SAN DIEGO – When psoriasis patients present to Dr. Abrar A. Qureshi with concomitant pain or stiffness, he routinely asks, "What is your worst time of day?"
"If patients say they experience an hour or more of profound morning stiffness, think inflammatory arthritis," Dr. Qureshi said at the annual meeting of the American Academy of Dermatology. "Some patients will be stiff in the morning for 5-15 minutes. That’s more suggestive of osteoarthritis, though there is no hard and fast rule."
Dr. Qureshi of the department of dermatology at Brigham and Women’s Hospital, Boston, also asks patients about joint swelling and if they have trouble getting into a car. His recommended physical exam consists of vitals, weight, height, nail changes, inverse psoriasis, swollen joints, warm joints, "sausage" digits, and the Schober test. "We do see patients with fatigue and malaise, occasionally low grade fever, and we always ask about TB exposure," he said.
He emphasized that dermatologists "are on the front line in the care of these patients. It behooves us to think about psoriatic arthritis, because the numbers suggest that 20%-25% of patients with psoriasis may develop psoriatic arthritis. If the diagnosis is missed, this can lead to debilitating pain, permanent joint damage, and disability."
If a psoriasis patient presents with pain or stiffness, consider inflammatory arthritis, including dactylitis and spondyloarthropathy, Dr. Qureshi said. Other differential diagnoses to consider include noninflammatory arthritis (osteoarthritis) or soft tissue problems such as enthesitis. "Osteoarthritis is probably the biggest red herring for dermatologists," he said.
In a study of patients referred by rheumatologists to the department of dermatology at Brigham and Women’s Hospital, the three most common diagnoses made by the rheumatologists prior to referral were psoriatic arthritis (41%), osteoarthritis (27%), and psoriatic arthritis plus osteoarthritis (15%).
Dr. Qureshi said that he had no relevant financial conflicts to disclose.