegative spondyloarthritis. The spectrum of extra-articular pathology and its severity is associated with many factors, the leading of which are the activity of the inflammatory process and the nature of psoriasis. The presented data allow us to interpret PA from the standpoint of systemic psoriatic disease. Diagnostics So, Diagnostic criteria:

N	Criteria	Points
1.	Psoriatic eruptions on the skin.	5
2.	Arthritis of the distal interphalangeal joints.	5
3.	Arthritis of 3 joints of one finger.	5
4.	Asymmetric arthritis.	2
5.	Typical paraarticular phenomena.	5
6.	"Sausage" defiguration of the toes.	3
7.	Multidirectional subluxations of the joints of the fingers.	1
8.	Pain and morning stiffness in spine.	5
9.	Osteolysis in the joints.	5
10.	Ankylosis of the distal interphalangeal (hands, feet) and metatarsophalangeal joints.	5
11.	Radiographic evidence of definite sacroiliitis.	2
12.	Syndesmophytes or paravertebral ossificates.	4
13.	Seronegativity for rheumatoid factor.	2
14.	The relationship of increased skin manifestations with exacerbation of the articular syndrome or its appearance.	4
15.	Family history of psoriasis.

To diagnose a particular PA, at least three of the above criteria are required, one of which must be:

Skin manifestations.
Family history of psoriasis.
characteristic radiological manifestations.

In the presence of the RF, it is necessary to have two more additional criteria, i.e. there are at least five criteria, and among them are mandatory:

Defeat of ileosacral joints.
Typical paravertebral ossification.

The significance of each criterion increases if it was possible to exclude diseases such as Bechterew's disease, Reiter's disease, osteoarthritis of the fingers (Heberden's nodes). The Institute of Rheumatology of the Russian Academy of Medical Sciences developed diagnostic criteria for psoriatic arthritis, also with a score for each criterion, including exclusion criteria. The use of these criteria allows you to clarify the diagnosis in the early stages of its development. Diagnostic and exclusion criteria for psoriatic arthritis (E. R. Agababova et al., 1989)

N p / p	Criteria	Points
1. 2. 3. 4. 5. 6. 7. 8. 9 10. 11. 12. 13. 14. 1. 2. 3. 4. 5.	Psoriasis: -psoriatic skin rashes; -psoriasis of the nails; - skin psoriasis in close relatives Arthritis of the distal interphalangeal joints of the hand Arthritis of three joints of the same finger (axial lesion) Multidirectional subluxations of the fingers Asymmetric chronic arthritis Crimson-cyanotic coloration of the skin over the affected joints with mild palpation tenderness "Sausage-shaped" defiguration of the toes Parallelism of the course of skin and joint syndromes Pain and morning stiffness in any part of the spine that persists for 3 months. Seronegativity for rheumatoid factor Acral osteolysis Ankylosis of the distal interphalangeal joints of the hands and/or metatarsophalangeal joints Radiographic evidence of definite sacroiliitis Syndesmophytes or paravertebral ossificates Exclusion Criteria Absence of psoriasis Seropositivity for rheumatoid factor Rheumatoid nodules Tophi Close connection of articular syndrome with intestinal or urogenital infection	+5 +2 +1 +1 +5 +4 +2 +5 +3 +4 +1 +2 +5 +5 +2 +4 -5 -5 -5 -5 -5

Diagnostic Rule . With a score of 16- classic psoriatic arthritis; 11-15 points- certain psoriatic arthritis; 8-10 points- psoriatic arthritis probable; 7 points or less- the diagnosis of psoriatic arthritis is rejected. Differential Diagnosis 1. Peripheral arthritis in patients with RA and psoriasis represent the most important groups in the spectrum of polyarthritis. There are significant crossovers between them, so there are more similarities than differences. Usually, these diseases must be differentiated when mono- or oligoarthritis is detected, as well as in patients with polyarticular lesions that do not affect the distal interphalangeal joints. – Strict symmetry of articular lesions can speak in favor of RA. – Damage to the tendons, more pronounced muscle atrophy, classic deformity of the joints of the hands - “rheumatoid hand” (tendon damage in PA is observed casuistically rarely). – For RA, the defeat of the sacroiliac joints is not typical (only in the late stage). An axial lesion of the distal joints is not typical - The identification of subcutaneous rheumatoid nodules, the development of vasculitis, peripheral neuropathy, Sjögren's syndrome, scleritis, and fibrosing alveolitis also speak in favor of RA. – Positive immunological tests (high titer for RF in the blood and synovial fluid. Absence of ragocytes in synovial fluid with PA. - Typical for RA - a characteristic histological picture of the synovial membrane. – The age of onset of RA is usually over 45 years. The onset of psoriatic arthritis is more evenly distributed across age groups - RA is more often observed in women, while among patients with PA there is only a slight predominance of women. – The course of PA, in comparison with RA, is in most cases more favorable and almost does not give systemic manifestations. 2. Unlike ankylosing spondylitis , psoriatic lesions of the spine are almost never the first manifestation of the disease and are rarely accompanied by severe pain and stiffness in the back (at least in the early stages). But sometimes pain in the spine is noted throughout the day. A change in posture in patients with PA is extremely rare, the functions of the spine deteriorate gradually. Unlike spondyloarthritis that develops in Bechterew's disease, psoriatic spondylitis is characterized by the absence of a strict sequence of involvement in the inflammatory process of various parts of the spine (from bottom to top from the lumbosacral to the thoracic and then cervical). In psoriatic spondylitis, changes can begin in any department (for example, the thoracic spine may be affected in the absence of changes in its lumbar spine). The features of psoriatic spondylitis also include its asymmetry and coarseness of the syndesmophytes, which are detected radiographically. X-ray signs of spondylitis and sacroiliitis in psoriatic arthritis are determined quite often (in 57% of cases), but clinical symptoms from these joints (pain, impaired posture) are rare (only in 5% of cases), which also distinguishes psoriatic spondylitis from idiopathic ankylosing spondylitis. X-ray examination can play a significant role in clarifying the diagnosis: psoriatic ankylosing spondylitis is usually manifested by unilateral sacroiliitis, which progresses extremely slowly. An x-ray examination in BD shows damage to the overlying sections of the spine and the formation of rough intervertebral adhesions in some patients. – Eye damage in PA (conjunctivitis, episcleritis) is found on different stages diseases, and in Bechterew's disease, iritis and pridocicaitis are usually the first symptoms of the pathological process. – HLA-B27 positive patients with late psoriasis may experience rapid progression of spondylitis and sacroiliitis, development of iritis, and rarely peripheral arthritis. It is believed that in the case of such clinical manifestations, it is also not psoriatic arthritis that occurs, but a combination of psoriasis and ankylosing spondylitis. 3. The biggest difficulty for differential diagnosis represent cases of PA and Reiter's disease if the latter proceeds with conjunctivitis, with damage to the mucous membranes and skin (keratoderma) and nails. And there, and there can be asymmetric arthritis. - Keratoderma of the palms and soles, psoriasis-like skin rashes in patients with Reiter's disease are not always easy to differentiate even for an experienced dermatologist. Such similarity of the symptoms of the two diseases, apparently, is genetically determined. This was proved by the study of family cases of both diseases, the distribution of similar histocompatibility antigens in groups of probands and their relatives. – It is necessary to differentiate Reiter's disease and PA, first of all, according to anamnestic data, indicating a chronological relationship between the appearance of signs of arthritis and acute urogenital and intestinal infection which is characteristic of Reiter's disease. By the way, conjunctivitis and urethritis can occasionally develop in a patient with PA. – It is necessary to take into account the gender of the patient, since Reiter's disease develops mainly in young men. - The features of the evolution of the process are also important, including skin lesions, which are episodic in urogenital arthritis, and persistent in PA, persisting even during remission of the articular syndrome. 4. In patients with PA, one of the manifestations of metabolic disorders in the body may be hyperuricemia as a result of a violation of purine metabolism. – If at the same time there is an isolated lesion of the joints of the big toes, then it is necessary to exclude gouty arthritis . - With the latter, acute attacks are observed with a rapid complete regression of arthritis symptoms, an increase in the level of uric acid in the blood and daily urine, tophi appear. - Hyperuricemia in psoriasis, even at its high level, is most often asymptomatic. - If a patient with psoriasis has attacks of classic gouty arthritis (with fever, laboratory indicators of inflammatory activity in the acute period), there are deposits of urate in the tissues (tophi), uric acid crystals are found in the synovial fluid, nephrolithiasis with the discharge of urate stones, then, most likely, one can think of a combination of dermatosis and gout, or of “secondary gout”, which develops as a result of increased formation of purines from the nuclei of epidermal cells. 5 . SAP HO syndrome (S - sinovitis, synovitis, A - asne, acne, P - pustulosis, pustulosis, H - hiperostosis, hyperostosis, O - osteitis, osteitis) is a group of often combined symptoms. Synovitis develops in the area of the joints of the anterior chest wall of the sternoclavicular, sternocostal joints and the joint of the sternum handle and joints of the cervical and lumbar spine. Hyperostosis also develops in the area of these joints. Clinically, these changes are manifested by pain and swelling in the area of the joints of the anterior chest wall and prolonged pain in these parts of the spine. Such changes in the skeleton are combined with the presence of palmar-plantar pustular psoriasis and multiple acne, often confluent. (acneconglobata). The combination of these symptoms distinguishes SAPHO syndrome from psoriatic arthritis.
PA treatment The goal of therapy for psoriatic arthritis is to suppress the inflammatory process in the joints, achieve and maintain remission, and prevent the occurrence of destructive changes in the joints. Due to the lack of knowledge about the etiology of psoriatic arthritis, all therapy is pathogenetic in nature. 1. Treatment of PA that is not accompanied by high inflammatory activity should be carried out mainly non-steroidal anti-inflammatory drugs. Treatment begins with the appointment of non-steroidal anti-inflammatory drugs in high doses for a long time (2-6 months), and with persistent pain - longer, if necessary. From a large group of NSAIDs, those drugs that have high therapeutic activity and minimal side effects should be used. These requirements are met by drugs - derivatives of arylacetic acid (Voltaren, diclofenac sodium, ortofen, etc.), prescribed at 150-200 mg / day, a propionic acid derivative - flurbiprofen (flugalin, froben) at a dose of 30 mg / day, oxicam derivatives - piroxicam at a dose of 20-40 mg / day, meloxicam (Movalis) at a dose of 7-15 mg / day. Among the listed means the least expressiveness side effects characteristic of meloxicam, due to the peculiarity of the mechanism of its action on inflammatory mediators (selective suppression of the activity of the cyclooxygenase-2 enzyme. The appointment of non-steroidal anti-inflammatory drugs in psoriatic arthritis requires caution, since these drugs are included in a number of medications that can provoke an exacerbation of psoriasis. 2. Since many patients, only some joints are affected, it is of great importance intraarticular administration of glucocorticosteroids. Injections are carried out alternately in all inflamed joints until the signs of arthritis disappear. The course of treatment consists of 3-6 injections, however, it should be remembered that no more than 3 injections are allowed in the same joint during the year. Intra-articular emulsions of hydrocortisone (from 25 to 125 mg, depending on the size of the joint) or other corticosteroid drugs are widely used. For local treatment, preference is given to long-acting drugs (diprospan, depo-medrol). The dose of the administered drug depends on the size of the joint: large - 1 ml, medium - 0.5 ml, small - 0.25 ml. The slow absorption of intra-articular glucocorticosteroids provides not only a pronounced local anti-inflammatory effect, but also has a resorptive effect, reducing the symptoms of inflammation in other joints. In some cases, local glucocorticosteroid therapy can achieve remission of psoriatic arthritis. Injections are made once a week - a month or even a little less often in accordance with clinical indications. 3 . General corticosteroid therapy used in cases that are not amenable to non-hormonal agents and local treatment. The use of systemic glucocorticosteroid hormonal drugs for the treatment of psoriatic arthritis is limited to the appointment of short courses (up to 6-8 weeks) of small doses (5-7.5 mg / day in terms of prednisolone) in the absence of the effect of other methods of treatment, as it is possible to develop a paradoxical reaction to large doses of these drugs, on the one hand, and on the other hand, the progression of psoriasis is possible against the background of their cancellation. - It must be remembered that if in torpid cases an increase in the dose of prednisolone to 20-30 mg / day. does not lead to the desired result, then immunosuppressants should be added to the treatment. - Recently, especially with a high activity of the process that is not amenable to conventional methods of therapy, pulse therapy with 6-methyl-prednisolone will be changed. It should be borne in mind that, despite the rapid achievement of a positive result after pulse therapy, the usual treatment should be long-term - to consolidate the effect obtained. Cases are described when glucocorticosteroids, especially in high doses, caused a paradoxical effect - a generalization of the skin process and an increase in the activity of the disease - a malignant variant. 4. With PA moderate the appointment of long-acting (basic) agents in the treatment of the articular process is shown - gold preparations krizanol (17-34 mg of pure gold per week), especially tauredone. Gold preparations (tauredon, myocrysin) are administered intramuscularly once a week. The first 2 weeks are administered at 10 mg / week to assess the tolerability of the drug. Then, for 2 weeks, 20 mg / week is administered. With good tolerance, treatment is continued at 50 mg / week until clinical and laboratory remission is achieved, which usually occurs no earlier than 7-10 months later. from the start of therapy. Subsequently, the dose of the drug is gradually reduced by increasing the intervals between injections up to 10 days, 2 weeks, no more than 3 weeks. Further treatment can be continued with gold tablets (Auranofin 3 mg 2-3 times a day), however, oral gold preparations are less effective than parenteral ones. Chrysotherapy should be continued without interruption for many years, provided it is effective and well tolerated. 5. There are conflicting prescribing data quinoline drugs. Their definite efficacy in psoriatic arthritis has been demonstrated. Although against the background of the treatment of the latter with these drugs, cases of exacerbation and generalization of the skin process (exfoliative dermatitis) are described. 6. Patients with the most severe and rapidly progressive forms of PA, especially with a sharp pain syndrome, severe dysfunction of the joints and signs (according to laboratory tests) of a high activity of the process, torpid to conventional anti-inflammatory treatment, are shown a long-term (many months) appointment immunosuppressants, especially methotrexate. The first signs of a therapeutic effect are detected after 3-4 weeks of treatment. The most rational dose can be considered as taking 7.5 mg of the drug in the first week (for the next 2 days of each week). A single dose is 2.5 mg, the interval between doses is 12 hours. You can 10-15 mg / week. and even 25 mg/week. with a malignant form. When the effect is achieved, the dose is reduced to 10-15 mg / week. If oral administration is not effective enough, the drug is administered intravenously. To prevent hematopoiesis suppression, folic acid (1 mg / day) is prescribed simultaneously with methotrexate. Some researchers use 5 mg of methotrexate every other day for a number of months. Side effects when using this drug, they occur relatively often (nausea, diarrhea, stomatitis, and with longer treatment, ulcerative lesions of the oral mucosa, neutro- and thrombocytopenia with general bleeding, alopecia, toxic hepatitis and kidney damage, secondary infection). Therapy with methotrexate can continue for two years. Its longer use is possible after the exclusion of signs of fibrosis or cirrhosis of the liver (liver biopsy). In order not to miss these complications, a liver biopsy should be performed when the total dose of the drug reaches 1.5 g, and then repeated every 2 years. The development of liver fibrosis can be predicted by an increase in the level of the N-terminal propeptide of type III procollagen in serum. In any case, it is recommended to avoid nephrotoxic and hepatotoxic substances, in particular not to drink alcohol. Methotrexate can cause worsening in HIV infection. Do not prescribe drugs that inhibit hematopoiesis, salicylates and anticoalulants simultaneously with methotrexate. Noticeable therapeutic effect other immunosuppressants also have PA: chlorbutine, azathioprine, and mercaitopurine. 7. Application data available sulfasalazine or salazopyridazine in patients with PA. In this case, it is effective in symmetrical arthritis and arthritis associated with spondylitis, does not cause exacerbation of skin lesions. Commonly used dose in adults: 2 g (1 g 2 times a day with meals). To reduce the risk of side effects, the following regimen is recommended: 1st week - 500 mg, 2nd week - 1000 mg, 3rd week - 1500 mg, 4th week - 2000 mg. And so for several months. Then the dose can be reduced (0.5-1 g / day). This is a long acting drug. immunosuppressive effect. Anti-inflammatory action. If there is no effect after 4 months, continued treatment is not advisable. Contraindications: drug intolerance, signs of impaired liver and kidney function, stomatitis. A general blood test is performed: the first 3 months - 1 time in 2-4 weeks, then every 3 months. With the appearance of sore throat, mouth ulcers, fever, severe weakness, the drug must be immediately canceled on its own. Possible side effects Nausea, abdominal pain, headache, dizziness, allergic rash, ↓ leukocytes, platelets less often - diarrhea, transaminases. Cyanotic-grayish coloration of the skin, granulocytosis, megaloblastic anemia. Rare: severe skin lesions such as Stevens-Johnson and Lyell syndromes, fibrosing alveolitis. A comparative evaluation of the listed basic drugs in the treatment of psoriatic arthritis showed that gold preparations are the most effective, followed by salazo derivatives, and methotrexate occupies the last place in this row. In terms of tolerance, sulfosalazine turned out to be the best. Methotrexate and gold preparations were equal in terms of tolerability. 8. Emergence of an immunosuppressant in rheumatological practice cyclosporine A, well-established in the treatment of skin psoriasis, gave hope for its effectiveness in the treatment of articular syndrome. However, these hopes were not justified. Cyclosporine A is prescribed in a daily dose of 2.5-3.0 mg/kg of body weight under the control of serum creatinine during treatment. 9. Approximately the same situation has developed for aromatic retinoids (etretinate, acitretin). The drugs of this group are highly effective in suppressing the exacerbation of skin psoriasis, their effectiveness in the treatment of psoriatic arthritis is much more modest. When prescribing these drugs, second-generation retinoids should be used (acitretin 30-50 mg / day at the beginning of treatment with a dose reduction to a maintenance dose of 10-50 mg / day in 2 divided doses with meals; the course of treatment is from 1 to 4 months) under careful laboratory monitoring of blood biochemical parameters for the timely detection of side effects. 10. Several open-label and 2 randomized, placebo-controlled studies have investigated the effectiveness infliximab in psoriatic arthritis and psoriasis resistant to standard therapy. During treatment with infliximab, there is a pronounced positive trend in both skin and joint manifestations. A preliminary analysis of the results of the IMPACT (The Infliximab Multinational Psoriatic Arthritis Controlled Trial) study, which included 102 patients with severe psoriatic arthritis (more than 5 affected joints), divided into two equal groups, showed the following. During treatment with infliximab in the first group, improvement according to the criteria of the American College of Rheumatology AKP20 occurred in 36 (70.6%) patients, AKP50 in 27 (52.9%), AKP70 in 13 (25.5%). In the second group; placebo, improvement in AKP20 levels was observed in only 5 patients (9.8%). 11. In the treatment of psoriatic arthritis, it is also advisable to use drugs that correct the rheological properties of blood (reopoliglyukin 400 ml with the addition of 100-200 mg of pentoxifylline and 4 ml of no-shpa intravenously, drip at a rate of 40 drops / min 1 time in 2 days; for a course of 6-8 infusions; dipyridamole 20 mg (4 ml) in 250 ml of isotonic sodium chloride solution, intravenously, drip, every other day, for a course of 6-8 injections.It is advisable to alternate the introduction of dipyridamole with rheopolyglucin.A good effect is observed when heparin therapy is carried out in microdoses.Heparin is prescribed 5000 IU subcutaneously in the abdomen 4 times a day for 2-3 weeks, followed by a dose reduction to 5000 IU 2 times a day (with an interval of 12 hours) for 2 weeks with further withdrawal.Correction of the rheological properties of the blood is especially necessary in patients with a mutilating variant of the articular syndrome.12. Sometimes PA is used to treat extracorporeal photochemotherapy (photopheresis) or mixed PUVA therapy. This is a novel method of immunotherapy in which peripheral blood leukocytes sensitized with 8-methoxyprosalene are exposed to long-wave ultraviolet irradiation and then returned to the patient. This method of treatment is effective for long-term PA. The method consists in the combined use of the oral photosensitizer psoralen 2 hours before the procedure, followed by exposure to long-wave ultraviolet rays in the range of 320-400 nm, in a PUVA cabin. Sessions of photochemotherapy are carried out with an interval of 2-3 days with a gradual increase in the dose of UV radiation by 0.5-1.5 J/cm 2 . The course of PUVA therapy is 20-30 procedures. 13. With a high degree of activity of psoriatic arthritis, the treatment complex is administered apheresis methods (ECMOC), most often plasmapheresis, which can be combined with intravenous ultraviolet irradiation of autologous blood or laser irradiation of autologous blood. Plasmapheresis sessions are carried out 1 time in 3 days, the course of treatment consists of 3-4 procedures. Such therapy increases the effectiveness of treatment by 2 times, contributes to the prolongation of remission and shortening of the terms of hospitalization of patients. 14. With the so-called "winter" forms of psoriasis, it is recommended general ultraviolet exposure. 15. Shown local use of ointments , including hormonal (sinalar, fluorocort, etc.) on the affected areas of the skin. 16. Recommended vitamins: A, B 1, B 6, B 12. 17. Sedatives: valerian extract, elenium, seduxen, relanium, radedorm, etc. 18. For the treatment of PA, apply therapeutic gymnastics, physiotherapy and balneological treatment. Also widely used are such methods of treatment as magnetotherapy, transcutaneous laser therapy, electro- and phonophoresis with a 50% solution of dimexide, glucocorticosteroids, etc.; ultrasound with hydrocortisone on the affected joints, paraffin applications, radon and hydrogen sulfide baths. 19. Patients with a low overall activity of the process can be recommended such resorts like Sochi, Naftalan, Talgi, etc. 20 . Surgical methods treatment necessary in cases of persistent synovitis or the development of gross changes in the joints that significantly impair the functional ability of the patient. The types of surgery are the same as in RA, but the results are usually worse and less durable than in the rheumatoid process (arthroplasty). Forecast Until recently, it was believed that the prognosis of psoriatic arthritis is more favorable than that of RA. However, it is now established that psoriatic arthritis, like RA, often leads to disability and shortened life expectancy. Markers of an unfavorable prognosis are the onset of the disease at a young (especially childhood) age, the carriage of certain antigens of the HLA system (DR-3, DR-4), the presence of severe psoriasis, and a polyarticular variant of the disease. Patients with poor prognostic signs require early aggressive therapy.

Medical statistics show that it is one of the most frequently diagnosed skin diseases and is 1-2% of them. In many patients with a sufficiently long history of psoriasis, joints are also involved in the pathological process, given state is called psoriatic arthritis. In the past, this disease was considered a special variant, under the influence of skin pathology acquiring individual features. Recently, however, serious differences have been found between rheumatoid and psoriatic arthritis, which made it possible to single out the latter as an independent nosological entity.

In this article, we look at the symptoms and treatment of psoriatic arthritis.

Epidemiology of psoriatic arthritis

Psoriatic arthritis is diagnosed in approximately 5-7% of people with psoriasis. The onset of the disease occurs, as a rule, at the age of 20-50 years, in some cases it develops even in childhood. This pathology occurs with the same frequency, both in men and women.

Causes and mechanisms of development of psoriatic arthritis

psoriatic arthritis associated skin rashes in 5-7% of patients with psoriasis.

The etiology of psoriatic arthritis coincides with that of psoriasis itself and is not completely known to date. Scientists believe that the excessive proliferation of epidermal cells observed in psoriasis is based on a violation of their biochemical processes, which is associated with an imbalance between a number of biologically active substances: cAMP, cGMP, prostaglandins and others. Some authors believe that proliferating cells synthesize a special substance, namely epidermopoietin, which induces cell division, which leads to hyperplasia.

And yet, one of the leading theories of the occurrence of psoriasis and psoriatic arthritis is genetic. It has been proven that persons with a psoriatic process are carriers of certain antigens of the HLA system, in addition, almost every patient with psoriasis has a close relative with the same diagnosis. Individuals with this genotype feature are predisposed to psoriasis. When exposed to any adverse external factors, in particular stress, trauma, infectious agents, especially in combination with general or local disorders in the immune system, the body fails, namely, a number of biochemical reactions characteristic of psoriasis are triggered.

In the pathogenesis of psoriasis and psoriatic arthritis, autoimmune disorders undoubtedly play a role, that is, the body produces antibodies to its own cells. Evidence of this is found in the blood elevated levels gamma globulins, IgA, IgM and IgG, streptococcal antibodies, antibodies to skin antigens and other immunological indicators.

Symptoms of psoriatic arthritis

In 68-75% of cases, arthritis develops in patients who have suffered from psoriasis for 2-10 years, less often it occurs simultaneously with the first skin manifestations, and sometimes the articular syndrome even precedes the appearance of signs of skin pathology.

Arthritis debuts, as a rule, imperceptibly, gradually progressing, but in some cases the onset of the disease can be acute.

There are 5 types of joint damage in psoriatic arthritis:

Arthritis, in which the distal (those closer to the periphery) interphalangeal joints are affected;
Monooligoarthritis (i.e., only 1-2-3 joints are affected);
Polyarthritis, proceeding according to the type of rheumatoid;
mutilating arthritis;
Spondyloarthritis ( chronic inflammation of the spine, leading to a decrease in mobility in the joints of the lumbosacral spine, up to ankylosis).

Arthritis affecting the distal interphalangeal joints

The first type - inflammation of the distal interphalangeal joints of the feet and hands - is classic in psoriatic arthritis. At the beginning of the disease, one or more joints are affected, as it progresses, the rest are involved in the process, and multiple damage to them is observed. The skin over the affected joints is bluish or purplish. The joints are edematous (on palpation, this swelling is very dense), painful. The terminal joints change shape as the disease progresses, which, combined with the specific coloration of the skin above them, gives them a radish-like appearance. In addition, nails are usually involved in the pathological process with this type of arthritis: they are dried out, exfoliate, and break.

A pathognomonic sign (i.e., characteristic exclusively for this disease) of psoriatic arthritis is “osciform defiguration of the fingers. It occurs when the 3 - distal, proximal interphalangeal and metacarpophalangeal - joints of one finger are simultaneously affected up to their ankylosis (complete fusion with an absolute absence of movements in them) and is called the "axial" lesion.

Mutilating form of arthritis

The mutilating form of arthritis, fortunately, is quite rare, only in 5% of patients. This is a severe inflammation of the joints, leading to their rapid destruction, osteolysis. Outwardly, the fingers are shortened, bent, look like a folding telescope - if desired, you can straighten them "manually" to their original length (the so-called telescopic fingers). Examination reveals multiple subluxations and ankylosis of the affected joints. These changes are always asymmetric and disorderly - on the same hand, the axes of the fingers are displaced in different directions, there are both flexion and extensor contractures of the joints.

The variants of joint damage described above, although they are classic for the disease we are describing, are found only in 5-10% of people suffering from psoriasis. In 7 out of 10 patients, inflammation of one or two large joints is detected - knee, ankle, hip. In 15% of patients, involvement in the pathological process of more than 3 joints is diagnosed, and absolutely any localization. Polyarthritis can be both asymmetric and the same on both sides, resembling the clinical picture of rheumatoid arthritis.

Spondyloarthritis

Sometimes, in 5% of cases, psoriatic arthritis proceeds as ankylosing spondylitis (ankylosing spondylitis).

This pathology is often accompanied by eye damage - as a rule, iritis, episcleritis are diagnosed. If at the same time ulcerative lesions of the genital organs and oral mucosa are also detected, the patient is diagnosed with Reiter's disease.

In the case of a malignant course of psoriatic arthritis, internal organs may also be involved in the pathological process. As a rule, this phenomenon is noted in young (under 35 years of age) men suffering from atypical form psoriasis. Patients complain of alternating sharp rises and sudden drops in temperature (the so-called hectic fever), accompanied by tremendous chills and severe sweating. They quickly lose weight, hair actively falls out, muscles atrophy, bedsores form on the skin and trophic ulcers, regional lymph nodes, especially inguinal, increase in size. The defeat of the heart proceeds according to the type: it is enlarged in size, the heart rate is increased; during auscultation (listening through a phonendoscope), a weakening of the first tone, systolic murmur is determined; found on the ECG and diffuse changes myocardium. The liver is also affected - hepatolienal syndrome also develops. In some cases, the kidneys are affected with the development of diffuse glomerulonephritis, and subsequently renal amyloidosis. With a particularly malignant course of psoriatic arthritis, the central nervous system is also involved in the pathological process - epileptic seizures, and polyneuritis develop.

Hyagnostically important features psoriatic arthritis. It:

pain and swelling of the distal interphalangeal joints of the hands and feet;
pain and swelling of 3 joints of the same finger - both hands and feet;
asymmetric mono- or oligoarthritis;
night or early morning deep pain in the sacrum;
pain in the heel;
the presence on the skin of areas characteristic of psoriasis;
looking ahead, we note a negative rheumatoid factor, increased ESR and characteristic changes on the radiograph of the affected joints.

Diagnosis of psoriatic arthritis

Based on complaints, medical history and life history (especially important is the presence of psoriasis in the patient), the results of an objective examination of the patient, the doctor will determine the preliminary diagnosis of psoriatic arthritis. To confirm it, it will be necessary to carry out a series of laboratory and instrumental research, namely:

general analysis blood (for severe inflammation in the joints, the blood will react increase in ESR up to 30 mm/h and more; an increase in the level of leukocytes, a decrease in hemoglobin and erythrocytes can also be determined with normal value color index (ie, normochromic anemia);
a blood test for rheumatic tests, in particular, the determination of the rheumatoid factor (with this pathology it is negative, that is, it is not detected or absent in the blood) and C-reactive protein(it is determined in large numbers);
biochemical blood test (increased content of gamma globulins, IgA, IgG or IgM are determined);
analysis of the synovial (intra-articular) fluid, taken by puncture of the joint (high cytosis is determined, that is, a large number of cells, with the presence of many neutrophils, the viscosity of the fluid is low, the mucin clot is loose);
radiography of the affected joints and / or spine (at the initial stage of the disease, areas of osteoporosis and osteosclerosis (replacement of connective bone tissue) are determined in the image); at the stage of moderate lesions, narrowing of the joint spaces is visualized, both in the joints of the fingers and in the intervertebral joints, sacroiliac joints (sacrum with the iliac bones) are also narrowed; at a late, advanced stage of the disease, there are no gaps between the articular surfaces in the affected joint, ankylosis is determined; with a mutilating type of joint damage, the articular surfaces and adjacent areas of the bone are completely destroyed).

In 1989, the Institute of Rheumatology of the Russian Academy of Medical Sciences developed diagnostic criteria, according to which the probability of psoriatic arthritis is determined by the number of points awarded in the testing process. The table of correspondence of scores to certain criteria is presented below.

Diagnostic criterion	score
The presence of psoriatic rashes on the skin	+5
Psoriasis of the nails	+2
Skin psoriasis diagnosed in a close relative	+1
Inflammation of the distal interphalangeal joints	+5
Axial joint injury	+5
Finger subluxations upper limbs directed in different directions	+4
Chronic asymmetric arthritis	+2
Bluish or purple-tinged skin over inflamed joints, slight soreness	+5
Sausage-shaped toe defiguration	+3
Skin and joint syndrome are determined simultaneously	+4
Pain and stiffness in the morning in the spine for the last 3 months	+1
Rheumatoid factor negative	+2
Bone destruction at the apex (acral osteolysis)	+5
Lack of mobility (ankylosis) of the distal interphalangeal joints of the hand or metatarsophalangeal joints of the feet	+5
Signs of sacroiliitis on x-ray	+2
Bone growths along the edges of the joint spaces of the intervertebral joints: paravertebral ossificates	+4

Classic psoriatic arthritis is set if the score is 16 or more. With a score equal to 11-15, definite psoriatic arthritis is diagnosed. If the total score is 8-10 - psoriatic arthritis is likely, and with a value of 7 points or less, this diagnosis is rejected.

Differential diagnosis in psoriatic arthritis

Since this disease does not always proceed in the classical form, one should be able to distinguish it from a number of other rheumatological diseases. Usually carry out differential diagnosis with:

rheumatoid arthritis;
ankylosing spondylitis;
Reiter's disease;

Treatment of psoriatic arthritis

The patient will be prescribed injections of anti-inflammatory and analgesic drugs.

Therapeutic measures should be directed not only to the treatment of articular syndrome, but also to influence the skin psoriatic process.

Therapy of skin manifestations of the disease is usually carried out by a dermatologist, while therapeutic measures include ultraviolet irradiation, topical application hormonal ointments, systemic intake of vitamins and.

As for arthritis itself, the following drugs can be used to eliminate the inflammatory process in the joints: pharmacological groups:

intra-articular (inside the joint) - Depo-medrol, hydrocortisone, kenalog, etc.
long-term course - meloxicam, celecoxib, nimesulide, diclofenac, indomethacin, piroxicam.
Basic drugs in the case of rheumatoid-like, polyarticular, mutilating forms of psoriatic arthritis: sulfasalazine, gold preparations (Tauredon, Krizanol), cytostatics (Methotrexate).
Preparations of systemic enzyme therapy - Wobenzym, Phlogenzym.

As part of complex treatment arthritis, efferent methods such as plasmapheresis can also be used.

Of the non-drug treatments for psoriatic arthritis, the following can be recommended:

physiotherapy;
physiotherapy (ultrasound with hydrocortisone on the affected joints, paraffin baths);
balneological treatment (hydrogen sulfide and radon baths);
treatment at the resorts of Sochi, Talgi, Naftalan.

In case of persistent synovitis (inflammation of the synovial membrane of the joint), which is not amenable to treatment with drugs, as well as in case of gross changes in the joints that impair the functional activity of the patient, he may be recommended surgery, however, its results are not always good and long-term.

The criteria for the effectiveness of treatment are the normalization or reduction in the severity clinical syndromes diseases: skin, joint and others; normalization of hematological indicators of process activity: ESR, leukocytes, C-reactive protein, immunoglobulins; slowing down the progression of the disease, determined on x-rays.

Prognosis for psoriatic arthritis

The course of the disease is unpredictable in most cases. Sometimes it proceeds benignly, and in some cases - aggressively and in a short time inflammation leads to the destruction of the joint. The prognosis is determined individually, depending on the frequency and severity of exacerbations, the timeliness and adequacy of the prescribed treatment, the duration of medication.

Psoriatic arthritis is considered the second most common inflammatory joint disease after rheumatoid arthritis, it is diagnosed in 7-39% of patients with psoriasis.

Due to the clinical heterogeneity of psoriatic arthritis and the relatively low sensitivity diagnostic criteria it is difficult to accurately estimate the prevalence of this disease. Evaluation is often hampered by the late development of typical signs of psoriasis in patients with inflammatory joint disease.

Psoriatic arthritis develops between the ages of 25-55. Men and women get sick equally often, with the exception of psoriatic spondylitis, which is 2 times more common in men. In 75% of patients, joint damage occurs on average 10 years (but not more than 20 years) after the first signs of psoriatic skin lesions appear. In 10-15%, psoriatic arthritis precedes the development of psoriasis, and in 11-15% it develops simultaneously with skin lesions. It should be noted that in most patients there is no correlation between the severity of psoriasis and the severity of the inflammatory process in the joints, except for cases of synchronous occurrence of two diseases.

Pathogenesis

Psoriatic arthritis is thought to result from complex interactions between internal factors(genetic, immunological) and environmental factors.

Genetic factors

Many studies point to a hereditary predisposition to the development of both psoriasis and psoriatic arthritis: more than 40% of patients with this disease have first-degree relatives with psoriasis, and the number of cases of these diseases increases in families with identical or dizygotic twins.

To date, seven PSORS genes responsible for the development of psoriasis have been identified, which are localized in the following chromosomal loci: 6p (PSORS1 gene), 17q25 (PSORS2 gene), 4q34 (PSORS3 gene), lq (PSORS4 gene), 3q21 (PSORS5 gene). 19p13 (PSORS6 gene), 1p (PSORS7 gene).

The results of immunogenetic phenotyping of patients with psoriatic arthritis are contradictory. Population studies have found an increased frequency of HLA major histocompatibility complex genes: B13, B17, B27, B38, DR4 and DR7. Patients with psoriatic arthritis and those with x-ray signs of sacroiliitis are more likely to have HLAB27. With polyarticular erosive form diseases - HLADR4.

It should also be noted that non-HLA-associated genes included in the region of the major histocompatibility complex, in particular, the gene encoding TNFa. The study of polymorphism of the TNF-a gene revealed a significant relationship between the alleles of TNF-a-308, TNF-b+252 and erosive psoriatic arthritis. In case of early disease, this fact has a prognostic value for the rapid development of destructive changes in the joints, and the carriage of TNF-a-238 in representatives of the Caucasian population is considered as a risk factor for the development of the disease.

Immunological factors

Psoriasis and psoriatic arthritis are considered disorders of the T cell immunity. The main role is assigned to TNF-a, a key pro-inflammatory cytokine that regulates inflammation processes using various mechanisms: gene expression, migration, differentiation, cell proliferation, and apoptosis. It was found that in psoriasis, keratocytes receive a signal for increased proliferation when T-lymphocytes release various cytokines, including PIO-a,

At the same time, a high level of TNF-a is found in the psoriatic plaques themselves. It is believed that TNF-a promotes the production of other inflammatory cytokines, such as IL-1, IL-6, IL-8, as well as granulocyte-macrophage colony-stimulating factor.

With a high concentration of TNF-a in the blood of patients with psoriatic arthritis, such clinical manifestations are associated as:

fever;
enthesopathy;
osteolysis;
the appearance of destructive changes in the joints:
ischemic necrosis.

In early psoriatic arthritis, IL-10 is found in high concentrations in the cerebrospinal fluid. TNF-a and matrix metalloproteinases. A direct correlation between TNF-a levels is shown. matrix metalloproteinase type 1 and markers of cartilage degradation. Synovial biopsy specimens from patients showed intense infiltration with T- and B-lymphocytes, in particular CD8+ T-cells. They are also detected in the places of attachment of the tendons to the bone in early stage inflammation. CD4 T cells produce other cytokines: IL-2, interferon y, lymphotoxin a, which are found in the cerebrospinal fluid and synovium of patients with this disease. Frequent sporadic cases of psoriasis in HIV infection is one of the evidence for the involvement of CD8/CD4 cells in the pathogenesis of psoriatic arthritis.

Recently, the question of the causes of increased bone tissue remodeling in psoriatic arthritis in the form of resorption of the terminal phalanges of the fingers, the formation of large eccentric joint erosions, and a characteristic “pencil in cup” deformity has been discussed. A bone tissue biopsy revealed a large number of multinuclear osteoclasts in the resorption zones. For the transformation of osteoclast precursor cells into osteoclasts, two signal molecules are needed: the first is a macrophage colony-stimulating factor that stimulates the formation of macrophage colonies that are precursors of osteoclasts, the second is the RANKL protein (receptor activator of NF-kB ligand - ligand of the receptor activator NF-kB) , which starts the process of their differentiation into osteoclasts. The latter has a natural antagonist, osteoprotegerin, which blocks the physiological responses of RANKL. It is assumed that the mechanism of osteoclastogenesis is controlled by the ratio between the activity of RANKL and osteoprotegerin. Normally, they should be in balance, if the ratio of RANKL / osteoprotegerin is violated in favor of RANKL, uncontrolled formation of osteoclasts occurs. In synovial biopsy specimens from patients with psoriatic arthritis, an increase in the level of RANKL and a decrease in the level of osteoprotegerin were revealed, and in the blood serum, an increase in the level of circulating CD14-monocytes, precursors of osteoclasts.

The mechanism of periostitis and ankylosis in psoriatic arthritis is not yet clear; suggest the participation of transforming growth factor b, vascular endothelial growth factor, bone morphogenic protein. Increased expression of transforming growth factor b was found in the synovium of patients with psoriatic arthritis. In an animal experiment, a bone morphogenic protein (in particular, type 4), acting in conjunction with vascular endothelial growth factor, promoted bone tissue proliferation.

Symptoms of psoriatic arthritis

The main clinical symptoms of psoriatic arthritis:

psoriasis of the skin and / or nails;
spinal injury;
damage to the sacroiliac joints;
enthesitis.

Psoriasis of the skin and nails

Psoriatic skin lesions may be limited or widespread, and some patients have psoriatic erythroderma.

The main localization of psoriatic plaques:

scalp;
elbow area and knee joints;
navel area;
axillary areas; o intergluteal fold.

One of the frequent manifestations of psoriasis, in addition to rashes on the skin of the trunk and scalp, is nail psoriasis, which can sometimes be the only manifestation of the disease.

The clinical manifestations of nail psoriasis are varied. The most common are:

thimble-like psoriasis;
onycholysis:
subungual hemorrhages, which are based on papillomatosis of the papillae with dilated terminal vessels (synonymous with subungual psoriatic erythema, "oil spots");
subungual hyperkeratosis.

Peripheral psoriatic arthritis

The onset of the disease can be either acute or gradual. In most patients, the disease is not accompanied by morning stiffness, for a long time it can be limited and localized to one or more joints, such as:

interphalangeal joints of the hands and feet, especially the distal ones;
metacarpophalangeal;
metatarsophalangeal;
temporomandibular;
wrist;
ankle;
elbow;
knee.

Less often, psoriatic arthritis may debut with damage to the hip joints.

Often the involvement of new joints occurs asymmetrically, in the joints of the hands randomly (chaotically). Characteristic signs of peripheral inflammation of the joints:

involvement of the distal interphalangeal joints of the hands and feet with the formation of a "radish-like" deformity; o dactylitis;
axial psoriatic arthritis with periarticular phenomena (simultaneous damage to three joints of one finger: metacarpophalangeal or metatarsophalangeal, proximal and distal interphalangeal joints with a kind of cyanotic-purple staining of the skin over the affected joints).

In 5% of patients, a mutilating (osteolytic) form is observed - a "calling card" of psoriatic arthritis. Outwardly, this fails by shortening the fingers and toes due to resorption of the terminal phalanges. At the same time, multiple multidirectional subluxations of the fingers are observed, a symptom of “looseness” of the finger appears. The bones of the wrist, interphalangeal joints of the hands and feet, styloid processes of the ulna, heads of the temporomandibular joints are also subjected to osteolysis.

Dactylitis is found in 48% of patients with psoriatic arthritis, in many of them (65%) the toes are involved, followed by the formation of radiological signs of destruction of the articular surfaces. It is believed that dactylitis develops both due to inflammation of the flexor tendons, and as a result of inflammation of the interphalangeal, metatarsophalangeal or metacarpophalangeal joints of one finger. Clinical manifestations of acute dactylitis:

severe pain;
swelling, swelling of the entire finger;
pain limitation of mobility, mainly due to flexion.

In combination with periarticular phenomena, an axial inflammatory process in the joints forms a “sausage-like” deformity of the fingers. Dactylitis can also be not only acute, but also chronic. In this case, there is a thickening of the finger without pain and redness. Persistent dactylitis without adequate treatment can lead to rapid development of flexion contractures of the fingers and functional limitations of the hands and feet.

Spondylitis

It occurs in 40% of patients with psoriatic arthritis. Often, snondylitis is asymptomatic, while an isolated lesion of the spine (without signs of peripheral inflammation of the joints) is a rarity: it occurs only in 2-4% of patients. Changes are also localized in the sacroiliac joints, the ligamentous apparatus of the spine with the formation of syndesmophytes, paravertebral ossificates.

Clinical manifestations are similar to Bechterew's disease. Pain of an inflammatory rhythm and stiffness are characteristic, which can occur in any part of the spine (thoracic, lumbar, cervical, sacral region). In most patients, changes in the spine do not lead to significant functional disorders. However, 5% of patients develop a clinical and radiological picture of a typical ankylosing spondylitis, up to the formation of a "bamboo stick".

Enthesitis (enthesopathy)

Epthesis - the place of attachment of ligaments, tendons and joint capsule to the bone, enthesitis is a common clinical manifestation of psoriatic arthritis, manifested by inflammation at the sites of attachment of ligaments and tendons to bones, followed by resorption of the subchondral bone.

The most typical localizations of enthesitis:

posterior-superior surface of the calcaneus directly at the site of attachment of the Achilles tendon;
the place of attachment of the plantar aponeurosis to the lower edge of the calcaneal tubercle;
tibial tuberosity;
the place of attachment of the ligaments of the muscles of the "rotator cuff" of the shoulder (to a lesser extent).

Entheses of other localizations may also be involved:

1st costochondral articulation on the right and left;
7th costochondral articulation on the right and left;
Posterior superior and anterior superior spines ilium;
iliac crest;
Spinous process of the 5th lumbar vertebra.

Radiographically, enthesitis manifests itself in the form of periostitis, erosions, and osteophytes.

Forms

There are five main clinical options psoriatic arthritis.

Psoriatic arthritis of the distal interphalangeal joints of the hands and feet.
Asymmetric mono/aligoarthritis.
Mutilating psoriatic arthritis (osteolysis of the articular surfaces with the development of shortening of the fingers and / or feet).
Symmetric polyarthritis ("rheumatoid-like" variant).
Psoriatic spondylitis.

Distribution in these clinical groups is carried out on the basis of the following features.

The predominant lesion of the distal interphalangeal joints: more than 50% of the total articular score is the distal interphalangeal joints of the hands and feet.
Oligoarthritis/polyarthritis: Involvement of less than 5 joints is defined as oligoarthritis, 5 or more joints as polyarthritis.
Mutilating psoriatic arthritis: identification of signs of osteolysis (radiological or clinical) at the time of examination.
Psoriatic spondyloartitis: inflammatory pain in the spine and localization in any of the three sections - lumbar, thoracic or cervical, reduced mobility of the spine, detection of radiological signs of sacroiliitis, including isolated sacroiliitis.
Symmetric polyarthritis: more than 50% of the affected joints (paired small joints of the hands and feet).

Diagnosis of psoriatic arthritis

The diagnosis is made based on the detection of psoriasis of the skin and / or nails in the patient or his close relatives (according to the patient), characteristic damage to the peripheral joints, signs of damage to the spine, sacroiliac joints, enthesopathy.

When questioning the patient, it is necessary to establish what preceded the disease, especially if there were complaints from the gastrointestinal tract or the genitourinary system, eyes (conjunctivitis), which is necessary for differential diagnosis with other diseases of the group of seronegative spondyloarthropathies, in particular with reactive post-enterocolitis or urogenic inflammation of the joints, Reiter's disease (sequence of joint involvement, the presence of complaints from the spine, sacroiliac joints).

Clinical diagnosis of psoriatic arthritis

On examination pay attention to:

the presence of skin psoriasis of characteristic localization:
scalp, behind auricles:
navel area:
crotch area:
intergluteal fold;
armpits;
and/or the presence of popey psoriasis.

Examination of joints reveals characteristics psoriatic arthritis:

dactylitis;
inflammation of the distal interphalangeal joints.

Palpate the attachment sites of the tendon.

The presence or absence of clinical signs of sacroiliitis is detected by direct or lateral pressure on the wings of the iliac bones, and the mobility of the spine is determined.

The condition of the internal organs is assessed in accordance with general therapeutic rules.

Laboratory diagnosis of psoriatic arthritis

There are no specific laboratory tests for psoriatic arthritis.

There is often a dissociation between clinical activity and laboratory values. RF is usually absent. At the same time, RF is detected in 12% of patients with psoriatic arthritis, which creates certain difficulties in diagnosis, but is not a reason for revising the diagnosis.

CSF analysis does not give specific results; in some cases, high cytosis is detected.

The activity of peripheral joint inflammation in psoriatic arthritis is assessed by the number of painful and inflamed joints, the level of CRP, the severity of joint pain and disease activity.

Instrumental diagnosis of psoriatic arthritis

Of great help in the diagnosis is the data of an X-ray examination of the hands, feet, pelvis, spine, where characteristic signs of the disease are found, such as:

osteolysis of the articular surfaces with the formation of changes of the "pencil in a glass" type;
large eccentric erosions;
resorption of the terminal phalanges of the fingers;
bone proliferations:
asymmetric bilateral sacroiliitis:
paravertebral ossificates, syndesmophytes.

confirmed psoriasis of the skin or nails in a patient or his relatives;
asymmetric peripheral psoriatic arthritis with a predominant joint lesion lower extremities:
- hip,
- knee.
- ankle,
- metatarsophalangeal,
- tarsal joints,
- interphalangeal joints of the toes.
damage to the distal interphalangeal joints,
presence of dactylitis
inflammatory pain in the spine,
damage to the sacroiliac joints,
enthesopathy;
radiological signs of osteolysis;
the presence of bone proliferation;
no RF.

In 2006, the International Group for the Study of Psoriatic Arthritis proposed the CASPAR criteria (Classification Criteria for Psoriatic Arthritis) as diagnostic criteria. The diagnosis can be established by the presence of inflammatory joint disease (spinal involvement or entheses) and at least three of the following five features.

The presence of psoriasis, psoriasis in the past or a family history of psoriasis.
The presence of psoriasis is defined as a psoriatic lesion of the skin or scalp, confirmed by a dermatologist or rheumatologist.
Information about past psoriasis can be obtained from the patient, family doctor, dermatologist or rheumatologist, o Family history of psoriasis is defined as the presence of psoriasis in first- or second-degree relatives (according to the patient).
Typical for psoriasis lesions of the nail plates: onycholysis, "thimble symptom" or hyperkeratosis - recorded during physical examination.
A negative test result for the presence of RF using any method other than the latex test: solid-phase ELISA or nephelometry is preferable.
Dactylitis at the time of examination (defined as swelling of the entire finger) or a history of dactylitis recorded by a rheumatologist.
X-ray confirmation of bone proliferation (ossification of the edges of the joint), excluding the formation of osteophytes, on radiographs of the hands and feet.

Indications for consulting other specialists

Psoriatic arthritis often co-occurs with conditions such as:

hypertonic disease;
cardiac ischemia;
diabetes.

If signs of these diseases occur, patients need to consult the relevant specialists: a cardiologist, an endocrinologist.

With the development of signs of progressive destruction and deformity of the joints of the hands, ischemic necrosis of the supporting (hip, knee) joints, a consultation with an orthopedic surgeon is indicated to resolve the issue of performing arthroplasty,

Diagnosis example

Psoriatic arthritis, monoarthritis of the knee joint, moderate activity, stage II, functional deficiency 2. Psoriasis, limited form.
Psoriatic arthritis, chronic asymmetric polyarthritis with a predominant lesion of the joints of the feet, high activity, stage III, functional deficiency 2.
Psoriatic spondyloarthritis, asymmetric bilateral sacroiliitis, stage 2 on the right, stage 3 on the left. Paravertebral ossification at the level of Th10-11. Psoriasis common, psoriasis of the nails.

To determine the activity, x-ray stage and functional insufficiency, the same methods are currently used as for rheumatoid.

Differential Diagnosis

Treatment of psoriatic arthritis

The goal of therapy is an adequate effect on the main clinical manifestations of psoriatic arthritis:

psoriasis of the skin and nails;
spondylitis;
dactylitis;
enthesitis.

Indications for hospitalization

Indications for hospitalization are:

complex differential diagnostic cases;
poly- or oligoarticular lesions of the joints;
recurrent psoriatic arthritis of the knee joints; the need for injection into the joints of the lower extremities;
selection of therapy for DMARDs;
conducting therapy with biological agents;
assessment of tolerability of previously prescribed therapy.

Non-pharmacological treatment of psoriatic arthritis

Use of the complex therapeutic gymnastics both in the hospital and at home, it is especially important for patients with psoriatic spondyloarthritis in order to reduce pain, stiffness and increase overall mobility.

Medical treatment of psoriatic arthritis

Standard therapy for psoriatic arthritis includes NSAIDs, DMARDs, and intra-articular HA injections.

NSAIDs

Diclofenac and indomethacin are mainly used in average therapeutic doses. Recently, selective NSAIDs have been widely used in practical rheumatology to reduce adverse effects from the gastrointestinal tract.

Systemic glucocorticosteroids

There is no evidence of their effectiveness based on the results of controlled studies in psoriatic arthritis, except for the opinion of experts and descriptions of individual clinical observations. The use of glucocorticosteroids is not recommended due to the risk of exacerbation of psoriasis.

Intra-articular administration of glucocorticosteroids is used in the mono-oligoarticular form of psoriatic arthritis, as well as in order to reduce the severity of symptoms of sacroiliitis by the introduction of glucocorticosteroids into the sacroiliac joints.

Basic anti-inflammatory drugs

Sulfasalazine: effective against symptoms of joint inflammation, but does not inhibit the development of radiographic signs of joint destruction, is usually well tolerated by patients, is prescribed at a dose of 2 g / day.

Methotrexate: Two placebo-controlled studies have been conducted. The water shows the effectiveness of intravenous pulse therapy with methotrexate at a dose of 1-3 mg/kg of body weight, the other - methotrexate at a dose of 7.5-15 mg/week orally, in the third - a higher efficiency of methotrexate at a dose of 7.5-15 mg /week compared with cyclosporine A at a dose of 3-5 mg/kg. Methotrexate had a positive effect on the main clinical manifestations of psoriatic arthritis and psoriasis, but did not inhibit the development of radiological signs of joint destruction.

When using methotrexate in high doses, one patient died from bone marrow aplasia.

Further management

After discharge from the hospital, the patient should be under the supervision of a rheumatologist and a dermatologist at the place of residence in order to monitor the tolerability and effectiveness of therapy, treat exacerbations of inflammatory processes in the joints in a timely manner, and assess the need for biological therapy.

What should a patient know about psoriatic arthritis?

When the first signs of inflammation in the joints appear, a patient with psoriasis should contact a rheumatologist. If you have been diagnosed with psoriatic arthritis, but provided adequate and timely treatment You can remain active and efficient for many years. The choice of a therapy program depends on the clinical form of the disease, the activity of the inflammatory process in the joints and spine, and the presence of concomitant diseases. During treatment, strive to fully comply with all the recommendations of a rheumatologist and dermatologist, regularly see a doctor to monitor the effectiveness and tolerability of all drugs prescribed to you.

]

Psoriatic arthritis is a chronic systemic progressive disease associated with psoriasis, belongs to the group of seronegative spondyloarthropathies, accompanied by synovitis of varying severity, including proliferation of the synovial membrane in combination with articular effusion.

A characteristic clinic for psoriatic arthritis is formed due to the development of erosive arthritis, bone resorption, multiple enthesitis and spondyloarthritis.

The prevalence of psoriasis in the population ranges from 2% to 8%, and psoriatic arthritis in patients with psoriasis ranges from 13.5% to 47%. Psoriatic arthritis develops between the ages of 20 and 50, with equal frequency in both men and women.

According to modern literature, the current course of psoriatic arthritis is characterized by a torpid, therapy-resistant course, with the formation of disabling forms, with disability in 30% of cases.

Currently, the immune system and genetic predisposition play a leading role in the pathogenesis of both psoriasis and psoriatic arthritis. Thus, the main phenomenon is the formation of a complex network of interactions between immunocompetent cells, keratinocytes, synovial membrane cells and cytokines, which are among the most significant markers of impaired immunoregulatory processes in inflammatory diseases. In psoriatic arthritis, as in other spondyloarthritis, various changes in the profile of pro- and anti-inflammatory cytokines are observed, which form a regulatory network and, having a pleiotropic effect, participate in the pathogenetic mechanisms of this type of arthritis, being inducers of inflammation and tissue destruction.

The genetic determinant of psoriatic arthritis, according to domestic and foreign researchers, is most often determined by a complex of histocompatibility antigens and its specific haplotypes. In addition, with psoriatic joint damage, great importance is attached to antigens B27, B38, DR7, DR4, Cw6 and others. It is believed that the presence of the B38 antigen is associated with the rapid progression of osteochondral destruction already in early period development of the disease, B17 and Cw6 antigens are a predictor of a limited number of affected joints, the B57 antigenic structure is a multiple number of joints, DR4 is associated with destructive polyarthritis.

The polymorphism of psoriatic skin changes in combination with various forms of damage to the joints, spine and often internal organs caused a variety of terminology found in the scientific literature: psoriatic arthropathy, psoriatic arthritis with systemic and extra-articular manifestations, psoriatic disease, etc. . However, when making a diagnosis, it should be remembered that according to the ICD-10, this pathology is defined as psoriatic arthritis (L 40.5). The following clinical and anatomical variants of the articular syndrome of psoriatic arthritis are distinguished:

distal;
monooligoartric;
osteolytic;
spondyloarthritic.

The degree of activity of psoriatic arthritis is characterized by the following nominations:

minimal - characterized by minor pain when moving. Morning stiffness is either absent or less than 30 minutes. Body temperature corresponds to physiological parameters, erythrocyte sedimentation rate (ESR) is not more than 20 mm/hour;
moderate - characterized by pain both at rest and during movement. Morning stiffness reaches 3 hours, in addition, moderate exudative edema is possible in the area of \u200b\u200bthe joints. Subfebrile body temperature, ESR up to 40 mm/h, possible leukocytosis and stab shift;
maximum - characterized by severe pain at rest and during movement. Morning stiffness exceeds 3 hours. In the area of periarticular tissues, persistent edema is noted. The temperature is febrile, a significant excess of biochemical laboratory parameters is detected.

The clinical and anatomical variant of joint damage is determined by the predominance of one of the symptom complexes in the clinical picture of the disease. So, for example, in the distal variant, isolated lesions of the distal interphalangeal joints will prevail. An asymmetric lesion will be observed with oligoarthritic localization of the process. Typical localization is large joints, most often the knee. In the polyarthritic variant, the process will be symmetrical and both large and small joints will be affected. The osteolytic variant of psoriatic joint damage will be characterized by bone resorption: intra-articular, acral osteolysis, true bone atrophy. The spondyloarthritic variant is characterized by the development of sacroiliitis and ankylosing spondylitis.

In addition to the typical forms, there are atypical variants of the course of acute psoriatic arthritis:

rheumatoid-like form, characterized by damage to the small joints of the hands, wrist joints and a long course;
pseudo-phlegmanous form, manifested by monoarthritis with a pronounced inflammatory process in the area of the joint and surrounding tissues, accompanied by a high temperature reaction, chills, leukocytosis, an increase in ESR;
subacute form of monoarthritis of typical localization with minor pain;
primary lesion of tendons, articular bags, most often Achilles bursitis.

In psoriatic arthritis, various comorbid conditions can be recorded. The most frequently observed arterial hypertension, coronary heart disease, obesity and diabetes mellitus.

For the diagnosis of psoriatic arthritis, relevant are biochemical research blood and x-ray examinations of the joints and spine. X-ray changes in psoriatic arthritis will be represented by the following changes:

uneven narrowing of the joint space;
thinning, fuzziness, partial or complete destruction of the end plates;
marginal destruction in the form of patterns;
osteoporosis of epimetaphyses;
periosteal layers in the area of metaphyses, dislocations and subluxations;
ankylosis;
increased intensity and loss of structure of periarticular soft tissues;
osteolysis of epiphyses of small bones.

In order to make a diagnosis of "psoriatic arthritis", the following diagnostic criteria can be considered relevant:

psoriatic skin rashes;
psoriasis of the nails;
skin psoriasis in close relatives;
arthritis of three joints of the same finger;
subluxation of the fingers;
asymmetric chronic arthritis;
paraarticular phenomena;
sausage-like configuration of toes and hands;
parallelism of the course of skin and articular syndromes;
pain and morning stiffness in the spine, persists for at least three months;
seronegativity for rheumatoid factor;
acral osteolysis;
ankylosis of the distal interphalangeal joints of the hands and / or interphalangeal joints of the feet;
radiographic signs of sacroiliitis;
syndesmophytes or paravertebral ossificates.

Exclusion criteria for psoriatic arthritis:

absence of psoriasis;
seropositivity for rheumatoid factor;
rheumatoid nodules;
tophi;
close connection of articular syndrome with urogenital and intestinal infections.

Differential diagnosis in psoriatic arthritis is carried out with ankylosing spondylitis, reactive arthritis, gout, undifferentiated spondyloarthropathy.

The therapeutic route of psoriatic arthritis should be complex, since in the absence of adequate therapy, joint deformity is possible with subsequent disability of the patient. The main goals of treatment for psoriatic arthritis are: reducing the activity of the inflammatory process in the joints, spine and enthesis - places of attachment of tendons; reduction of manifestations of psoriasis of the skin and nails; slowing the progression of joint destruction; maintaining the quality of life and activity of patients. Although there is currently no medicines for the complete cure of psoriatic arthritis, modern drugs allow you to manage the disease, removing the symptoms of the disease. Non-steroidal anti-inflammatory drugs (meloxicam, nimesulide, celecoxib, diclofenac, etc.), glucocorticosteroid drugs (prednisolone, betamethasone, triamcinolone) are used as symptom-modifying drugs. Drugs of choice for disease-modifying drugs are methotrexate, cyclosporine, sulfasalazine, leflunomide.

In the period of remission or minimal severity of psoriatic arthritis, sanatorium treatment is indicated (Sochi, Matsesta, Pyatigorsk, Kemeri, Kislovodsk, Talgi, Nemirov, Krainka, Mirgorod) and balneotherapy (hydrogen sulfide, radon, sulfide baths). Balneotherapy is used very carefully and only under the supervision of a doctor, otherwise the articular syndrome may worsen.

Patients with psoriatic arthritis during the period of remission are recommended to lead a mobile lifestyle and exercise daily.

Thus, the current course of psoriatic arthritis tends to an earlier onset of the disease, with an unpredictable course and a tendency to develop disabling forms. However, to improve the prognosis of the course of psoriatic arthritis allows systematic medical supervision and targeted therapy with the control of laboratory parameters.

Literature

Badokin V.V. Prospects for the use of TNF-a inhibitors in psoriasis and psoriatic arthritis // Clinical pharmacology and therapy. 2005. No. 14. S. 76-80.
Kungurov N. V. et al. Genetic factors of the etiology and pathogenesis of psoriasis // Bulletin of dermatology and venereology. 2011. No. 1. S. 23-27.
Yusupova L. A., Filatova M. A. Current state of the problem of psoriatic arthritis // Practical medicine. 2013. No. 3. S. 24-28.
Belyaev G. M. Psoriasis. Psoriatic arthropathy (etiology, pathogenesis, diagnosis, treatment, prevention). Moscow: MED-press-inform. 2005. 272 p.
Badokin V.V. Modern therapy psoriatic arthritis // Consilium Medicum. 2005. V. 7. No. 3.
Dovzhansky S.I. Genetic and immunological factors in the pathogenesis of psoriasis // Russian Journal of Skin and Venereal Diseases. 2006. No. 1. S. 14-18.
Konovalenko A.A. State immune system in patients with complicated forms of psoriasis // Medical panorama. 2008. No. 2. S. 64-66.
Melnikov A. B. Psoriatic arthritis: clinical picture, diagnosis and therapy // Clinical dermatology and venereology. 2010. No. 5. S. 17-24.
Korotaeva T.V. Leflunomide in the treatment of psoriatic arthritis (PsA) // Farmateka. 2007. No. 6. S. 24-28.
Kubanova A.A. et al. Immune mechanisms of psoriasis. New strategies for biological therapy // Bulletin of dermatology and venereology. 2010. No. 1. S. 35-47.
Bakulev A. L. The use of hepatoprotectors in psoriasis: comparative clinical, laboratory and ultrasonographic evaluation of effectiveness. Bulletin of Dermatology and Venereology. 2010. No. 1. P. 112-117.
Kochergin N. G. Results of the First World Conference on Psoriasis and Psoriatic Arthritis // Russian Medical Journal. Dermatology. 2006. V. 14, No. 15. S. 1151-1155.
Piruzyan A.L. Molecular genetics of psoriasis // Bulletin of the Russian Academy of Medical Sciences. 2006. No. 3. S. 33-43.
Clinical guidelines. Dermatovenereology. Ed. A. A. Kubanova. M.: DEKS-Press, 2010. 428 p.
Korotaeva T.V. Standards of therapy for psoriatic arthritis // Scientific and practical rheumatology. 2009. No. 3. S. 29-38.
Akovbyan V. A. et al. The use of calcipotriol in the treatment of psoriasis // Bulletin of dermatology and venereology. 2007. No. 3. S. 45-46.
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Z. Sh. Garaeva 1 ,Candidate of Medical Sciences
L. A. Yusupova, doctor of medical sciences, professor
G. I. Mavlyutova,Candidate of Medical Sciences
E. I. Yunusova, Candidate of Medical Sciences

(PA), as well as other rheumatic diseases, is based on the compliance of the symptoms of the disease with certain criteria. Treatment is carried out in accordance with the standards of therapy and may include pathogenetic and symptomatic agents. The main directions are the relief of inflammation and slowing down the progression of the pathological process.

Damage to the joints of the hand is a typical sign of psoriatic arthritis.

10 diagnostic criteria for PA have been formulated.

The patient must have one or more of the following:

psoriatic lesions of the skin or nails;
psoriasis in close relatives (parents, children, brothers, sisters);
x-ray changes, including osteolysis (destruction of bone tissue) and periosteal stratification in the absence of osteoporosis of the periarticular region.

In addition, some of the following signs must be recorded to confirm the diagnosis:

arthritis of the distal interphalangeal joints of the hands, located between the nail and middle phalanges of the fingers;
damage to all three joints of the first finger of the hand;
changes thumb feet;
heel pain;
negative rheumatoid factor;
sacroiliitis (damage to the sacroiliac joints), confirmed by x-ray;
paravertebral calcification (deposition of calcium salts in paravertebral tissues).

In total, the diagnosis of PA requires the presence of at least three of the listed mandatory and additional features. If a positive rheumatoid factor is determined in a patient, the presence of an x-ray picture of sacroiliitis and paravertebral calcification, that is, five of the above symptoms, is additionally necessary for the diagnosis of PA.

X-ray features of PA:

asymmetric arthritis;
lack of osteoporosis (decrease in bone density) near the joint;
arthritis of the distal interphalangeal joints;
destruction of the ends of the phalanges with the formation of a kind of picture of a "pencil in a cap";
bone ankylosis (fusion) in the region of the sacroiliac joints and between the vertebrae.

There is no specific laboratory diagnosis of PA. In the blood test, inflammatory changes are determined: an increase in the number of leukocytes, an erythrocyte sedimentation rate, a moderate decrease in the number of erythrocytes and hemoglobin while maintaining a normal color index (normochromic anemia). When other organs and systems are affected, corresponding diagnostic signs develop.

Treatment

PA therapy includes non-drug and medicinal methods of exposure.

Lifestyle and diet

A patient with PA must change his life. He should avoid factors that provoke exacerbation. These include stress, trauma, infectious diseases. You must stop smoking and drinking alcohol.

It is recommended to follow a diet aimed at normalizing weight, containing a small amount of salt and animal fats. Excessive consumption of refined carbohydrates, including sugar, should be avoided. It is necessary to limit food such as citrus fruits, red fruits and berries (raspberries, strawberries, pomegranates), salted fish and sushi, tomatoes, legumes, meat (beef and pork).

To reduce the risk of cardiovascular complications, a patient with PA needs to determine the body mass index every six months, control the level of glucose and cholesterol in the blood, as well as blood pressure.

It has been proven that smoking and obesity are the two leading factors in reducing the life expectancy of patients with PA.

Non-drug therapy

Some studies have noted the effect of such methods of physiotherapy as acupuncture, balneotherapy, homeopathic remedies. These methods enhance the effect of symptomatic treatment, improve joint function, but do not affect the prognosis of the disease.

With PA, it is necessary to engage in physiotherapy exercises daily, which helps maintain joint mobility and avoid muscle atrophy. The complex includes exercises for the feet, joints of the hands, shoulder, elbow, hip and knee joints, that is, for the most commonly affected organs. Adequate strength and stretching exercises are important.

Among the methods of physiotherapy, ultrahigh-frequency therapy (UHF), centimeter wave therapy, infrared laser therapy, inductothermy and others are important. Physiotherapeutic procedures can be carried out only in the stage of remission of the disease.

In the rehabilitation of patients with PA, you can use manual therapy, mud therapy, including the use of "dry" brine and mud extracts.

Medical therapy

Goals drug treatment PA:

achieving minimal activity or remission of the disease, that is, getting rid of the patient's disturbing signs;
improving the quality of life of patients and increasing its duration;
reducing the risk of diseases often associated with PA: coronary disease heart disease, myocardial infarction, type 2 diabetes mellitus, metabolic syndrome, arterial hypertension, depression and inflammatory bowel disease.

The effectiveness of therapy is evaluated by special standardized indices, taking into account the condition of the joints, spine, skin, the presence of dactylitis and enthesitis, as well as impaired function of the musculoskeletal system.

Groups of drugs used to treat PA:

non-steroidal anti-inflammatory drugs (NSAIDs);
glucocorticosteroids (GCS), most often intraarticular;
basic anti-inflammatory drugs (BPP);
genetically engineered biological preparations (GIBP).

NSAIDs are the first choice drugs for active PA. They relieve the symptoms of the disease well, but do not affect its progression. Taking these medicines may be accompanied by adverse reactions from the digestive system and of cardio-vascular system therefore, they should be prescribed with caution to elderly patients and regularly (every 3 to 6 months) monitor their effectiveness and tolerability. All subgroups of NSAIDs are equally effective in treating the symptoms of PA.

Systemic corticosteroids are usually not prescribed for PA, as their use can exacerbate psoriasis. Most often, when one or more joints are affected, intra-articular administration of diprospan is prescribed. It also helps with enthesitis and tendonitis (inflammation of the tendons). Such treatment should be combined with NSAIDs or BPPs.

With an unfavorable prognosis of the disease, the patient should be prescribed BPP as soon as possible, primarily methotrexate, and if it is impossible to use it, leflunomide (Arava), sulfasalazine or cyclosporine A. An unfavorable prognosis is indicated by erosion of the articular surfaces, damage to five or more joints, previous taking systemic corticosteroids, dysfunction of the joints, increased erythrocyte sedimentation rate, the need for active therapy, psoriatic skin lesions, onset of the disease over the age of 60 years. PPPs reduce the severity of PA symptoms, but do not slow down its progression.

PPPs are fairly well tolerated. Reception of methotrexate must be combined with the appointment of folic acid. During treatment with these drugs, it is necessary to regularly monitor the complete blood count and the level of hepatic transaminases.

A new promising group for the treatment of PA are GIBDs: infliximab, adalimumab, golimumab, and etanercept. All of them are tumor necrosis factor inhibitors, not only relieve the symptoms of the disease, but also slow down its progression.

They are indicated for the ineffectiveness of methotrexate or NSAIDs and the presence of articular erosions in courses of at least three months. In the presence of unfavorable prognostic factors, active PA, significant psoriasis, GEBAs can be prescribed immediately, without the use of BPPs.

Traditional medicine

PA is a serious disease that, if not properly treated, leads to joint destruction, damage to internal organs, and the development of comorbid diseases. Its treatment should be carried out by a rheumatologist, based on modern recommendations of evidence-based medicine. Any additional interventions should be carried out only after consulting a doctor. It should be remembered that the effectiveness and safety of traditional medicine has not been studied by anyone.

Traditional medicine in some cases can help treat the symptoms of the disease, in particular, pain and swelling of the joints. To do this, you can use the following recipes:

make a compress from raw grated potatoes, apply it to the joint, cover with polyethylene and a towel, leave for 2-3 hours;
wrap the diseased joint with leaves of burdock, cabbage or plantain;
make compresses from grated carrots or chopped aloe, combined with a small amount of vegetable oil and turpentine;
rub sore joints with alcohol tincture of lilac flowers;
drink a decoction of birch buds.

With great care, all these methods should be used in patients with skin manifestations of psoriasis.

Rheumatologist, PhD, Mikhail Protopopov talks about psoriatic arthritis: