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Psoriasis (PsO) is an immune-mediated skin disease associated with multiple comorbidities including psoriatic arthritis (PsA).¹ Although the prevalence of PsO varies across the world, approximately 3.0% of adults in both the United States and Germany are affected.^1,2 Prevalence of PsA among PsO patients also varies widely; one meta-analysis of 266 studies from around the world found a pooled prevalence of 19.7%.³

Approximately 3% of PsO patients develop PsA within the first 5 years of onset, 7% after 10 years, and 20% after 30 years.² Conversely, the number of patients with confirmed PsA prior to the onset of PsO is very low. In fact, more than 85% of patients with PsA show skin symptoms of PsO first.²

Dermatologists are often the primary contact for patients with PsA and therefore play a role in screening for comorbidities. Training dermatologists to detect early signs of PsA, such as enthesitis, is important, especially since early treatment of PsA has been shown to yield better outcomes. To evaluate the efficacy of current dermatology screening practices, comprehensive data are needed on screening, monitoring, and associated outcomes in patients with suspected or confirmed PsA.²

Beginning to PARTICIPATE

To help meet this need, Andreas Pinter, MD, from the Department of Dermatology, Venereology and Allergology at the University Hospital in Frankfurt, Germany, and colleagues initiated the PARTICIPATE (Psoriatic Arthritis Screening and Treatment by Dermatological Practitioner) study, a non-interventional, prospective, epidemiological, cross-sectional study conducted from 2016 to 2018 at 48 German dermatological sites that included private practices and outpatient clinics of university and non-university hospitals. 

Patients with moderate-to-severe plaque PsO, over the age of 18, under current systemic drug therapy, and with suspected PsA were enrolled. Demographic and disease characteristics were collected during a single patient visit, with disease severity assessed via the Psoriasis Area and Severity Index (PASI) and affected body surface area (BSA). Information on applied screenings for PsA was also gathered.²

PARTICIPATE further

Of the 195 patients recruited from 48 centers, 73.3% were enrolled by office-based physicians. Special signs and symptoms of PsA, typically including swollen and tender joints, morning stiffness, back pain, and enthesitis, were assessed in all patients.²

Physical exams to screen for PsA were performed in most patients²:

• 85.3% (122/143) enrolled by office-based physicians 
• 75.0% (15/20) enrolled in non-university hospitals 
• 87.5% (28/32) enrolled in university hospitals 

Questionnaires for PsA screening were rarely used at university hospitals (6.3%), and used by office-based physicians more often (44.8%). The most common questionnaire used was the German Psoriasis Arthritis Diagnostic (GEPARD) questionnaire. Diagnostic imaging was infrequently conducted, with x-ray being the most commonly used modality. Ultrasound was only used in 5% or less of patients from each center type, and magnetic resonance imaging (MRI) was only used in 6.3% of university hospital patients, 4.8% of office-based patients, and not at all in non-university hospital patients.²

Suspected PsA was confirmed in 75.0% of university hospital patients, 34.3% of office-based patients, and 30.0% of non-university hospital patients. Although only between 51.0% and 83.3% of patients with confirmed PsA were referred to another physician, the vast majority of these referrals were for a rheumatologist. Treatment was initiated in 61.2% of office-based patients with confirmed PsA, 33.3% of university hospital patients with confirmed PsA, and none of the non-university hospital patients with confirmed PsA.²

PARTICIPATE Implications

This study reflects the status of PsA screening activity by dermatologists in an office-based setting, in university hospitals, and in non-university hospitals. In all 3 settings, imaging techniques were inadequately used. 鈥淭his is particularly relevant, as our data showed further that the initial suspicion of PsA proved in many cases not to be correct,鈥� the authors state in the discussion section. When imaging techniques were performed, x-ray was used most often.

However, the authors explain, 鈥渢he high number of x-rays taken is surprising for early diagnosis, as bone changes are not among the early signs of PsA.鈥� Since ultrasound and MRI are more specific in detecting soft tissue inflammation and enthesitis, increased use of these modalities may be warranted.²

Although this study provides a comprehensive understanding of PsO patient care in Germany, some limitations exist. Since participating study sites tended to have experience in trial participation and PsO treatment, results may not reflect the practices of typical dermatological settings. Consequently, the authors postulate, 鈥渢he low number of imaging procedures may be even lower at less experienced sites.鈥� Also, the inclusion of only patients on systemic therapy may also mask some signs and symptoms of PsA.²

Despite these limitations, the PARTICIPATE study revealed the appropriate use of medical history and questionnaires by dermatologists when screening for PsA; however, ultrasound and MRI were inadequately utilized. A future focus on increased collaboration between dermatologists and rheumatologists may help improve screening practices and the earlier initiation of systemic treatment.²

Published: December 18, 2024