java library barcode reader Clinical Findings in Objective-C

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Clinical Findings
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A Symptoms and Signs
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Although psoriasis usually precedes the onset of arthritis, arthritis precedes or occurs simultaneously with the skin disease in approximately 20% of cases Arthritis is at least five times more common in patients with severe skin disease than in those with only mild skin findings Occasionally, however, patients may have a single patch of psoriasis (typically hidden in the scalp, gluteal cleft, or umbilicus) and are unaware of its connection to the arthritis Thus, a detailed search for cutaneous lesions is essential in patients with arthritis of new onset Also, the psoriatic lesions may have cleared when arthritis appears in such cases, the history is most useful in diagnosing previously unexplained cases of mono- or oligoarthritis Nail pitting, a residue of previous psoriasis, is sometimes the only clue Sausage swelling of one or more digits is a common manifestation of enthesopathy in psoriatic arthritis
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B Laboratory Findings
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PSORIATIC ARTHRITIS
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ESSENTIALS OF DIAGNOSIS
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Psoriasis precedes onset of arthritis in 80% of cases Arthritis usually asymmetric, with sausage appearance of fingers and toes; resembles rheumatoid arthritis; rheumatoid factor is negative Sacroiliac joint involvement common; ankylosis of the sacroiliac joints may occur Radiographic findings: osteolysis; pencil-in-cup deformity; relative lack of osteoporosis; bony ankylosis; asymmetric sacroiliitis and atypical syndesmophytes
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Laboratory studies show an elevation of the ESR, but rheumatoid factor is not present Uric acid levels may be high, reflecting the active turnover of skin affected by psoriasis There is a correlation between the extent of psoriatic involvement and the level of uric acid, but gout is no more common than in patients without psoriasis Desquamation of the skin may also reduce iron stores
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Radiographic findings are most helpful in distinguishing the disease from other forms of arthritis There are marginal erosions of bone and irregular destruction of joint and bone, which, in the phalanx, may give the appearance of a sharpened pencil Fluffy periosteal new bone may be marked, especially at the insertion of muscles and ligaments into bone Such changes will also be seen along the shafts of metacarpals, metatarsals, and phalanges Paravertebral ossification occurs, which may be distinguished from ankylosing spondylitis by the absence of ossification in the anterior aspect of the spine
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General Considerations
In 15 20% of patients with psoriasis, arthritis coexists The patterns or subsets of arthritis that may accompany psoriasis include the following: 1 Joint disease that resembles rheumatoid arthritis in which polyarthritis is symmetric Usually, fewer joints are involved than in rheumatoid arthritis 2 An oligoarticular form that may lead to considerable destruction of the affected joints 3 A pattern of disease in which the DIP joints are primarily affected Early, this may be monarticular,
Treatment
Treatment regimens are symptomatic NSAIDs are usually sufficient for mild cases Corticosteroids are less effective in psoriatic arthritis than in other forms of inflammatory arthritis In addition, they may exacerbate the skin disease during tapers Antimalarials may also exacerbate psoriasis Methotrexate (75 15 mg orally per week) is generally considered the drug of choice for patients who have not responded to NSAIDs, since methotrexate can improve both the cutaneous and arthritic
Arthritis & Musculoskeletal Disorders
manifestations For cases with disease that is refractory to methotrexate, etanercept or infliximab is usually effective for both arthritis and psoriatic skin disease Successful treatment of the skin lesions (eg, by PUVA therapy) commonly though not invariably is accompanied by an improvement in peripheral articular symptoms Both the cutaneous and the articular findings associated with psoriasis respond dramatically in most cases to TNF inhibitors Alefacept, a biologic agent that is administered by subcutaneous injection, blocks the activation and proliferation of memory effector T cells by binding to CD2 This drug is a promising new treatment for psoriatic arthritis as well as cutaneous disease
Antoni CE et al Sustained benefits of infliximab therapy for dermatologic and articular manifestations of psoriatic arthritis: results from the infliximab multinational psoriatic arthritis controlled trial (IMPACT) Arthritis Rheum 2005 Apr;52 (4):1227 36 [PMID: 15818699] Gottlieb AB Alefacept for psoriasis and psoriatic arthritis Ann Rheum Dis 2005 Nov;64 Suppl 4:iv58 60 [PMID: 16239390]
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