Approach ConsiderationsNo specific diagnostic tests are available for psoriatic arthritis. [4] Diagnosis of the disease is instead based on clinical and radiologic criteria in a patient with psoriasis. Radiologic features can, for example, help to distinguish psoriatic arthritis from other causes of polyarthritis, such as rheumatoid arthritis (RA). Show
The most characteristic laboratory abnormalities in patients with psoriatic arthritis are elevations of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level. The results from these laboratory tests help to track the activity of the disease by measuring inflammation.  Laboratory StudiesErythrocyte sedimentation rateAn elevated ESR is found in approximately 40% of patients with psoriatic arthritis. An ESR of greater than 15 mm/h, along with medication use before the first clinical visit, evidence of radiologic damage, and absence of nail lesions, has been associated with increased mortality in patients with psoriatic arthritis. Rheumatoid factorPatients with psoriatic arthritis are typically seronegative for rheumatoid factor (RF), although RF is detected in 5-9% of patients. RF testing is usually associated with a high false-positive rate; thus, RF-positive and RF-negative patients should receive the same treatment. Antinuclear antibodiesAntinuclear antibody titers in persons with psoriatic arthritis do not differ from those of age- and sex-matched controls. In 10-20% of patients with generalized skin disease, the serum uric acid concentration may be increased and, on occasion, may predispose patients to acute gouty arthritis. Low levels of circulating immune complexes have been detected in 56% of patients with psoriatic arthritis but do not appear to parallel disease activity. ImmunoglobulinSerum IgA levels are increased in two thirds of patients with psoriatic arthritis and in one third of patients with psoriasis. Synovial fluidSynovial fluid is inflammatory in psoriatic arthritis, with white blood cell (WBC) counts ranging from 5000-15,000/µL and with polymorphonuclear leukocytes comprising more than 50% of cells. Within the synovium, the infiltrate consists predominantly of T lymphocytes. Glucose levels are within reference ranges, and synovial fluid complement levels are either within reference ranges or increased. Psoriatic versus rheumatoid arthritisThe table below compares laboratory values in psoriatic arthritis with those in RA. Table. Comparison of Expected Laboratory Values in Psoriatic Arthritis and Rheumatoid Arthritis (Open Table in a new window)
Histologic findingsThe histopathology of psoriatic synovitis is similar to that observed in other inflammatory arthritides, with a notable lack of intrasynovial immunoglobulin and RF production and a greater propensity for fibrous ankylosis, osseous resorption, and heterotopic bone formation. Imaging StudiesRadiologic features may help distinguish psoriatic arthritis from other causes of polyarthritis. For full discussion, see Psoriatic Arthritis Imaging. In general, the common subtypes of psoriatic arthritis, such as asymmetrical oligoarthritis and symmetrical polyarthritis, tend to result in only mild erosive disease. Early bony erosions occur at the cartilaginous edge, and cartilage initially is preserved, with maintenance of a normal joint space. Juxta-articular osteopenia, which is a hallmark of RA, is minimal in persons with psoriatic arthritis. Asymmetrical erosive changes in the small joints of the hands and feet are typical of psoriatic arthritis and have a predilection (in decreasing order) for the distal interphalangeal (DIP), proximal interphalangeal, metatarsophalangeal, and metacarpophalangeal joints. (See the images below.) Erosive disease frequently occurs in patients with either DIP involvement or progressive deforming arthritis and may lead to subluxation and, less commonly, to bony ankylosis of the joint. Erosion of the tuft of the distal phalanx, and even of the metacarpals or metatarsals, can progress to complete dissolution of the bone. Although this form of acro-osteolysis is not diagnostic, it is highly suggestive of psoriatic arthritis. The pencil-in-cup deformity observed in the hands and feet of patients with severe joint disease usually affects the DIP joints but also may involve the proximal interphalangeal joints. RadiographyRadiographic evaluations, along with clinical assessment for joint inflammation or damage, are a traditional method for monitoring patients with rheumatic conditions. Radiography shows a combination of erosion (unlike in ankylosing spondylosis) and bone growth (unlike in RA) in affected joints. [63] The following radiographic abnormalities are suggestive of psoriatic arthritis:
A study by Tillett et al of four radiographic scoring methods for psoriatic arthritis reached the following conclusions [64] :
Salaffi et al have reported preliminary validation of a novel radiographic scoring system for psoriatic arthritis, the Simplified Psoriatic Arthritis Radiographic Score (SPARS). SPARS correlated strongly with the SHS and Ratingen scores, and proved quicker to calculate (4.5 min, versus 14.4 min for SHS and 10.1 min for Ratingen). [65] CT scanning and MRIComputed tomography (CT) scanning and MRI may be useful for detecting early signs of joint synovitis. MRI is particularly sensitive for detecting sacroiliitic synovitis, enthesitis, and erosions; it can also be used with gadolinium to increase sensitivity. MRI may show inflammation in the small joints of the hands, involving the collateral ligaments and soft tissues around the joint capsule, which is not seen in RA.
UltrasonographyUltrasonography has an emerging role in the diagnosis and management of psoriatic arthritis. Its uses include the following [66] :
Author Anwar Al Hammadi, MD, FRCPC Consultant and Head of Dermatology, Rashid Hospital, Dubai Health Authority; Clinical Associate Professor of Dermatology, Dubai Medical College; Clinical Assistant Professor of Dermatology, University of Sharjah, UAE Anwar Al Hammadi, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology, Royal College of Physicians and Surgeons of Canada, Canadian Dermatology Association, Skin Cancer Foundation Disclosure: Nothing to disclose. Coauthor(s) Khadija Aljefri, MBChB, MSc, MRCP(UK), MRCP(Derm) Consultant Dermatologist, DermaMed Clinic; Lecturer, Dubai Medical College, UAE Khadija Aljefri, MBChB, MSc, MRCP(UK), MRCP(Derm) is a member of the following medical societies: British Medical Association, British Association of Dermatologists, Emirates Dermatology Society, Saudi Society of Dermatology and Dermatologic Surgery Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Galderma, Sanofi, Ego <br/>Received income in an amount equal to or greater than $250 from: Galderma, Sanofi, Ego . Chief Editor Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa Disclosure: Nothing to disclose. Additional Contributors Acknowledgements Bruce Buehler, MD Professor, Department of Pediatrics and Genetics, Director RSA, University of Nebraska Medical Center Bruce Buehler, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Pediatrics, American Association on Mental Retardation, American College of Medical Genetics, American College of Physician Executives, American Medical Association, and Nebraska Medical Association Disclosure: Nothing to disclose. Denise I Campagnolo, MD, MS Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds investigator; Novartis investigator; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator Vinod Chandran, MBBS, MD, PhD Assistant Professor, Department of Medicine, Division of Rheumatology, University of Toronto Faculty of Medicine; Staff Physician, Division of Rheumatology, Toronto Western Hospital, Canada Disclosure: Nothing to disclose. Michael J Dans, MD, PhD Clinical Instructor, Department of Dermatology, University of California at San Francisco Michael J Dans, MD, PhD is a member of the following medical societies: American Academy of Dermatology and American Medical Association Disclosure: Nothing to disclose. Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology Disclosure: Nothing to disclose. Patrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society Disclosure: Nothing to disclose. Dafna D Gladman, MD, FRCPC Professor of Medicine, University of Toronto Faculty of Medicine; Staff Physician, Division of Rheumatology, Toronto Western Hospital, Canada Disclosure: Nothing to disclose. Elliot Goldberg, MD Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology Disclosure: Nothing to disclose. Peter D Gorevic, MD, Professor and Chief, Division of Rheumatology, Mount Sinai School of Medicine Disclosure: Nothing to disclose. Jeffrey M Heftler, MD Interventional Physiatrist, Orthopaedic and Neurosurgical Specialists, Greenwich, CT Jeffrey M Heftler, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and International Spine Intervention Society Disclosure: Nothing to disclose. Alexa F Boer Kimball, MD, MPH Associate Professor of Dermatology, Harvard University School of Medicine; Vice Chair, Department of Dermatology, Massachusetts General Hospital; Director of Clinical Unit for Research Trials in Skin (CURTIS), Department of Dermatology, Massachusetts General Hospital Alexa F Boer Kimball, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Society for Investigative Dermatology Disclosure: Nothing to disclose. Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology Disclosure: Nothing to disclose. Christen M Mowad, MD Associate Professor, Department of Dermatology, Geisinger Medical Center Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Dermatological Association, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, and Phi Beta Kappa Disclosure: Nothing to disclose. Michael F Saulino, MD, PhD Assistant Professor, Department of Physical Medicine and Rehabilitation, MossRehab, Jefferson Medical College of Thomas Jefferson University Michael F Saulino, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Abby S Van Voorhees, MD Assistant Professor, Director of Psoriasis Services and Phototherapy Units, Department of Dermatology, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania Abby S Van Voorhees, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, National Psoriasis Foundation, Phi Beta Kappa, Sigma Xi, and Women's Dermatologic Society Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Merck Salary Management position; Abbott Honoraria Speaking and teaching; Amgen Honoraria Review panel membership; Centocor Honoraria Consulting; Leo Consulting; Merck None Other Karolyn A Wanat, MD Resident Physician, Department of Dermatology, University of Pennsylvania School of Medicine Karolyn A Wanat, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and American Medical Women's Association Disclosure: Nothing to disclose. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Rajesh R Yadav, MD Associate Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas Medical School at Houston Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation Disclosure: Nothing to disclose. How do doctors determine if you have psoriatic arthritis?X-rays. These can help pinpoint changes in the joints that occur in psoriatic arthritis but not in other arthritic conditions. MRI. This uses radio waves and a strong magnetic field to produce detailed images of both hard and soft tissues in your body.
What can mimic psoriatic arthritis?Other conditions that can mimic or have similar symptoms as psoriatic arthritis include axial spondyloarthritis, enteropathic arthritis, gout, osteoarthritis, plantar fasciitis, reactive arthritis, and rheumatoid arthritis.
What blood test tells you if you have psoriatic arthritis?Psoriatic Arthritis Blood Test: HLA-B27
HLA-B27 is a blood test that looks for a genetic marker for psoriatic arthritis — a protein called human leukocyte antigen B27 (HLA-B27), which is located on the surface of white blood cells.
What tests are positive with psoriatic arthritis?The most characteristic laboratory abnormalities in patients with psoriatic arthritis are elevations of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level. The results from these laboratory tests help to track the activity of the disease by measuring inflammation.
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