Manifestation Radiological of type Distal Interphalangeal

Predominan in Psoriatic Arthritis

Wahyuddin. Mahriani Sylvawani
Division Rheumatology/ Departments of Internal Medicine
Dr. Zainoel Abidin General Hospital Banda Aceh
Introduction
Psoriasis approximately 2% of the population.1 Psoriatic arthritis (PsA) is a chronic
inflammatory arthropathy affecting up to 40%of patients with skin or nail psoriasis. It is
considered a type of seronegative spondyloarthropathy and can cause arthritis, enthesitis,
dactylitis and axial inflammation.2 A variation of PsA is polyarthritis with distal
interphalangeal predominant (DIP).3
Case illustration
A man, 47 years old with skin rash accompanied pain in the joint of the hands and
feet (Fig 1A). Medical history was significant for psoriasis of more than 3 years duration,
He also experienced prolonged morning stiffness. Rheumatoid factor was within normal
limits. In the hand radiographic examination was perform extensive deformities were
noted involving all the digits (Fig 2A). Radiographs of the feet showed the first
metatarsophalangeal joint in both feet were narrowed and showed articular erosions (Fig
3). The patient was subsequently diagnosed as DIP type of PsA and was treated by
dermatologist with steroid topical. We gave steroid injection than continue with
methotrexate. The patients pain and stiffness in the digits were relieved dramatically
after 10 days hospitalized.
Discussion
Tabel I: CASPAR criteria for the diagnosis of Psoriasis arthritis (modified)4
Criteria consist of established inflammatory articular disease* with at least 3 points from the
following features:
A. Current psoriasis (assigned a score of 2; all other features are assigned a score of 1)
B. A personal history of psoriasis (unless current psoriasis is present)
C. A family history of psoriasis (unless current psoriasis is present or there is a personal history of
psoriasis)
D. Current dactylitis or history of dactylitis recorded by a rheumatologist
E. Juxta-articular new bone formation
F. Rheumatoid factor negativity
G. Typical Psoriasis nail dystrophy including onycholysis, pitting, and hyperkeratosis

These CASPAR criteria have a specificity of 98.7% and sensitivity of 91.4% for
diagnosing PsA.4 The man has 6 score and established as PsA. Radiographs of the feet
showed the first metatarsophalangeal joint in both feet were narrowed and showed
articular erotions. In the hand, there was radiographic evidence of diffuse soft tissue
swelling on both sides as well (Figure 2A). Suspect enthesitis?
1

The study in India showed early addition of low dose systemic steroids to methotrexate in
severe Psoriasis arthritis prevents significant joint damage5 We gave methylprednisolone
for 7 day than continue with methotrexate 25 mg/week.

Figure 1. (A) There was an extensive area on the skin scaly and silver colored. (B) Pitting of the nails,
dactylitis and Onycholysis
A

Figure 2: (A). Articular erotion and deformities in the phalanges. (B). The bone of humerus relatively
spared from radius-ulna

Figure 3: The first metatarsophalangeal joint were narrowed and showed articular erosions

Daftar Pustaka
1.

Parisi R, Symmons DP, Griffiths CE, Ashcroft DM; Identification and Management of Psoriasis and
Associated ComorbidiTy (IMPACT) project team. Global epidemiology of psoriasis: A systematic
review of incidence and prevalence. J Invest Dermatol 2013;133:377-85.
2. Coates CL, Tillett W, Chandler D, Helliwell PS, Korendowych E, Kyle S et al. The BSR and BHPR
guideline for the treatment of psoriatic arthritis with biologics. Rheumatology 2013;263:299.
3. Wright V: Rheumatisim and psoriasis: A re-evaluation. Am J Med 27:454, 1959.
4. Tan AL, Benjamin M, Toumi H, Grainger AJ, Tanner SF, Emery P, et al. The relationship between the
extensor tendon enthesis and the nail in distal interphalangeal joint disease in Psoriasis arthritisea highresolution MRI and histological study. Rheumatology (Oxford) 2007;46:253-6.
5. Mahajan VK, Sharma AL, Chauhan PS, Mehta KS, Sharma NL. Early Treatment with Addition of Low
Dose Prednisolone to Methotrexate Improves Therapeutic Outcome in Severe Psoriasis Arthritis.
Indian J Dermatol. 2013 May-Jun; 58(3): 240.