Pre-Activity Question 1. Psoriasis and PsA Clinical Features, Associated Conditions, Screening, and Assessment. Pre-Activity Question 2

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1 Pre-Activity Question 1 Psoriasis and PsA Clinical Features, Associated Conditions, Screening, and Assessment How confident are you in your ability to establish a clinical framework to diagnose and screen the psoriasis patient for psoriatic arthritis? 1. Very confident 2. Confident 3. Somewhat confident 4. Not confident Content Developers Pre-Activity Question 2 Amit Garg, MD Associate Professor and Founding Chair Department of Dermatology Hofstra NSLIJ School of Medicine North Shore LIJ Health System Manhasset, New York Kristina Callis Duffin, MD, MS Associate Professor Department of Dermatology University of Utah Salt Lake City, Utah Laura Coates, MBChB, MRCP, PhD NIHR Clinical Lecturer in Rheumatology Leeds Institute of Rheumatic and Musculoskeletal Medicine University of Leeds and the Leeds Musculoskeletal Biological Research Unit Leeds Teaching Hospitals NHS Trust Leeds, England PASI includes a component for patient-reported outcomes. 1. True 2. False Speakers Pre-Activity Question 3 Kristina Callis-Duffin, MD, MS Associate Professor Department of Dermatology University of Utah Salt Lake City, Utah Philip Mease, MD Director, Rheumatology Research Swedish Medical Center Clinical Professor University of Washington School of Medicine Seattle, Washington For what percentage of psoriasis patients do you currently perform an annual assessment for PsA? % % % % 1

Objective: Plaque Type Psoriasis After this presentation,

framework to diagnose and screen the patient with

(80%) Well demarcated plaques with varying degrees of

(thickness) Photo courtesy of Kristina Callis Duffin Photo

Kristina Callis Duffin Psoriasis Phenotypes Inverse

(generalized, localized) Palmoplantar Nail disease Overlap

Scale is minimal or entirely absent Sometimes eroded,

infection Photos courtesy of Kristina Callis Duffin & Amit

erythematous, scaly papules and small plaques May follow

2 Objective: Plaque Type Psoriasis After this presentation, the attendee will be able to: Establish a clinical framework to diagnose and screen the patient with psoriasis and psoriatic arthritis Most common morphology (80%) Well demarcated plaques with varying degrees of Erythema (pink to red) Scale (desquamation) Induration (thickness) Photo courtesy of Kristina Callis Duffin Photo courtesy of Kristina Callis Duffin Photo courtesy of Kristina Callis Duffin Psoriasis Phenotypes Inverse Psoriasis Plaque Inverse Guttate Erythrodermic Pustular (generalized, localized) Palmoplantar Nail disease Overlap Involves skin folds Smooth, well-demarcated red patches Scale is minimal or entirely absent Sometimes eroded, moist Often mistaken for a dermatophyte or candidal infection Photos courtesy of Kristina Callis Duffin & Amit Garg Plaque Type Psoriasis Guttate Psoriasis Eruptive Red erythematous, scaly papules and small plaques May follow streptococcal pharyngitis 4 6p Photos courtesy of Kristina Callis Duffin Photo courtesy of Kristina Callis Duffin 2

Erythrodermic Psoriasis Palmar Psoriasis Means red skin Warm,

Disrupted barrier function: temperature, fluids, electrolytes

lymphoma, atopic dermatitis Photos courtesy of Kristina Callis

Pustular Psoriasis Plantar Psoriasis Localized PPP steroid

pustular dermatoses (pustular drug eruption/ AGEP) Photos

Palmar Plantar Psoriasis (PPP): Pustular and non-pustular

predominance of pustules Pustular variant: (palmoplantar

associated with HLA-Cw6 2 Associated with smoking Treatment

introduction of a new quality-of-life assessment tool.

Genetic analysis of PSORS1 distinguishes guttate psoriasis and

3 Erythrodermic Psoriasis Palmar Psoriasis Means red skin Warm, red, scaly patches covering almost entire body surface Disrupted barrier function: temperature, fluids, electrolytes Differential diagnosis includes drug reaction, cutaneous T cell lymphoma, atopic dermatitis Photos courtesy of Kristina Callis Duffin Photos courtesy of Kristina Callis Duffin and Amit Garg Pustular Psoriasis Plantar Psoriasis Localized PPP steroid withdrawal Generalized (von Zumbusch) Mimics include other pustular dermatoses (pustular drug eruption/ AGEP) Photos courtesy of Amit Garg Photos courtesy of Kristina Callis Duffin Palmar Plantar Psoriasis (PPP): Pustular and non-pustular Spectrum: Non-pustular: hyperkeratotic plaques Pustular: predominance of pustules Pustular variant: (palmoplantar pustulosis) Regarded as a distinct entity by some Not associated with HLA-Cw6 2 Associated with smoking Treatment poses a challenge Associated with plaque psoriasis in ~20% 1. Farley E, Masrour S, McKey J, Menter A. Palmoplantar psoriasis: A phenotypical and clinical review with introduction of a new quality-of-life assessment tool. J Am Acad Dermatol. 2009;60: Asumalahti K, Ameen M, Suomela S, et al. Genetic analysis of PSORS1 distinguishes guttate psoriasis and palmoplantar pustulosis. J Invest Dermatol. 2003;120: Plantar Psoriasis Keratoderma over weight bearing areas of the foot 3

4 Psoriatic Nail Disease Affects 50% - 85% of psoriasis pts Difficult to treat May be associated with joint involvement oil spot Silver colored scale pitting Photos courtesy of Kristina Callis Duffin crumbling Margination along hairline Jiaravuthisan, et al. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol, 2007;57:1-27. Zaias N: Psoriasis of the nail. A clinical-pathology study. Arch Dermatol. 1969;99: Samman PD: The Nails in Disease, ed 3. London, William Heinemann Medical, Photos courtesy of Amit Garg Clues to the Diagnosis of Psoriasis Phenotypes Demarcation Type of Scale Distribution Hidden places Is the Distinction Clear? Places Psoriasis Likes to Hide Dx: Psoriasis Photos courtesy of Kristina Callis Duffin and Amit Garg 4

5 Dx: Atopic Dermatitis Dx: Psoriasis Dx: Dyshidosis Dx: Contact Dermatitis Dx: Nummular Eczema Dx: Contact Dermatitis 5

6 Dx: Contact Dermatitis Dx: Lichen Simplex Chronicus Dx: Lichen Planus Dx: CTCL Dx: Tinea Corporis Cutaneous T-cell Lymphoma/ Mycosis Fungoides Increased risk of CTCL: biologic vs misdiagnosed? 6

7 Differential Dx PASI Limitations Some conditions which may be difficult to distinguish from Psoriasis Erythema, induration, and scaling are equally weighted Seborrheic dermatitis Nummular eczema Atopic Dermatitis Contact dermatitis Hand Dermatitis Balanitis Dermatophyte or Candidal infection Palmoplantar keratodermas Cutaneous T Cell Lymphoma Onychodystrophy related to a number of etiologies including Dermatophyte infection and trauma Interpretation not so intuitive Nonlinear Composite score has no clinical frame of reference Lacks sensitivity to change at lower ranges No component for patient input Assessment of Psoriasis: PASI Most commonly utilized disease severity measure in clinical trials Quantify severity based on: Erythema, Induration, and Scale Body parts and surface area involved Separate calculation for head, trunk, upper extremities, and lower extremities Seeking Out Your Dermatology Colleague When diagnosis of psoriasis is not certain Optimization of topical therapies and regimens When use of oral retinoid may be appropriate When phototherapy may be useful Guttate psoriasis, or with diffuse thin plaques Adjunctive to systemic therapy Poor candidacy for systemic therapy When Psoriasis is flaring or unstable Undifferentiated or seronegative inflammatory disease and a rash PASI Strengths Assesses both lesion quality and extent of involvement Validated instrument Low intra-observer variability Moderate inter-observer variability Reproducible when performed by trained individuals Diagnosis/Presentation of PsA Allows some historical comparison across several treatments 7

Features of PsA Identifying PsA An inflammatory arthritis that occurs in 6%-42% of patients with psoriasis 1 Psoriasis typically precedes development of the arthritic component of PsA In 70% of

8 Features of PsA Identifying PsA An inflammatory arthritis that occurs in 6%-42% of patients with psoriasis 1 Psoriasis typically precedes development of the arthritic component of PsA In 70% of patients with PsA, psoriasis is the first symptom to present 2,3 20% have PsA before psoriasis 2,3 10%-15% report simultaneous onset of skin and joint disease 2,3 Severity of psoriasis is not predictive of severity of PsA 3 Dermatology Recognize relevant MSKL sxs among Pso pts CASPAR may not yet be applicable without a definition of inflammatory arthritis Rheumatology Distinguish inflammatory and non-inflammatory disease Identify PsA within inflammatory arthritis CASPAR criteria applicable to all patients 1. Gladman D, et al. Ann Rheum Dis. 2005; 64 (Suppl II): ii Leung Y, et al. J Postgrad Med. 2007; 53: Cohen M, et al. J Rheumatol. 1999; 26: Assessing the Psoriasis Patient Annual assessment for PsA to people with any type of psoriasis. Especially important within the first 10 years of onset of psoriasis. Use a validated tool to assess adults for psoriatic arthritis in primary care and specialist settings, such as the Psoriasis Epidemiological Screening Tool (PEST). Clinical Presentation of PsA PEST does not detect axial arthritis or inflammatory back pain As soon as psoriatic arthritis is suspected, refer to a rheumatologist for assessment and advice about planning their care. NICE clinical guideline 153 The assessment and management of psoriasis Available at: Date accessed: November Arthritis Peripheral Arthritis Uveitis Skin and nails Inflammatory bowel disease Psoriatic Disease Enthesitis Arthritis Present Absent Metabolic Syndrome Dactylitis Axial Disease Helliwell, et al. ARD. 2007;66:

PM3 PsA: Radiographic Features PM5 Enthesitis Juxta-articular periostitis and ankylosis Enthesitis

(pencil-in-cup) Mease P, van der Heijde D. Int J Adv Rheumatol. 2006;4:38-48. Helliwell, et al. ARD.

Other Radiological Features of PsA How to Spot PsA Enthesitis Periostitis Tuft Resorption Common sites

Psoriatic Arthritis Rheumatoid Arthritis RF and anti-ccp seronegative 1 RF and anti-ccp seropositive 1

Rheumatoid nodules present over bony prominences 1 Asymmetric oligoarticular manifestations 1 Symmetric

affects the metacarpophalangeal and proximal interphalangeal (PIP) joints 2 US of AT Radiological damage

ankylosis 2 50% of patients have spinal manifestations 2 Spine is largely unaffected 2 T2W Skin

9 PM3 PsA: Radiographic Features PM5 Enthesitis Juxta-articular periostitis and ankylosis Enthesitis Present Absent Inflammation at the site of insertion of muscle/tendon into bone Joint osteolysis (pencil-in-cup) Mease P, van der Heijde D. Int J Adv Rheumatol. 2006;4: Helliwell, et al. ARD. 2007;66: Other Radiological Features of PsA How to Spot PsA Enthesitis Periostitis Tuft Resorption Common sites Achilles tendon Plantar fascia Elbows Costochondral joints Patellar Mease P, van der Heijde D. Int J Adv Rheumatol. 2006;4: PsA vs RA Sub-clinical Bone and Entheseal Inflammation in Psoriasis Patients Scintigraphy MRI of 3 rd MCP Psoriatic Arthritis Rheumatoid Arthritis RF and anti-ccp seronegative 1 RF and anti-ccp seropositive 1 Inflammatory markers often normal Inflammatory markers usually raised Absence of rheumatoid nodules 1 Rheumatoid nodules present over bony prominences 1 Asymmetric oligoarticular manifestations 1 Symmetric polyarticular manifestations 1 Predilection for the distal interphalangeal (DIP) joints 2 Typically affects the metacarpophalangeal and proximal interphalangeal (PIP) joints 2 US of AT Radiological damage commonly involves periostitis, pencil-in-cup changes and Radiological changes include osteopenia 2 ankylosis 2 50% of patients have spinal manifestations 2 Spine is largely unaffected 2 T2W Skin manifestations (psoriasis) Skin manifestations are atypical 1. Gladman D, et al. Ann Rheum Dis. 2005;64 (Suppl II):ii Gladman D. Ann Rheum Dis. 2006;5 (Suppl III):iii22-4. Namey TC. Arthritis Rheum. 1976;19(3):607. Offidani A, et al. ActaDerm Venereol. 1998;78:463. Gisondi, et al. Ann Rheum Dis. 2008;67:

10 Slide 53 PM3 Reference I have added to this slide and next is a general review article on radiologic features of PsA and is not specific to the specific images admin, 10/29/2014 Slide 58 PM5 remove build please admin, 10/29/2014

Lower Limb Enthesopathy in Psoriasis Patients without PsA Ultrasound evaluation of Achilles, quadriceps,

30 psoriasis patients 10% of patients with psoriasis 30 controls The mean thickness of all tendons was

Inflammatory back pain Chronic back pain >3 months Onset at age <40 yrs Pain eased by exercise, worse at

*Girolomoni, et al. JEADV. 2009;23(Suppl. 1):3-8.

MSK diagnosis, 28 OA, 24 Other, 17 Severe PsA, 7 Mild PsA, 10 Helliwell, et al. ARD. 2007;66:113-7. Husni.

11 Lower Limb Enthesopathy in Psoriasis Patients without PsA Ultrasound evaluation of Achilles, quadriceps, patellar entheses and plantar aponeurosis according to Glasgow Ultrasound Enthesitis Scoring System (GUESS) 30 psoriasis patients 10% of patients with psoriasis 30 controls The mean thickness of all tendons was higher in psoriasis patients than controls Mean GUESS score was significantly higher with 7.9 in psoriasis patients vs. 2.9 in controls progressed to PsA over 2 yrs * Bursitis enthesophyte How to Spot PsA Axial Disease Inflammatory back pain Chronic back pain >3 months Onset at age <40 yrs Pain eased by exercise, worse at rest Early morning stiffness Waking in second half of the night Gisondi, et al. Ann Rheum Dis. 2008;67: *Girolomoni, et al. JEADV. 2009;23(Suppl. 1):3-8. PM6 Dactylitis PsA in Dermatology Clinics Dactylitis Present Absent uniform/fusiform swelling of a digit No MSK diagnosis, 28 OA, 24 Other, 17 Severe PsA, 7 Mild PsA, 10 Helliwell, et al. ARD. 2007;66: Husni. JAAD. 2007;57(4): Spinal Involvement Referral to Rheumatology Spinal pain/stiffness Present Absent Arthralgia that doesn t settle Inflammatory features Early morning stiffness Better with exercise Swollen joints Enthesitis Low back / buttock pain Helliwell, et al. ARD. 2007;66:

12 Slide 62 PM6 remove build please admin, 10/29/2014

Screening Tools for PsA PEST Most people have psoriasis before joint symptoms Is there a simple screening test for PsA?

Arthritis Questionnaire; PASE = Psoriatic Arthritis Screening and Evaluation. ToPAS = Toronto Psoriatic Arthritis Screen; PEST = Psoriasis Epidemiology Screening Tool.

Do your finger nails or toe nails have holes or pits? Have you had pain in your heel? Have you had a finger or toe that was completely swollen and painful for no apparent reason? Ibrahim G, et al.

e stiff, swollen or painful joints) PASE Symptoms Identifying PsA in Early Arthritis Clinics I feel tired for most of the day My joints hurt My back hurts My joints become swollen My joints feel hot

13 Screening Tools for PsA PEST Most people have psoriasis before joint symptoms Is there a simple screening test for PsA? Quick and easy Patient completed Sensitive Reasonably specific Patient-completed questionnaires PAQ (1997) and modified PAQ (2002) PASE (2007) ToPAS (2008) PEST (2008) PASQ (2009) PAQ = Psoriasis and Arthritis Questionnaire; PASE = Psoriatic Arthritis Screening and Evaluation. ToPAS = Toronto Psoriatic Arthritis Screen; PEST = Psoriasis Epidemiology Screening Tool. PASQ =Psoriatic Arthritis Screening Questionnaire. Have you ever had a swollen joint (or joints)? Has a doctor ever told you that you have arthritis? Do your finger nails or toe nails have holes or pits? Have you had pain in your heel? Have you had a finger or toe that was completely swollen and painful for no apparent reason? Ibrahim G, et al. Clin Exp Rheumatol. 2009;27: In the drawing below, please tick the joints that have caused you discomfort (i.e stiff, swollen or painful joints) PASE Symptoms Identifying PsA in Early Arthritis Clinics I feel tired for most of the day My joints hurt My back hurts My joints become swollen My joints feel hot Occasionally, my entire finger or toe becomes swollen, making it look like a sausage I have noticed that the pain in my joints moves from one joint to another, for example, my wrist will hurt for a few days, then my knee will hurt, and so on Presence of psoriasis! Psoriatic nail disease Negative immunology Features of SpA Use CASPAR features... Husni M, et al. J Am Acad Dermatol. 2007;57: ToPAS 1 and 2 PsA Disease Complex and Variable Features: Pictures Questions on joint symptoms back pain dactylitis Gladman D, et al. Ann Rheum Dis. 2009;68: Images supplied by Laura Coates, University of Leeds, UK. 11

Current Practice Arthritis Poor documentation of outcome measures UK DAS28 used in 25% of biologic assessments 68/66 joint count used for most Some assessment of skin disease Poor documentation of

Skin Disease Assessment of PsA BSA PASI (often only if BSA>3) Target Lesion score Lattice System PGA (very severe clear) Copenhagen Psoriasis Severity Index (CoPSI) NPF Psoriasis Score 1% BSA Coates,

Assessment of Psoriatic Arthritis in Clinical Trials Assessing Enthesitis - LEI Domains Joint assessment Axial assessment Skin assessment Pain Patient global Physician global Function/QOL Fatigue

14 Current Practice Arthritis Poor documentation of outcome measures UK DAS28 used in 25% of biologic assessments 68/66 joint count used for most Some assessment of skin disease Poor documentation of enthesitis/dactylitis/axial disease activity Generally composite measure of arthritis (RA) used 68/66 (tenderness/swelling) joint count recommended Mease P. Arth Care & Research. 2011;63: Skin Disease Assessment of PsA BSA PASI (often only if BSA>3) Target Lesion score Lattice System PGA (very severe clear) Copenhagen Psoriasis Severity Index (CoPSI) NPF Psoriasis Score 1% BSA Coates, et al. J Rheum Jul;38(7): Assessment of Psoriatic Arthritis in Clinical Trials Assessing Enthesitis - LEI Domains Joint assessment Axial assessment Skin assessment Pain Patient global Physician global Function/QOL Fatigue Enthesitis assessment Dactylitis assessment Acute phase reactant Imaging Instruments 68/66 T/S joint count, ACR, DAS, PsARC BASDAI, BASFI, BASMI PASI, Target lesion, Global VAS VAS (global, skin + joints) VAS (global, skin + joints) HAQ, SF-36, PsAQoL, DLQI FACIT, Krupp, MFI, VAS Mander, MASES, Leeds, Berlin, SPARCC, 4-point Leeds, present/absent, acute/chronic ESR, CRP Xray (modified Sharp or van der Heijde-Sharp), MRI, US Lateral epicondyle of elbow Medial condyle of femur Achilles tendon insertion Mease P. Arth Care & Research. 2011;63: Mease P, et al. Ann Rheum Dis. 2005;64: ii49-ii54. Mease P, van der Heijde D. Int J Adv Rheum. 2006;4: Healy PJ and Helliwell PS. Arthritis Rheum. 2008;59(5):

Assessing Enthesitis - SPARCC PM7 IMPART: Arthritis and Dactylitis Supraspinatus Med/lat epicondyles Greater trochanter Patellar insertion Quads insertion Tibial tuberosity Achilles tendons Plantar

45) 0.42 (0.23, 0.65) 0.31 (0.12, 0.57) Dactylitis 0.29 (0.15, 0.51) 0.69 (0.52, 0.84) 0.08 (-0.07, 0.32) PGA-PsA 0.39 (0.23, 0.60) 0.29 (0.11, 0.54) 0.50 (0.29, 0.

Dactylitis Quality of Life and Function Simple count (tender/swollen) 1 Count + grade 0-3 score 2 Leeds Dactylitis Instrument (LDI) 3 SF-36 EQ5D DLQI PsAQOL HAQ-DI MID 0.

15 Assessing Enthesitis - SPARCC PM7 IMPART: Arthritis and Dactylitis Supraspinatus Med/lat epicondyles Greater trochanter Patellar insertion Quads insertion Tibial tuberosity Achilles tendons Plantar fascia Measure Tender joint count Swollen joint count Overall ICC (95% CI) Rheumatologist ICC (95% CI) Dermatologist ICC (95% CI) 0.78 (0.65, 0.89) 0.81 (0.68, 0.91) 0.73 (0.56, 0.86) 0.24 (0.12, 0.45) 0.42 (0.23, 0.65) 0.31 (0.12, 0.57) Dactylitis 0.29 (0.15, 0.51) 0.69 (0.52, 0.84) 0.08 (-0.07, 0.32) PGA-PsA 0.39 (0.23, 0.60) 0.29 (0.11, 0.54) 0.50 (0.29, 0.72) PGA = physician s global assessment; ICC = intraclass correlation coefficients. Chandran V, et al. Arthritis Rheum. 2009;27;61: Dactylitis Quality of Life and Function Simple count (tender/swollen) 1 Count + grade 0-3 score 2 Leeds Dactylitis Instrument (LDI) 3 SF-36 EQ5D DLQI PsAQOL HAQ-DI MID 0.35 HAQ-S Images supplied by Laura Coates, University of Leeds, UK 1. Kyle S, et al. Rheumatology. 2005;44: Antoni CE, et al. [erratum appears in Arthritis Rheum Sep;52(9):2951] Arthritis & Rheumatism. 52(4): Helliwell PS, et al. Journal of Rheumatology. 2005;32(9): Mease P. Arth Care & Research. 2011;63: Mease P, et al. J Rheum. 2011;38: Axial Disease BASDAI doesn t differentiate axial activity BASFI doesn t differentiate axial activity BASMI ASDAS Coates, et al. J Rheum Jul;38(7): Image supplied by Laura Coates, University of Leeds, UK Composite Measures of Psoriatic Disease ENB1049a Date of Preparation November

16 Slide 89 PM7 ICC for swollen joint count for "Overall" is 0.24? Yet ICC for rheum is 0.42 and derm is 0.31 so theoretically the Overall should be in between those two numbers. Please check manuscript. admin, 10/29/2014

17 Composite Assessment of PsA Observational Database - Toronto Composite Measures of Arthritis DAS ACR responses PsARC DAPSA PsAJAI n=344 59% male, mean age 43 years Patients Achieving MDA Progression of Joint Damage per year P=.0005 CDAI SDAI Composite Measures of PsA MDA CPDAI >1 year <1 year never Increase damaged JC PASDAS AMDF 0 MDA not MDA Mease P. Arth Care & Research. 2011;63: Coates LC, et al. Arthritis Care and Res. 2010;62(7): A Disease State Measure Interventional Trial Cohort Minimal disease activity is ideal concept a state which is deemed a useful target of treatment by both physician and patient, given current treatment possibilities and limitations Can act as a target for treatment Developed for PsA including 7 key outcome measures covering arthritis, enthesitis, skin disease, patient reported outcomes and functional ability Achieving MDA in IMPACT and IMPACT2 studies Percentage of patients achieving MDA Week 16 Week 52 Infliximab Placebo Week 16 P<.0001 Percentage of patients achieving MDA Week 24 Week 52 Infliximab Placebo Week 24 P<.001 Wells GA, et al. J Rheumatol. 2005;32: ; Coates LC, et al. Ann Rheum Dis. 2010; 69(1): Coates LC, et al. Arthritis Care and Res. 2010;62(7): MDA Criteria for PsA MDA A patient is classified as in MDA when they meet 5 of 7 of the following criteria: tender joint count 1 swollen joint count 1 PASI 1 or BSA 3 patient pain VAS 15 patient global activity VAS 20 HAQ 0.5 tender entheseal points 1 Validated measure of disease state Doesn t measure disease activity Now being reported as outcome in RCTs Being used in clinical trials as target Coates LC, et al. Ann Rheum Dis. 2010;69(1): Coates LC, et al. Arthritis Care and Res. 2010;62(7):965-9 and Coates, et al. BMC Musculoskelet Disord Mar 21;14:

18 Composite Psoriatic Disease Activity Index (0-15) AMDF None (0) Mild (1) Moderate (2) Severe (3) 4 joints but function 4 joints; normal function > 4 joints and function Peripheral Arthritis NONE impaired; or > 4 joints, (HAQ 0.5) impaired normal function PASI 10 but DLQI >10; Skin Disease NONE PASI 10 and DLQI 10 or PASI > 10 but DLQI PASI > 10 and DLQI > sites but function 3 sites; normal function >3 sites and function Enthesitis NONE impaired; or >3 sites but (HAQ 0.5) impaired normal function 3 digits but function 3 digits; normal function >3 digits and has function Dactylitis NONE impaired; or >3 digits but (HAQ 0.5)) impaired normal function BASDAI >4 but normal BASDAI 4; normal BASDAI >4 and function Spinal Disease NONE function; BASDAI 4 but function (ASQol 6) impaired function impaired Sum of TJC SJC HAQ Patient VAS global Patient VAS joints Patient VAS skin PASI PsAQOL HAQ only counted for most severe domain involved (enthesitis/dactylitis/peripheral arthritis) Mumtaz, A. Ann Rheum Dis. 2011;70: Helliwell PS, et al. Ann Rheum Dis. 2013;72: GRACE Project (GRAPPA) Optimizing Roles of Dermatologist and Rheumatologist Longitudinal international cohort High disease activity identified by increase in therapy 2 different methods for development PASDAS following methodology of RA DAS or ASDAS Logistic regression to develop weighting AMDF Each component translated to 0-1 desirability function Simple addition of each component Screening for PsA in at-risk population Confirm presence of inflammatory arthritis in pt with psoriasis PASDAS Post-Activity Question x physician global x patient global x SF36-PCS x ln (SJC+1) x ln (TJC+1) x ln (LEI+1) x ln (tender dactylitis count+1) x ln (CRP+1) How confident are you in your ability to establish a clinical framework to diagnose and screen the psoriasis patient for psoriatic arthritis? 1. Very confident 2. Confident 3. Somewhat confident 4. Not confident Helliwell PS, et al. Ann Rheum Dis. 2013;72:

Post-Activity Question 2 PASI includes a

percentage of psoriasis patients do you intend

19 Post-Activity Question 2 PASI includes a component for patient reported outcomes. 1. True 2. False Post-Activity Question 3 For what percentage of psoriasis patients do you intend to perform an annual assessment for PsA? % % % % Questions & Answers 16

Content Developers. Psoriasis and PsA Clinical Features, Associated Conditions, Screening, and Assessment. Plaque Type Psoriasis. Psoriasis Phenotypes

Content Developers. Psoriasis and PsA Clinical Features, Associated Conditions, Screening, and Assessment. Plaque Type Psoriasis. Psoriasis Phenotypes Content Developers Psoriasis and PsA Clinical Features, Associated Conditions, Screening, and Assessment Amit Garg, MD Associate Professor and Founding Chair Department of Dermatology Hofstra NSLIJ School