Table Of Content

Kenneth B.Gordon Eric M.Ruderman Editors Psoriasis and Psoriatic Arthritis An IntegratedApproach Kenneth B.Gordon Eric M.Ruderman Editors Psoriasis and Psoriatic Arthritis An Integrated Approach With 47 Figures and 36 Tables Kenneth B.Gordon,MD Division of Dermatology Loyola University Stritch School of Medicine 2160 S.First Ave.,Building 112,Room 342 Maywood,IL 60153 USA Eric M.Ruderman,MD Division of Rheumatology Northwestern University Feinberg Schoolof Medicine 675 N.St.Clair St. Chicago,IL 60611 USA Library of Congress Control Number:2004113294 ISBN 3-540-21280-9 Springer Berlin Heidelberg New York This work is subject to copyright.All rights are reserved,whether the whole or part of the material is concerned,specifically the rights of translation,reprinting,reuse of illustrations,recitation,broadcast- ing,reproduction on microfilm or in any other way,and storage in data banks.Duplication of this pub- lication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9,1965,in its current version,and permission for use must always be obtained from Springer.Violations are liable to prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media springeronline.com © Springer-Verlag Berlin Heidelberg 2005 Printed in Germany The use of general descriptive names,registered names,trademarks,etc.in this publication does not imply,even in the absence of a specific statement,that such names are exempt from the relevant pro- tective laws and regulations and therefore free for general use. Product liability:the publishers cannot guarantee the accuracy of any information about dosage and application contained in this book.In every individual case the user must check such information by consulting the relevant literature. Editor:Marion Philipp Desk Editor:Irmela Bohn Production:ProEdit GmbH,69126 Heidelberg,Germany Cover:Frido Steinen-Broo,EStudio Calamar,Spain Typesetting:K.Detzner,67346 Speyer,Germany Printed on acid-free paper 21/3150ML 5 4 3 2 1 0 Preface Dermatologists and rheumatologists alike are confronted with patients suffering from both psoriasis and psoriatic arthritis,and are often asked to address the dis- ease with which they are least familiar.In our experience,proper care ofeither ail- ment requires a working knowledge ofboth.Working together to manage these pa- tients,we have found that the most effective treatments must account for all mani- festations ofdisease,whether skin or joint,and that this approach is the best way to ensure satisfied patients with the most unrestricted quality oflife. Our goal with this book is to bring current information about psoriasis and psor- iatic arthritis together in a form that is useful for a satisfactory understanding ofthe pathophysiology,clinical aspects,and therapy ofboth diseases.Ideally,the integrat- ed approach ofthis text will give specialists the necessary tools to work together ef- fectively in the same office or in consultation.While this type of coordinated care strikes us as the best approach,we recognize that all dermatologists and rheumatol- ogists will not have this luxury,and we hope this book will also serve as a useful re- view ofthose disease elements both within and outside the reader's own area ofex- pertise. This book is dedicated to our families: Dafna, Danny, and Jake Gordon, and Stacey Empson and Lucy Ruderman.We thank them for their patience in helping us through this endeavor. Kenneth B.Gordon,MD Eric M.Ruderman,MD December 2004 Contents I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Kenneth B.Gordon,Eric M.Ruderman II Genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Mahreen Ameen,Jonathan N.W.N.Barker B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 ProtonRahman,Dafna D.Gladman III Immunopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Brian K.Bonish,Brian J.Nickoloff B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Jennifer Barton,Christopher T.Ritchlin IV Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Christine C.Jacobson,Alexa B.Kimball B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Dafna D.Gladman V Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Jennifer Soung,Mark Lebwohl B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Philip S.Helliwell VIII Contents VI Diagnostic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Bettina M.Prinz Vavricka,Joan Guitart B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Soumya M.Reddy,Clifton O.Bingham III VII Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Steven R.Feldman,Stephen R.Rapp B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Dafna D.Gladman VIII Clinical Outcome Measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Kenneth B.Gordon B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Soumya M.Reddy,Clifton O.Bingham III IX Conventional Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 1. Topical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Rachel Quinby 2. Phototherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Jennifer Dempsey,Michael Zanolli 3. Systemic Retinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Milan J.Anadkat,Michael P.Heffernan 4. Methotrexate and Cyclosporine . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Jennifer C.Cather,Alan Menter B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Christopher G.Jackson,Daniel O.Clegg Contents IX X Biologic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 1. Anti-T-Cell Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Richard G.B.Langley,Christa L.Doherty,Scott J.Murray 2. TNF Antagonist Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Bruce E.Strober . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 1. TNFαInhibitors in Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . 223 Philip J.Mease 2. Other Biologic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Ja Huen Jung,Zuhre Tutuncu,Arthur F.Kavanaugh XI Synthesis and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Kenneth B.Gordon,Eric M.Ruderman Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 List of Contributors Mahreen Ameen Jennifer C.Cather,MD St.Johns Institute ofDermatology University ofTexas Southwestern Medical St.Thomas’Hospital School Dallas London Dallas,TX UK USA Milan J.Anadkat,MD Daniel O.Clegg,MD Division ofDermatology Division ofRheumatology Washington University School ofMedicine University ofUtah Medical Center St.Louis,MO Salt Lake City,UT USA USA Jonathan N.W.N.Barker,MD Jennifer Dempsey,MD St.Johns Institute ofDermatology Vanderbilt University Medical School St.Thomas' Hospital Dermatology Consultants London Nashville,TN UK USA Jennifer Barton,MD Christa L.Doherty,BSc (Hons) University ofRochester Medical Center QEII Health Sciences Centre Rochester,NY Halifax,Nova Scotia USA Canada Clifton O.Bingham,MD Steven R.Feldman,MD,PhD Johns Hopkins University WakeForest University School ofMedicine Baltimore,MD Medical Center Boulevard USA Winston-Salem,NC USA Brian K.Bonish,MD Loyola University ofChicago Dafna D.Gladman,MD FRCPC Medical Center Center for Prognosis Studies Skin Disease Research Laboratory Toronto Hospital Western Division Cardinal Bernardin Cancer Center Toronto,ON Maywood,IL Canada USA XII List of Contributors Kenneth B.Gordon,MD Alexa Kimball,MD,MPH Division ofDermatology Dermatology Clinical Studies Unit Loyola University Massachusetts General and Brigham Stritch School ofMedicine and Women’s Hospitals Maywood,IL Boston,MA USA USA Joan Guitart,MD Richard G.B.Langley,MD,FRCPC NorthwesternUniversity QEII Health Sciences Centre Department ofDermatology Halifax,Nova Scotia Chicago,IL Canada USA Mark Lebwohl,MD,FACP Michael P.Heffernan,MD Department ofDermatology Division ofDermatology The Mt.Sinai Medical Center Washington University School ofMedicine New York,NY St.Louis,MO USA USA Philip J.Mease,MD Philip Helliwell,MD Seattle Rheumatology Associates Academic Unit ofMusculoskeletal Disease University ofWashington University ofLeeds Seattle,WA Leeds USA UK M.Alan Menter Christopher Jackson,MD Division ofDermatology Division ofRheumatology Baylor University Medical Center University ofUtah Medical Center University ofTexas Southwestern Medical Salt Lake City,UT School Dallas USA Dallas,TX USA Christine C.Jacobson,AB Department ofDermatology Scott J.Murray,MD,FRCPC Stanford University School ofMedicine QEII Health Sciences Centre Stanford,CA Halifax,Nova Scotia USA Canada Ja Huen Jung,MD Brian J.Nickoloff,MD,PhD UCSD Loyola University Medical Center Rheumatology Division Maywood,IL Department ofMedicine USA La Jolla,CA USA Bettina M.Prinz Vavricka,MD Department ofDermatology Arthur F.Kavanaugh,MD University Hospital Zurich UCSD Zurich Rheumatology Division Switzerland Department ofMedicine La Jolla,CA USA

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In the past decade it has become increasingly clear that psoriatic disease, both of the skin and joints, can be a significant diagnostic and therapeutic challenge for the physician and a debilitating illness for the patient. At the same time, advances in genetics and immunology have increased our un
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Kenneth B.Gordon Eric M.Ruderman Editors Psoriasis and Psoriatic Arthritis An IntegratedApproach Kenneth B.Gordon Eric M.Ruderman Editors Psoriasis and Psoriatic Arthritis An Integrated Approach With 47 Figures and 36 Tables Kenneth B.Gordon,MD Division of Dermatology Loyola University Stritch School of Medicine 2160 S.First Ave.,Building 112,Room 342 Maywood,IL 60153 USA Eric M.Ruderman,MD Division of Rheumatology Northwestern University Feinberg Schoolof Medicine 675 N.St.Clair St. Chicago,IL 60611 USA Library of Congress Control Number:2004113294 ISBN 3-540-21280-9 Springer Berlin Heidelberg New York This work is subject to copyright.All rights are reserved,whether the whole or part of the material is concerned,specifically the rights of translation,reprinting,reuse of illustrations,recitation,broadcast- ing,reproduction on microfilm or in any other way,and storage in data banks.Duplication of this pub- lication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9,1965,in its current version,and permission for use must always be obtained from Springer.Violations are liable to prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media springeronline.com © Springer-Verlag Berlin Heidelberg 2005 Printed in Germany The use of general descriptive names,registered names,trademarks,etc.in this publication does not imply,even in the absence of a specific statement,that such names are exempt from the relevant pro- tective laws and regulations and therefore free for general use. Product liability:the publishers cannot guarantee the accuracy of any information about dosage and application contained in this book.In every individual case the user must check such information by consulting the relevant literature. Editor:Marion Philipp Desk Editor:Irmela Bohn Production:ProEdit GmbH,69126 Heidelberg,Germany Cover:Frido Steinen-Broo,EStudio Calamar,Spain Typesetting:K.Detzner,67346 Speyer,Germany Printed on acid-free paper 21/3150ML 5 4 3 2 1 0 Preface Dermatologists and rheumatologists alike are confronted with patients suffering from both psoriasis and psoriatic arthritis,and are often asked to address the dis- ease with which they are least familiar.In our experience,proper care ofeither ail- ment requires a working knowledge ofboth.Working together to manage these pa- tients,we have found that the most effective treatments must account for all mani- festations ofdisease,whether skin or joint,and that this approach is the best way to ensure satisfied patients with the most unrestricted quality oflife. Our goal with this book is to bring current information about psoriasis and psor- iatic arthritis together in a form that is useful for a satisfactory understanding ofthe pathophysiology,clinical aspects,and therapy ofboth diseases.Ideally,the integrat- ed approach ofthis text will give specialists the necessary tools to work together ef- fectively in the same office or in consultation.While this type of coordinated care strikes us as the best approach,we recognize that all dermatologists and rheumatol- ogists will not have this luxury,and we hope this book will also serve as a useful re- view ofthose disease elements both within and outside the reader's own area ofex- pertise. This book is dedicated to our families: Dafna, Danny, and Jake Gordon, and Stacey Empson and Lucy Ruderman.We thank them for their patience in helping us through this endeavor. Kenneth B.Gordon,MD Eric M.Ruderman,MD December 2004 Contents I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Kenneth B.Gordon,Eric M.Ruderman II Genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Mahreen Ameen,Jonathan N.W.N.Barker B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 ProtonRahman,Dafna D.Gladman III Immunopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Brian K.Bonish,Brian J.Nickoloff B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Jennifer Barton,Christopher T.Ritchlin IV Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Christine C.Jacobson,Alexa B.Kimball B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Dafna D.Gladman V Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Jennifer Soung,Mark Lebwohl B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Philip S.Helliwell VIII Contents VI Diagnostic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Bettina M.Prinz Vavricka,Joan Guitart B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Soumya M.Reddy,Clifton O.Bingham III VII Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Steven R.Feldman,Stephen R.Rapp B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Dafna D.Gladman VIII Clinical Outcome Measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Kenneth B.Gordon B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Soumya M.Reddy,Clifton O.Bingham III IX Conventional Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 1. Topical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Rachel Quinby 2. Phototherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Jennifer Dempsey,Michael Zanolli 3. Systemic Retinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Milan J.Anadkat,Michael P.Heffernan 4. Methotrexate and Cyclosporine . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Jennifer C.Cather,Alan Menter B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Christopher G.Jackson,Daniel O.Clegg Contents IX X Biologic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 A. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 1. Anti-T-Cell Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Richard G.B.Langley,Christa L.Doherty,Scott J.Murray 2. TNF Antagonist Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Bruce E.Strober . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 1. TNFαInhibitors in Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . 223 Philip J.Mease 2. Other Biologic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Ja Huen Jung,Zuhre Tutuncu,Arthur F.Kavanaugh XI Synthesis and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Kenneth B.Gordon,Eric M.Ruderman Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 List of Contributors Mahreen Ameen Jennifer C.Cather,MD St.Johns Institute ofDermatology University ofTexas Southwestern Medical St.Thomas’Hospital School Dallas London Dallas,TX UK USA Milan J.Anadkat,MD Daniel O.Clegg,MD Division ofDermatology Division ofRheumatology Washington University School ofMedicine University ofUtah Medical Center St.Louis,MO Salt Lake City,UT USA USA Jonathan N.W.N.Barker,MD Jennifer Dempsey,MD St.Johns Institute ofDermatology Vanderbilt University Medical School St.Thomas' Hospital Dermatology Consultants London Nashville,TN UK USA Jennifer Barton,MD Christa L.Doherty,BSc (Hons) University ofRochester Medical Center QEII Health Sciences Centre Rochester,NY Halifax,Nova Scotia USA Canada Clifton O.Bingham,MD Steven R.Feldman,MD,PhD Johns Hopkins University WakeForest University School ofMedicine Baltimore,MD Medical Center Boulevard USA Winston-Salem,NC USA Brian K.Bonish,MD Loyola University ofChicago Dafna D.Gladman,MD FRCPC Medical Center Center for Prognosis Studies Skin Disease Research Laboratory Toronto Hospital Western Division Cardinal Bernardin Cancer Center Toronto,ON Maywood,IL Canada USA XII List of Contributors Kenneth B.Gordon,MD Alexa Kimball,MD,MPH Division ofDermatology Dermatology Clinical Studies Unit Loyola University Massachusetts General and Brigham Stritch School ofMedicine and Women’s Hospitals Maywood,IL Boston,MA USA USA Joan Guitart,MD Richard G.B.Langley,MD,FRCPC NorthwesternUniversity QEII Health Sciences Centre Department ofDermatology Halifax,Nova Scotia Chicago,IL Canada USA Mark Lebwohl,MD,FACP Michael P.Heffernan,MD Department ofDermatology Division ofDermatology The Mt.Sinai Medical Center Washington University School ofMedicine New York,NY St.Louis,MO USA USA Philip J.Mease,MD Philip Helliwell,MD Seattle Rheumatology Associates Academic Unit ofMusculoskeletal Disease University ofWashington University ofLeeds Seattle,WA Leeds USA UK M.Alan Menter Christopher Jackson,MD Division ofDermatology Division ofRheumatology Baylor University Medical Center University ofUtah Medical Center University ofTexas Southwestern Medical Salt Lake City,UT School Dallas USA Dallas,TX USA Christine C.Jacobson,AB Department ofDermatology Scott J.Murray,MD,FRCPC Stanford University School ofMedicine QEII Health Sciences Centre Stanford,CA Halifax,Nova Scotia USA Canada Ja Huen Jung,MD Brian J.Nickoloff,MD,PhD UCSD Loyola University Medical Center Rheumatology Division Maywood,IL Department ofMedicine USA La Jolla,CA USA Bettina M.Prinz Vavricka,MD Department ofDermatology Arthur F.Kavanaugh,MD University Hospital Zurich UCSD Zurich Rheumatology Division Switzerland Department ofMedicine La Jolla,CA USA

Description:
In the past decade it has become increasingly clear that psoriatic disease, both of the skin and joints, can be a significant diagnostic and therapeutic challenge for the physician and a debilitating illness for the patient. At the same time, advances in genetics and immunology have increased our un
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