|Ahead of print publication
Clinical profiling of psoriatic arthritis: an observational cross-sectional study from Karnataka Psoriatic Arthritis Cohort
Chanakya Kodishala1, Vineeta Shobha1, S Chandrashekara2, Sharath Kumar3, Vikram Haridas4, Vijay K R Rao5, Ramesh Jois6, Manisha Daware7, Yogesh Preet Singh5, Shweta Singhai8, BG Dharmanand6, Pramod Chebbi9, R Subramanian10, Ashwini Kamath11, Uma Karjiigi12, Vikram Raj K Jain13, Chethana Dharmapalaiah14, Shiva Prasad15, C Srinivasa16, Ramya Janardana1, Benzeeta Pinto1, Beenish Nazir2, AS Harshini17, KM Mahendranath18
1 St. John's Medical College Hospital, Bengaluru, Karnataka, India
2 ChanRe Rheumatology and Immunology Research Centre, Bengaluru, Karnataka, India
3 Columbia Asia Hospital, Bengaluru, Karnataka, India
4 Arthritis Specialty Clinic, Hubli, Karnataka, India
5 Manipal Hospitals, Bengaluru, Karnataka, India
6 Vikram Hospital, Bengaluru, Karnataka, India
7 Narayana Health City, Bengaluru, Karnataka, India
8 Sakra Hospital, Bengaluru, Karnataka, India
9 SDM Medical College, Dharwad, Karnataka, India
10 JSS Medical College, Mysore, Karnataka, India
11 Yenepoya Specialty Hospital, Mangalore, Karnataka, India
12 Apollo Hospital, Bengaluru, Karnataka, India
13 Mahaveer Jain Hospital, Bengaluru, Karnataka, India
14 Aster CMI Hospital, Bengaluru, Karnataka, India
15 Apollo BGS Hospital, Mysore, Karnataka, India
16 Fortis Hospital, Bengaluru, Karnataka, India
17 Sparsh Hospital, Bengaluru, Karnataka, India
18 Samarpan Health Centre, Bengaluru, Karnataka, India
|Date of Submission||17-Sep-2021|
|Date of Acceptance||06-Mar-2022|
|Date of Web Publication||20-Jun-2022|
Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital, Sarjapur Road, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Clinical patterns and disease activity burden of psoriatic arthritis (PsA) varies in different parts of the world. There are limited studies from the Indian subcontinent.
Aims: To study the cutaneous and articular profile of PsA and describe their disease activity with validated outcome measures.
Methods: Karnataka psoriatic arthritis cohort study is a multicenter, prospective, cross-sectional, observational study which included all consecutive PsA patients defined by Classification criteria for psoriatic arthritis (CASPAR) from 18 rheumatology centers.
Results: A total of 549 PsA patients (M: F: 6:5), mean age 38.4 (±14) years were included. PsA preceded psoriasis in 81 (14.7%) while simultaneous onset was noted in 117 (21.5%). Plaque lesions (330 [78.8%]) and scalp (210 [49.2%]) were the most common type and site. Mild, moderate, and severe skin disease was noted in 480 (80%), 50 (9.3%), and 57 (10.6%) patients, respectively. Mean disease activity in PsA (DAPSA) was 18.8 (16.6); 100 (19.9%) were in remission. Low, moderate, and high joint disease activity was found in 145 (28.8%), 137 (27.2%), and 123 (24.5%), respectively. There was no correlation between skin and joint disease. Polyarthritis (216 [40.7%]) and oligoarthritis (202 [38.1%]) were the most frequent PsA subtypes. Those with a higher DAPSA (>28) were older (P = 0.02), had a shorter duration of psoriasis (P = 0.02) and higher psoriatic area and severity index scores (P = 0.0001).
Conclusions: We report high articular disease activity in half while cutaneous disease activity was minimal in majority.
Keywords: Arthritis, psoriasis, psoriatic
|How to cite this URL:|
Kodishala C, Shobha V, Chandrashekara S, Kumar S, Haridas V, R Rao VK, Jois R, Daware M, Singh YP, Singhai S, Dharmanand B G, Chebbi P, Subramanian R, Kamath A, Karjiigi U, K Jain VR, Dharmapalaiah C, Prasad S, Srinivasa C, Janardana R, Pinto B, Nazir B, Harshini A S, Mahendranath K M. Clinical profiling of psoriatic arthritis: an observational cross-sectional study from Karnataka Psoriatic Arthritis Cohort. Indian J Rheumatol [Epub ahead of print] [cited 2022 Oct 1]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=347863
| Introduction|| |
Psoriasis (PsO) is a common, chronic, immune-mediated skin disease, affecting approximately 2%–3% of the population across the world. About a quarter to one-third of them develops chronic synovioentheseal inflammation resulting in psoriatic arthritis (PsA)., PsA is heterogeneous in its clinical presentation and disease course. Many patients develop joint destruction early in the disease course and as many as one-third develop erosions by the end of 1st year, thereby implying need for early identification and institution of treatment. Overall, PsA is a substantial health burden, given that more than half of the patients are affected with comorbidities and health consequences beyond joint function., It carries significant morbidity estimated as at least 10 workdays lost due to arthritis flares in a year in nearly 40% of patients.
The clinical phenotypes can be divided into various subtypes, namely: Symmetric polyarthritis (SP), asymmetric oligoarthritis (AO), distal interphalangeal (DIP) joint predominant arthritis, axial spondyloarthritis (SpA), and arthritis mutilans (AM). There is very little information in the medical literature regarding risk factors in PsO patients which contribute to the development of arthritis. Predictors of severity and impairment due to PsA require elucidation of its pattern and prevalence.
It is well established that the clinical patterns and disease burden of PsA vary in different parts of the world. Epidemiological studies from the Indian subcontinent are few.,, Further, over the past decade, the therapeutic options for both PsO and PsA have expanded. There is a need to define and identify the various PsA populations in different geographic areas to streamline and optimize treatment options. In the current study, we aimed to describe the cutaneous and articular profile of patients with PsA and describe their disease activity parameters.
| Methods|| |
This is a multicenter, cross-sectional, observational, prospective study from a south Indian state. All consecutive patients with PsA fulfilling Classification for Psoriatic Arthritis (CASPAR) were enrolled from November 2018 to July 2019 from 17 dedicated Rheumatology centers across Karnataka (Karnataka Psoriatic Arthritis Cohort [KPsAC]). Those with other coexisting etiologies of inflammatory arthritis, osteoarthritis, and gout were excluded. All patients were evaluated using a specifically designed case record form which comprised various demographic and clinical variables and assessment scales [Supplementary 1]. Disease activity was assessed using tender joint count (TJC-68), swollen joint count (SJC-66), Physician global assessments (PhyGA), psoriatic area and severity index (PASI), disease activity in PsA (DAPSA), Leeds Enthesitis Index and dactylitis (past/present/absent, tender/nontender, and count) and Patient global (PtGA). Erythema, scaling, and induration in different regions of the body are considered for scoring PASI. A score of 0–5 is considered as mild skin involvement, while >10 as severe skin disease. Composite disease activity scores for PsA done by DAPSA include the sum of TJC, SJC, PtGA, PhyGA, and C-reactive protein (CRP) (mg/dl). A DAPSA score of 0–4 is considered as remission, 5–14 low, 14–28 moderate, and >28 as high disease activity. Minimal disease activity (MDA) was considered when five of the six criteria are met PtGA ≤20, Pt pain visual analog scale ≤15 health assessment questionnaire disability index ≤ 0.5, TJC ≤1, SJC ≤1, PASI or body surface area ≤ 1 or ≤3 respectively and LEI ≤1. All the participating rheumatologists underwent training and harmonization sessions before the data collection to score PASI and other relevant PsA parameters. Written consent was obtained from all participating subjects and respective institutional ethical clearances were obtained before the recruitment of patients in this study.
Continuous variables are expressed as mean standard deviation and median interquartile range for normal and nonGaussian variables, respectively. Categorical variables are depicted as percentages. Means between two groups are compared using independent Student's t-test for normally distributed variables and Mann–Whitney U test for nongaussian variables. Fisher's exact test was used to show the association between categorical variables. Univariate and multivariate analyses were used to find association between disease variables. Pearson's correlation was used to correlate normally distributed comparable variables while Spearman's rank test was used for nonGaussian variables. P < 0.05 was considered significant. All calculations were done using GraphPad prism for windows 10 software.
| Results|| |
A total of 549 patients were recruited; the mean age of the cohort was 39.1 (±14) years. Almost a quarter of patients (n = 133, 26.6%) had onset of the disease in their fourth decade. PsO preceded PsA in 351 (63.9%), while simultaneous onset was noted in. 117 (21.5%). Type II PsO (onset after the age of 40 years) was seen in 279 (55.8%). Demographic details and disease characteristics are presented in [Table 1].
Scalp was the most frequent 345 (62.9%) initial site of involvement as well as the most predominantly involved site (210, 49.2%). Plaque type PsO was seen in majority (330, 78.1%) followed by palmoplantar PsO (37, 8.7%). A family history of PsO was present in 107 (19.7%); while that of PsA was in 33 (6%). Stress was reported as an exacerbating factor by 33.8%, while 322 (65.1%) reported seasonal exacerbation, largely in winters 287 (89.1%). The median PASI of the KPsAC was 1 (0, 3.9); majority had a mild skin involvement 480 (80%); moderate PASI was seen in 50 (9.3%) while severe skin involvement (PASI >10) was observed in 57 (10.6%). PASI was not significantly different among the different subgroups of PsA.
Patients who had multiple skin sites involvement at the onset (n = 264) had higher PASI (2 [0.35, 6.50], 0.60 [0, 2.07] P < 0.0001) and DAPSA (21.2 [17.1], 16.8 [15.8] P = 0.003) compared to those with single skin site (n = 264) involvement.
Patients with plaque psoriasis (PP) were younger and had high DAPSA than those with erythrodermic psoriasis (EP) [Table 2]. Patients with EP had a longer duration of skin disease, higher PASI, and lower DAPSA compared to PP.
Patients with type 1 PsO had scalp involvement predominantly (P = 0.007), more frequent plaque PsO (P = 0.001) and more frequent enthesitis (P = 0.02) than those with type 2 PsO. No differences in PASI, DAPSA, achievement of MDA-5, CRP, and erythrocyte sedimentation rate (ESR) were noted in both the groups.
Joint disease psoriatic arthritis
SP was the most common 216 (40.7%) PsA subtype followed closely by AO 202 (38.1%). Demographics and disease activity measures of different PsA subtypes are compared in [Table 2]. Mean DAPSA of the cohort was 18.8 (16.6); 137 (27.2%) had moderate,,,,,,,,,,,,,, and 123 (24.5%) had high disease activity (>28). There was no correlation between skin (PASI) and joint disease (DAPSA) in our cohort. Those with axial involvement (clinical ± radiological) were younger than those without axial involvement. Furthermore, a higher proportion of them had joint involvement preceding skin involvement (25/96, 50/338, P = 0.002).
Dactylitis was noted by 182 (33.9%) patients at any time during the disease course. Active (tender) dactylitis was seen in 43 and chronic dactylitis in 46. Those with dactylitis (active and chronic) had higher joint activity, and fewer achieved MDA-5 (P = 0.02).
The mean ESR and CRP of the cohort were 34.7 (±26.4) mm/h and 1.6 (±2.4) mg/dl, respectively. Both ESR and CRP did not correlate with swollen and TJCs. Except for high ESR in women (P < 0.00001), there were no differences in disease variables of PsO or PsA among men and women.
When we divided patients into those with high DAPSA (>28) (123) and all others (380), it was noted that those with higher DAPSA were older (40.8 [12.8] vs. 37.5 [13.7], P = 0.02), had a shorter duration of PsO (87.8 (74.5) vs. 109.9 (95.4), P = 0.02) and higher PASI scores (7.6 [10.5] vs. 2.5 [5.4], P = 0.0001).
| Discussion|| |
This study has evaluated PsA and its clinical correlates in a multicentric large South Indian population referred to the rheumatologists. PsO started at a later age in our study compared to previously reported Chinese, German, and Israeli cohorts [Table 3].,,, The possible explanation for this could be due to increased sun exposure in this geographical area which could have delayed the onset of PsO. In about 15% of patients, arthritis preceded the onset of skin disease making the diagnosis of joint disease challenging in these patients. These numbers are in concurrence with the previous studies across different ethnic cohorts.
Polyarthritis was the most common presentation in our cohort closely followed by oligoarticular distribution. This finding has been concurrently reported from previous Indian, east Asian,, and European, cohorts. However, this contrasts with other Asian studies reported from China and Korea which found the oligoarticular presentation to be more common. This finding also contrasts from Western studies from the USA and Scandinavia.,, This difference reinforces that patterns of PsA differ across different ethnic groups. Furthemore, another important factor of note which has also been reported in previous studies, is that PsA evolves and changes the pattern over time which could be the reason for the difference in most common PsA patterns observed and reported across the world. AM was seen in nearly 10% of our cohort which is high compared to all the previously reported cohorts including another two Indian cohorts reported in 2003 and 2014., The possible reason for this could be because of a referral bias; those with severe joint involvement being referred to the rheumatologist. Another implication of reporting this finding is a much-needed heightened awareness about recognizing PsA early and treating aggressively to prevent this disabling complication. Nail involvement and PASI in our study were lowest compared to the other previously described cohorts.,,, One explanation could be an urge to seek early care for skin involvement by patients but not so for nail disease.
Patterns of PsA reported in various cohorts must be compared with a note that the definitions of the subgroups across studies vary;,,, for instance, axial SpA and axial plus peripheral SpA are collectively reported as SpA, DIP arthritis is considered in predominant DIP arthritis as well as into other phenotypes like SP. Concurrent with previous studies we found that those with axial involvement were younger and were likely to have arthritis earlier than skin disease.,, This reinstates the concept that axial disease with or without peripheral arthritis is a distinct category of PsA. This finding also should prompt rheumatologists seeing patients with axial involvement to screen hidden skin sites for PsO. In addition, we also found that those with AM were younger and had a longer duration of PsA. Similar findings have been reported in two previous studies from the United Kingdom.,
Dactylitis has been found in 35% of our cohort. Variable numbers have been reported in previous studies ranging up to 50%.,,,, Furthermore, we found that those with dactylitis had a higher joint activity which concurs with Brockbank et al. who reported a higher joint burden in patients with dactylitis.
Skin and joint disease activities (PASI and DAPSA) did not go hand in hand in our study. This has been consistently reported in previous studies.,,
More than 50% of our cohort had moderate-to-high joint disease activity as measured by DAPSA. The design of the present study is likely to have selected patients with a more severe joint disease as they were more likely to get referred to a rheumatologist. Appani et al. reported that 78% of the PsA patients had a moderate to high cDAPSA at the presentation from another south Indian PsA cohort. These findings are also concurrent with another cross-sectional study by rheumatologists from Brazil of 160 patients, 56% of whom had moderate to high DAPSA. Different groups across the world have measured psoriatic joint disease activity using various individual and composite disease activity measures. Most commonly measured activity was using swollen joint and TJCs which have been variable across different cohorts. We found that those with higher DAPSA were likely to be older, have shorter duration of arthritis and have high skin scores.
Patients affected by PsO of multiple skin sites at the onset were likely to have a higher skin (PASI) and joint disease burden (higher DAPSA). This emphasizes the need for multidisciplinary assessment of such patients with the involvement of rheumatologists in the evaluation as axial involvement and oligoarthritis may get overshadowed by the extensive skin involvement and likely to remain untreated if not identified.
Determination of Inflammatory markers in PsA is frequently disappointing as they are elevated only in 50% of patients.,, In our study also we did not find a correlation between inflammatory markers and swollen/ tender joints indicating a mismatch between these.,, It has been determined in the previous studies that ESR and CRP do not go hand in hand with the inflammatory musculoskeletal symptoms which are one important cause for a delayed diagnosis of the disease.
The strengths of our study are a large sample size, multi-centric design, and use of validated outcome measures for disease assessment. The limitations of our study would be referral bias; mild PsA may not be referred to rheumatologists. PASI was done by rheumatologists and not by dermatologists would be another limitation although all the participating rheumatologists underwent dedicated training to do PASI.
| Conclusion|| |
Patterns of joint involvement vary in different populations. Polyarthritis appears as the most frequent type of PsA and is associated with a higher disease burden and poorer outcomes. Axial disease stands out as a distinct category of PsA affecting younger patients and can occur earlier than skin disease. Although skin disease was mild, moderate-to-severe joint activity was noted in majority. There is a mismatch between inflammatory markers and joint activity. We re-emphasize the need for multidisciplinary care in the management of the psoriatic disease.
We thank Dr. Ashish Jacob Mathew, Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, Tamil Nadu, India, conducting training program for outcome measures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]