Psoriatic arthropathy

If you think you see RA in MRCP exam, think again ! It may be Psoratic arthropathy RA like or it may also be mixed connective tissue disease.

Examine this patient's hands

This patient has psoriatic arthropathy (Rheumatoid arthritis like) as evidence by bilateral symmetrical deforming arthropathy involving the MCP and PIP joints bilaterally sparing the DIP joints. There is also erythematous plaques with silvery scales involving the hands, scalp, behind the ears, extensor surface of the legs and the trunk. There are also nail changes if pitting and subungal hyperkeratosis but no discolouration,ridging or onycholysis. There is a vertical scar over the R knee suggestive of R knee replacement. There is no evidence of Koebner phenomenon over the scar. There is limitation of movement of the hands but functionally she could still grip and hold a key.

What is this type of psoriasis and what are the other types ?

This is chronic plaque psoriasis and the others include guttate, inverse, erythrodermic, pustular psoriasis

What are the arthropathy of psoriasis ?

- RA like

- Oligoarthritis

- Distal asymmetrical

- Ankylosing spondylitis type

- Arthritis mutilans

How would you like to manage this patient ?

Multidisciplinary approach

Treat pharmacologically and non-pharmacologically

Pharmacologically - Systemic treatment in view of arthropathy and also skin involvement of > 70% eg Methotrexate, Coal tar for the scalp

Non-pharmacologically - physiotherapy, occupational therapy, avoid precipitating factors eg drugs - beta blockers, qunidine, lithium, stress,

What infections can precipitate psoriasis ?

Streptococcal

HIV