1600 John F. Kennedy Blvd. Suite 1800 Philadelphia, PA 19103-2899 PSORIATIC AND REACTIVE ARTHRITIS ISBN-13: 978-0-323-03622-1 A COMPANION TO RHEUMATOLOGY ISBN-10: 0-323-03622-8 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.No part of this publication may be reproduced or transmitted in any form or by any means,electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: [email protected]. You may alsocomplete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions.’ Notice Knowledge and best practice in this field are constantly changing. 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Library of Congress Cataloging-in-Publication Data Psoriatic and reactive arthritis: a companion to rheumatology / [edited by] Christopher T. Ritchlin, Oliver FitzGerald.–1st ed. p.; cm. Includes bibliographical references and index. ISBN 0-323-03622-8 1. Psoriatic arthritis. 2. Infectious arthritis. I. Ritchlin, Christopher T. II. FitzGerald, Oliver. [DNLM: 1. Arthritis, Psoriatic. 2. Arthritis, Reactive. WE 344 P9734 2007] RC931.P76P75 2007 616.7’227–dc22 2006050135 Acquisitions Editor: Kimberly Murphy Publishing Services Manager: Frank Polizzano Project Manager: Lee Ann Draud Design Direction: Steve Stave Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 To our patients and mentors Contributors Firas Alkassab, MD Stephanie Diamantis, MD Clinical Fellow, Division of Rheumatology and Fellow, Mount Sinai School of Medicine, New York, Clinical Immunogenetics, University of Texas New York Health Science Center at Houston, Houston, Texas Dermatologic Management of Psoriasis Spectrum of Reactive Arthritis James T. Elder, MD, PhD Dominique Baeten, MD, PhD Professor, Department of Dermatology, University of Associate Professor of Clinical Immunology and Michigan Medical School; Physician, University of Rheumatology, Academic Medical Center, Michigan Health System and Ann Arbor Veterans University of Amsterdam, Amsterdam, The Netherlands Administration, Ann Arbor, Michigan Synovial Immunopathology in Spondyloarthropathy Psoriasis: Etiopathogenesis Juergen Braun, MD Luis R. Espinoza, MD Professor, Ruhr University, Bochum; Medical Professor and Chief, Section of Rheumatology, Director, Rheumazentrum Ruhrgebiet, Herne, Department of Internal Medicine, Louisiana State Germany University Health Sciences Center, New Orleans, Imaging in Reactive Arthritis Louisiana Historical Aspects of the Disease Antoni Chan, MB ChB, MRCP ARC Clinical Research Fellow, Nuffield Orthopaedic Ursula Fearon, PhD Centre and MRC Human Immunology Unit, Newman Fellow, University College Dublin; Senior Weatherall Institute of Molecular Medicine, John Scientist, St. Vincent’s University Hospital, Dublin, Radcliffe Hospital, Oxford, United Kingdom Ireland Genetics of Reactive Arthritis Angiogenesis in Psoriasis and Psoriatic Arthritis Daniel O. Clegg, MD Oliver FitzGerald, MD, FRCP Professor of Medicine; Chief, Division of Consultant Rheumatologist and Newman Clinical Rheumatology; and Harold J., Ardella T., and Helen T. Research Professor, St. Vincent’s Hospital and Stevenson Presidential Chair in Rheumatology, Conway Institute, University College Dublin, University of Utah School of Medicine; Chief, Dublin, Ireland Rheumatology Section, Salt Lake City Veterans Affairs Pathogenesis of Psoriatic Arthritis Medical Center, Salt Lake City, Utah Management of Reactive Arthritis Tracy M. Frech, MD Rheumatology Fellow, University of Utah School Filip De Keyser, MD, PhD of Medicine, Salt Lake City, Utah Professor of Rheumatology, Department of Management of Reactive Arthritis Rheumatology, University Hospital Ghent, Ghent, Belgium Enteric Infections and Arthritis; Natural History, Prognosis, Socioeconomic Aspects, and Quality vii of Life C Dafna D. Gladman, MD, FRCPC Gabrielle H. Kingsley, MB ChB, PhD, FRCP O N Professor of Medicine, University of Toronto Faculty Reader in Rheumatology, King’s College London; T RIB of Medicine; Senior Scientist, Division of Outcomes Consultant Rheumatologist, University Hospital U and Population Health, Toronto Western Research Lewisham, London, United Kingdom T O R Institute, Toronto Western Hospital, Toronto, Historical Aspects of Reactive Arthritis S Ontario, Canada Clinical Features of Psoriatic Arthritis Elli Kruithof, MD, PhD Physician, Department of Rheumatology, University Johann E. Gudjonsson, MD, PhD Hospital Ghent, Ghent, Belgium Resident/Research Fellow, Department of Synovial Immunopathology in Spondyloarthropathy Dermatology, University of Michigan Medical School; Resident, Department of Dermatology, University of Mark Lebwohl, MD Michigan Health System, Ann Arbor, Michigan Professor and Chairman, Department of Psoriasis: Etiopathogenesis Dermatology, Mount Sinai School of Medicine, New York, New York Shahir Hamdulay, BSc, MRCP Dermatologic Management of Psoriasis Specialist Registrar, Department of Rheumatology, Hammersmith Campus, Imperial College School of Marjatta Leirisalo-Repo, MD Medicine, London, United Kingdom Professor of Rheumatology, Department of Medicine, Outcomes in Reactive Arthritis Helsinki University Central Hospital, Kasarmikatu, Finland Philip S. Helliwell, MD, PhD Epidemiology of Reactive Arthritis Senior Lecturer in Rheumatology, University of Leeds, Leeds; Attending Physician, Bradford Teaching Dennis McGonagle, PhD, FRCPI Hospitals NHS Trust, Bradford, West Yorkshire, Academic Unit of Musculoskeletal Diseases, Chapel United Kingdom Allerton Hospital, University of Leeds, Leeds; Natural History, Prognosis, and Socioeconomic Aspects Consultant Rheumatologist, Calderdale Royal of Psoriatic Arthritis Hospital, Halifax, West Yorkshire, United Kingdom Imaging in Psoriatic Arthritis Robert D. Inman, MD Professor of Medicine and Immunology, University Neil McHugh, MB ChB, FRCP of Toronto Faculty of Medicine; Senior Scientist, Consultant Rheumatologist, Royal National Hospital Consultant, and Rheumatologist, Toronto Western for Rheumatic Diseases, Bath, United Kingdom Hospital, Toronto, Ontario, Canada Clinical Outcome Measures in Psoriatic Arthritis Chlamydia-Induced Arthritis Philip Mease, MD David John Kane, PhD, MB BCh, MRCPI Clinical Professor, University of Washington School Honorary Senior Lecturer, Newcastle University, of Medicine; Head, Seattle Rheumatology Associates; Northumbria Division, Newcastle upon Tyne, Chief, Rheumatology Clinical Research, Swedish England; Consultant Rheumatologist, Adelaide & Hospital Medical Center, Seattle, Washington Heath Hospital, Dublin, Ireland Management of Psoriatic Arthritis: Biologic Agents in Imaging in Psoriatic Arthritis Psoriatic Arthritis Arthur Kavanaugh, MD Herman Mielants, MD, PhD Division of Rheumatology, Allergy, and Immunology, Professor of Rheumatology, Ghent University; Head, University of California, San Diego, School of Department of Rheumatology, University Hospital Medicine, La Jolla, California Ghent, Ghent, Belgium Clinical Outcome Measures in Psoriatic Arthritis Enteric Infections and Arthritis Andrew Keat, MD, FRCP Peter Nash, MD Consultant Physician and Rheumatologist, Northwick Director, Rheumatology Research Unit, Department Park Hospital, Harrow, Middlesex, United Kingdom of Medicine, University of Queensland, Queensland, Outcomes in Reactive Arthritis Australia viii Management of Psoriatic Arthritis: Traditional Disease- Modifying Antirheumatic Drug Therapies for Psoriatic Arthritis Finbar D. O’Shea, MB, MRCPI Ai Lyn Tan, MRCP C o Research Fellow, Spondylitis Clinic, Toronto Western Specialist Registrar in Rheumatology, Academic Unit n Hospital, Toronto, Ontario, Canada of Musculoskeletal Disease, Chapel Allerton Hospital, trib u Chlamydia-Induced Arthritis Leeds, United Kingdom to Imaging in Psoriatic Arthritis rs Proton Rahman, MD, MSc, FRCPC Professor of Medicine, Memorial University of William J.Taylor, MB ChB, FRACP, FAFRM Newfoundland Faculty of Medicine; Staff Senior Lecturer, Department of Medicine, Wellington Rheumatologist, St. Clare’s Mercy Hospital, School of Medicine and Health Sciences, University of St. John’s, Newfoundland, Canada Otago; Consultant Rheumatologist, Hutt Valley Epidemiology of Psoriatic Arthritis District Health Board, Wellington, New Zealand Diagnostic Criteria of Psoriatic Arthritis John D. Reveille, MD Director, Division of Rheumatology, University of Auli Toivanen, MD Texas Health Science Center at Houston, Houston, Professor of Medicine Emerita, Turku University, Texas Turku, Finland Spectrum of Reactive Arthritis Clinical Picture and Diagnostic Criteria of Reactive Arthritis Christopher T. Ritchlin, MD Associate Professor of Medicine, University of Bert Vander Cruyssen, MD, PhD Rochester School of Medicine and Dentistry; Department of Rheumatology, University Hospital Director, Clinical Immunology Research Center, Ghent, Ghent, Belgium Allergy, Immunology, and Rheumatology Division, Natural History, Prognosis, Socioeconomic Aspects, and University of Rochester Medical Center, Rochester, Quality of Life New York Pathogenesis of Psoriatic Arthritis Douglas J.Veale, MD, FRCPI, FRCP (Lon) University College Dublin; Consultant, St. Vincent’s Eric Ruderman, MD University Hospital, Dublin, Ireland Associate Professor of Medicine, Division of Angiogenesis in Psoriasis and Psoriatic Arthritis Rheumatology, Northwestern University Feinberg School of Medicine; Attending Physician, Robert Winchester, MD Northwestern Memorial Hospital, Chicago, Illinois Professor of Medicine, Pediatrics, and Pathology, Natural History, Prognosis, and Socioeconomic Aspects Columbia University College of Physicians and of Psoriatic Arthritis Surgeons, New York, New York Genetics of Psoriatic Arthritis David L. Scott, MD, BSc, FRCP Professor of Clinical Rheumatology, King’s College Paul Wordsworth, PhD London and King’s College Hospital Trust, London, Professor of Clinical Rheumatology, University of United Kingdom Oxford; Honorary Consultant in Rheumatology, Historical Aspects of Reactive Arthritis Nuffield Orthopaedic Centre, Oxford, United Kingdom Joachim Sieper, MD Genetics of Reactive Arthritis Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany Pathogenesis of Reactive Arthritis ix Foreword Psoriatic and reactive arthritis, long-neglected though The section on reactive arthritis is similarly struc- valued siblings, have assumed their rightful places at tured. Scott and Kingsley discuss the historical aspects, the arthropathy family table. The chairs were shifted as while Leirisalo-Repo and Chan and Wordsworth the clinical criteria were affirmed, outcomes better describe the epidemiologic and genetic characteristics. appreciated, and pathophysiologic mechanisms more Insightful discussions of selected pathophysiologic clearly understood. This altered status is, in many mechanisms are provided by De Keyser and Mielants, ways, due to previous scientific contributions from the O’Shea and Inman, Kruithof and Baeten, and Sieper. esteemed authors of this excellent book. The spectrum of clinical features and diagnostic crite- There are two sections. In the section that addresses ria, natural history and prognosis, outcome measures, psoriatic arthritis, Espinoza outlines interesting and imaging modalities is elegantly outlined by historical misunderstandings, summarizes current Toivanen and Reveille and Alkassab, Vander Cruyssen thinking, and surmises on future directions. The and De Keyser, Keat and Hamdulay, and Braun, distinctive epidemiology and novel genetic associations respectively. Finally, Frech and Clegg summarize the are eloquently detailed by Rahman and Winchester, evidence for employing both traditional and novel respectively. Gudjonsson and Elder, Ritchlin and therapeutic approaches. FitzGerald, and Veale and Fearon each elucidate current As with other categories of inflammatory arthritis, knowledge of pivotal pathophysiologic mechanisms. there is still much to learn about psoriatic and reactive Gladman; Taylor; Helliwell and Ruderman; Kavanaugh arthritis, and further therapeutic advances are eagerly and McHugh; and Kane, Tan, and McGonagle sepa- awaited. This timely volume provides a comprehensive rately describe the clinical features, natural history and outline of our collected knowledge as it currently outcomes, diagnostic criteria, and emerging imaging stands in the early twenty-first century. modalities. Finally, Mease and Nash summarize therapeutic advances in the use of targeted therapies Barry Bresnihan, MD for arthritis, and Diamantis and Lebwohl outline a Dublin, Ireland systematic, evidence-based approach to the manage- ment of psoriasis of the skin. xi Preface It is instructive to note that less than 50 years have improved treatment for this disorder in the near passed since psoriatic and reactive arthritis were recog- future. nized as distinct forms of joint disease and not “atypi- The topics of psoriatic and reactive arthritis are usu- cal” variants of rheumatoid arthritis. Despite this ally covered in both medicine and rheumatology texts, recognition, both reactive arthritis, originally labeled but in-depth presentations have been precluded by Reiter’s syndrome, and psoriatic arthritis have lan- space considerations and a dearth of new information. guished in relative obscurity. Clinical studies of these The marked increase in new knowledge from both disorders were hampered by a striking heterogeneity in ascientific and clinical perspective, however, has kindled disease manifestations and course coupled with the great interest in these diseases. Thus, we thought it absence of a defining marker such as rheumatoid appropriate to provide an authoritative and compre- factor or HLA B27. Moreover, investigations of disease hensive volume to serve as a resource for health care mechanisms were relatively rare compared with the professionals and biomedical scientists. The material prodigious efforts made by those studying rheumatoid for this text has been provided by investigators and arthritis. clinicians from around the world in order to provide Over the past several years, significant advances have atruly global perspective. The style and format of the taken place in the classification and treatment of pso- book are the same as the user-friendly and easily acces- riatic arthritis. These advances are due in large part to sible parent textbook, Rheumatology. It is our sincere the development of effective biologic agents and hope and expectation that this resource will contribute improved clinical trial design and implementation. to improved care for patients and spark scientific In parallel, mechanistic investigations based on tissue investigators to focus attention on these two fascinating analysis, genetic studies, and novel imaging modalities inflammatory disorders. have provided new insights into disease pathogenesis. In reactive arthritis, the recognition of the role of the Christopher T. Ritchlin innate immune response combined with improved Oliver FitzGerald epidemiologic methods and pathogen detection holds great promise for increased understanding and xiii PSORIATIC ARTHRITIS 1 Epidemiology of Psoriatic Arthritis Proton Rahman HISTORICAL PERSPECTIVE dence of PsA. There is also a wide range in the reported prevalence and incidence rates of PsA related, in part, The first widely cited depiction of arthritis associated to the lack of a widely accepted classification or diag- with psoriasis was reported by Alibert in the early 1800s.1 nostic criteria. Until recently, there were seven classifi- Despite recognition of this association, there was a long- cation schemes proposed for PsA, six of which were standing impression that psoriatic arthritis (PsA) was a based on clinical experience.8 Historically, the most variant of rheumatoid arthritis (RA). It was not until the widely cited classification criteria were developed by emergence of epidemiologic studies that PsA surfaced as Wright and Moll.9 a unique disease entity separate from RA, and it was rec- ognized as a specific rheumatic entity by the American Prevalence Rheumatology Association in 1964.2 This, in part, was The reported prevalence of PsA varies from 0.056% to due to population studies demonstrating an increased 0.28%, and PsA affects men and women equally.10-13 frequency of inflammatory arthritis among patients with The most recent population-based study, by Gelfand psoriasis and an increased prevalence of arthritis among and colleagues, reported a PsA prevalence of 0.25% patients with psoriasis. The prevalence of psoriasis in (95% confidence interval [CI]: 0.18%, 0.31%).10This subjects with arthritis was found to be 2.6% to 7.0%, prevalence was estimated in a U.S. population by ran- whereas the prevalence of psoriasis in the general popu- domly interviewing 27,220 subjects.10 Cases were lation was estimated as 0.1% to 2.8%.3,4 On the other defined as patients who reported a physician diagno- hand, the prevalence of arthritis in subjects with psoria- sis of psoriasis and PsA. In this survey, 601 subjects sis varies from 7% to 25% and the prevalence of arthritis stated that they had psoriasis and 71 had PsA. The in the general population is estimated as 2% to 3%.3,4 prevalence of PsA in Gelfand’s study was substantially Historically, the rheumatoid factor further defined PsA, higher than that calculated using the Rochester as subjects with PsA tended to be seronegative. It is now Epidemiological Project computerized medical sys- apparent that 10% to 15% of patients with PsA are in fact tem. In the latter study, Shbeeb and associates seropositive for rheumatoid factors, albeit in a low titer.3 screened the records of all Olmsted County residents The entity of PsA is now well characterized and with a diagnosis consistent with psoriasis or PsA over encompasses unique clinical features including distinct a 10-year period.11 This screening identified 1844 patterns of peripheral joint involvement, periarticular patients with a diagnosis of psoriasis, of whom 1056 manifestations, and axial involvement.3 The delin- had the diagnosis of psoriasis confirmed by a derma- eation of PsA and RA is validated by responses to con- tologist. Among these individuals, 66 cases of PsA comitant human immunodeficiency virus infections, were identified, resulting in a prevalence of PsA of as symptoms of PsA worsen5and symptoms attributa- 0.1% (95% CI: 0.081% to 0.121%). ble to RA improve.6Furthermore, the genetic epidemi- Kay and coauthors carried out a similar study and ology of these two inflammatory arthropathies appear determined the prevalence of PsA in northeast to be distinct as noted by multiple disease-specific England by evaluating records from six general prac- associations within and more recently outside the tices.12One practice was used for the pilot study (5842 major histocompatibility complex region (e.g., associ- individuals) and five practices were used for the main ation of PTPN22and seropositive RA).7 study (29,348 individuals). A questionnaire, which was validated in the pilot study, was used to identify EPIDEMIOLOGY inflammatory arthritis in patients with psoriasis. Data determined from this evaluation showed that 81 of 772 There is a paucity of well-designed population-based psoriasis subjects had inflammatory arthritis, with a 1 studies that have estimated the prevalence and inci- crude prevalence of 0.28%. E In another population-based study, Alamanos and axial inflammatory symptoms. Two European studies P ID colleagues investigated the frequency and distribution that included assessments by dermatologists and E M of PsA in a defined area of northwest Greece with rheumatologists from outpatient clinics estimated a IO L a population of 500,000.13 All inpatient and outpa- prevalence of inflammatory arthritis of 30% and 31% O G tient PsA cases, diagnosed using the European in patients with psoriasis.16,17These estimates are simi- Y O Spondyloarthropathy Study Group criteria and lar to those reported in the mid-1980s by Scarpa and F P referred from rheumatology clinics in two hospitals, coauthors, who noted the prevalence of inflammatory S O were identified over a 9-year period. The age-adjusted arthritis to be 30%.18 R IA prevalence of PsA in this study was 0.056%. T Pattern of Inflammatory Arthritis IC A Incidence andPsoriasis R T H The reported incidence of PsA has varied from 3 to 23 Moll and Wright described five clinical patterns of R IT per 100,000.10-15 From the Rochester Epidemiological PsA and estimated the frequency of these subgroups IS Project, the average age- and sex-adjusted incidence on the basis of their own clinical observations.19The rate was 6.59 per 100,000 U.S. population (95% CI: five clinical patterns and their estimated frequencies 4.99 to 8.19). Alamanos and co-workers from northern are (1) “classical” PsA confined to distal interpha- Greece reported an age-adjusted mean incidence rate langeal (DIP) joints of the hands and feet (5%), of 3.02 per 100,000. No difference was noted between (2)arthritis mutilans with sacroiliitis (5%), (3) sym- males and females in the latter study, and the peak metric polyarthritis indistinguishable from RA incidence was observed between 45 and 64 years. (15%), (4) asymmetric oligoarthritis (70%), and Savolainen and colleagues systematically collected (5) spondyloarthropathy (15%). Subsequent reports data on a population of 87,000 inhabitants of Kuopio, validated these subgroups; however, there is consid- Finland.14 PsA was diagnosed as peripheral arthritis erable overlap and evolution of these subgroups.20At with psoriasis in the absence of rheumatoid factor– present, there is an ongoing debate about the most positive polyarthritis or spondylitis with psoriasis. prevalent subgroup of PsA (most acknowledge that Sixteen new cases of PsA were identified, resulting in a the polyarticular variant is probably the most fre- mean incidence rate of 23 per 100,000. Furthermore, quent) and the existence of pure DIP involvement. Soderlin and coauthors performed a prospective popula- These issues are addressed in detail in Chapter 3. tion-based study on the annual incidence of early arthri- The majority of patients with PsA have the classical tis in Kronoberg County in southern Sweden.15 The form of psoriasis vulgaris, although pustular psoriasis patients were referred from primary health care centers and erythredema have also been reported.3In approx- to the rheumatology department in the central hospital imately 70% of cases, psoriasis precedes the onset of or to private clinics participating in the study. Additional arthritis, but the interval in between is extremely vari- hospital records were checked. The patients were regis- able. In approximately 15% of cases, arthritis precedes tered as incident cases if the onset of the joint inflamma- the onset of psoriasis. In another 15% of cases, the pso- tion was between May 1, 1999 and May 1, 2000. In total, riasis and inflammatory arthritis are diagnosed 11 patients presented with PsA, corresponding to an together. There appears to be no clear relationship annual incidence of 8 per 100,000 for PsA. between the extent of psoriasis and the severity of inflammatory arthritis.4 Prevalence of Psoriatic Arthritis among Psoriasis Subjects Genetic Epidemiology of Psoriatic Arthritis The estimated prevalence of inflammatory arthritis Moll and Wright estimated the strength of familial clus- among patients with psoriasis has varied widely from tering of PsA.19 Evaluation of the first- and second- 6% to 42%.4 Historically, however, a value of 7% to degree relatives of 88 consecutive PsA probands 10% for the prevalence of inflammatory arthritis in showed that 12.5% had at least one relative with con- psoriasis patients was most often cited.4The U.S. study firmed PsA. Of the 181 first-degree relatives assessed, 10 by Gelfand and colleagues noted a self-reported inci- relatives had PsA, including 5 siblings. Thus, the over- dence of inflammatory arthritis of 11% (95% CI: 9% to all prevalence of PsA among first-degree relatives was 14%). This may be an underestimate as the diagnosis of 5.5%. Using the calculated prevalence of PsA in the psoriasis is often overlooked because it may not be in United Kingdom population of 0.1%, the risk for direct view of patients and physicians (such as scalp, affected first-degree relatives (λ) is 55, a heritability 1 buttocks). Also, there is a lower level of tenderness of substantially greater than those obtained for psoriasis.21 inflammatory arthritis among PsA patients. Thus, ide- In the mid-1980s, Henseler and Christophers noted 2 ally, patients with psoriasis should be carefully exam- that type I psoriasis, defined by the onset of psoriasis ined and questioned specifically about peripheral and prior to age 40, had a stronger genetic basis (defined by a family history of psoriasis) and exhibited stronger affected mother.25Interestingly, a linkage study in PsA R e human leukocyte antigen (HLA) associations.22 Two noted significant linkage only when assessing the fe re independent groups noted a similar trend for PsA transmission of alleles of paternal origin.26 n c when PsA was stratified according to the age of onset In summary, the exact prevalence and incidence of es of psoriasis.23,24PsA patients with early-onset psoriasis PsA are not known. There is a large variance in the (onset of psoriasis prior to age 40) were more likely to reported prevalence and incidence rates of PsA, in part have a family history of psoriasis and PsA and exhib- because of a lack of widely accepted diagnostic criteria. ited differential expression of HLA antigens. When the Classification of Psoriatic Arthritis (CASPAR) A parent-of-origin effect has also been demonstrated group arrives at a valid set of diagnostic-classification cri- in PsA as there appears to be a greater proportion of teria, a proper prospective epidemiologic study may pro- PsA probands with an affected father than with an vide better estimates regarding the epidemiology of PsA. REFERENCES 1. Alibert JL. Précis Théoretique et Pratique sur les Maladies de la in a defined population: Results from the Kuopio 2000 arthritis Peau. Paris: Caille et Ravier, 1818, p 21. survey. J Rheumatol 2003;30:2460-2468. 2. Blumberg BS, Bunim JJ, Calkins E, etal. Nomenclature and clas- 15. Soderlin MK, Borjesson O, Kautiainen H, etal. Annual incidence sification of arthritis and rheumatism (tentative) accepted by of inflammatory joint diseases in a population based study in the American Rheumatism Association. Bull Rheum Dis southern Sweden. Ann Rheum Dis 2002;61:911-915. 1964;14:339-340. 16. Zachariae H. Prevalence of joint disease in patients with psoria- 3. Gladman DD, Antoni C, Mease P, etal. Psoriatic arthritis: sis: Implications for therapy. Am J Clin Dermatol 2003;4:441- Epidemiology, clinical features, course, and outcome. Ann 447. Rheum Dis 2005;64 (Suppl 2):ii14-ii17. 17. Brockbank JE, Schentag C, Rosen C, Gladman DD. Psoriatic 4. Gladman DD. Psoriatic arthritis. In: Gordon K, Ruderman E (eds). arthritis (PsA) is common among patients with psoriasis and Psoriasis and Psoriatic Arthritis. Berlin: Springer-Verlag, 2005, family medical clinic attendees [abstract]. Arthritis Rheum pp 57-65. 2001;44 (Suppl 9):S94. 5. Arnett FC, Reveille JD, Duvic M. 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Wright V, Moll JMH. Psoriatic arthritis. In: Wright V, Moll JMH 22. Henseler T, Christophers E. Psoriasis of early and late onset: (eds). Seronegative Polyarthritis. Amsterdam: North Holland, Characterization of two types of psoriasis vulgaris. J Am Acad 1976, pp 169-223. Dermatol 1985;13:450-456. 10. Gelfand JM, Gladman DD, Mease PJ, etal. Epidemiology of pso- 23. Rahman P, Gladman DD, Schentag CT. Immunogenetic profile riatic arthritis in the population of the United States. J Am Acad of patients with psoriatic arthritis varies according to the age at Dermatol 2005;53:573. onset of psoriasis. Arthritis Rheum 1999;42:822-823. 11. Shbeeb M, Uramoto KM, Gibson LE, etal. The epidemiology of 24. Fernandez-Sueiro JL, Willisch A, Pinto J, etal. Clinical features of psoriatic arthritis in Olmsted County, Minnesota, USA, 1982- psoriatic arthritis according to the type of cutaneous psoriasis. 1991. J Rheumatol 2000;27:1247-1250. Arthritis Rheum 2005;52:S216. 12. 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