x
x

PSORIATIC ARTHRITIS

Introduction

Psoriatic arthritis (PsA) is a chronic, inflammatory condition associated with psoriasis, an inflammatory skin disorder characterized by a red, scaly rash most often occurring on the extensor surfaces of the skin and scalp.  Up to 6-48% of patients with psoriasis may develop PsA, presenting with pain and stiffness of the affected joints.4  Sometimes patients develop arthritis before the psoriatic skin changes. PsA was distinguished from rheumatoid arthritis (RA) with the discovery of rheumatoid factor (RF). Eighty-five percent of RA patients are RF-positive; PsA patients are usually seronegative for RF. PsA affects primarily fingers and toes, occasionally sacroiliac joints, and may progress to spondylitis.  Other clinical signs of psoriatic arthritis include fingernail deformities, fusiform, digital swelling (psoriatic dactylitis), autofusion of finger joints or wrist joints, MP joint hyperextension and digital shortening (opera glass hand deformity).

Pathophysiology

Structural changes observed with PsA include a pattern of increased vascularity of the synovial membrane distinguishable from that observed with RA, infiltration by a variety of leukocytes, and development of destructive pannus. Early inflammatory processes may be a result of the innate immune response, involving several cytokines including tumor necrosis factor alpha (TNF-a) and interleukins IL-1, IL-8, and IL-15. The acquired immune response may also play a role, with CD8+ T lymphocytes implicated.

Related Anatomy

  • Nalebuff described three types of psoriatic arthritis in the Hand:
    1. Ankylosing
    2. Osteolytic
    3. Rheumatoid arthritis-like deformities with stiffness

Related X-ray Changes

  • Soft tissue swelling and osteoporosis
  • Joint narrowing and marginal erosions which later widen and produce pencil-in cup joint deformities

Incidence and Related Conditions

  • Prevalent in 1−2% of population (up to 40% of people diagnosed with psoriasis)
  • PsA affects young adults of either gender
  • Higher risk of gout as co-morbidity
  • Called psoriatic juvenile idiopathic arthritis (JIA) when presenting with psoriasis in children

Differential Diagnosis

  • Rheumatoid arthritis
  • Osteoarthritis
  • Fibromyalgia
  • Gout
  • Arthritis mutilans
ICD-10 Codes

  • PSORIATIC ARTHRITIS

    Diagnostic Guide Name

    PSORIATIC ARTHRITIS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    PSORIATIC ARTHRITISL40.52   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Psoriatic Arthritis
  • Psoriatic arthritis - Noted marked DIP joint deformities
    Psoriatic arthritis - Noted marked DIP joint deformities
  • Psoriatic arthritis - Fingernail changes
    Psoriatic arthritis - Fingernail changes
Symptoms
Joint inflammation and pain
Morning stiffness lasting longer than 30 minutes
Complaints of psoriatic skin and nail lesions
Hand shortening deformities (opera glass hand)
Typical History

Prior diagnosis of psoriasis in a male or female with diffuse joint pain and swelling in the hands.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Psoriatic Arthritis
  • Psoriatic arthritis - Pencil-in-cup deformity of the DIP joint
    Psoriatic arthritis - Pencil-in-cup deformity of the DIP joint
Treatment Options
Treatment Goals
  • Maintain hand function
  • Correct deformities and stabilize joints
  • Preserve digital length
Conservative
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate (MTX) and sulfasalazine (SSZ)
  • Biologic agents targeting tumor necrosis factor (TNF), interleukin (IL12/23/17)
  • Steroid injections
  • Braces or splints
Operative
  • Arthrodesis often needed for DIP joints and thumb MP and IP joints
  • Arthroplasty (in cases of severely damaged MP joints)
  • For psoriatic wrist arthritis wrist arthrodesis and distal ulnar resections may be needed
Treatment Photos and Diagrams
Psoriatic arthritis
  • Psoriatic arthritis - Pencil-in-cup deformity of the DIP joint treated with a DIP arthrodesis. Note bone graft not needed in this case.
    Psoriatic arthritis - Pencil-in-cup deformity of the DIP joint treated with a DIP arthrodesis. Note bone graft not needed in this case.
CPT Codes for Treatment Options

Per an agreement between Hand Surgery Resource, LLC and the American Medical Association (AMA) users are required to accept the following End User Point and Click Agreement in order to view CPT content on this website.  Please read and then click "Accept" at the bottom to indicate your acceptance of the agreement.

End User Point and Click Agreement

CPT codes, descriptions and other data only are copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. The AMA reserves all rights to approve any license with any Federal agency.

You, as an individual, are authorized to use CPT only as contained in Hand Surgery Resource solely for your own personal information and only within the United States for non-commercial, educational use for the purpose of education relating to the fundamental principles of hand surgery and the common diseases, disorders and injuries affecting the human hand. You agree to take all necessary steps to ensure your compliance with the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 330 N. Wabash Avenue, Chicago, IL 60611. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt.

Common Procedure Name
MP joint arthrodesis
CPT Description
Arthrodesis metacarpophalangeal joint w/wo internal fixation
CPT Code Number
26850
Common Procedure Name
PIP/DIP joint arthrodesis
CPT Description
Arthrodesis interphalangeal joint with or without internal fixation
CPT Code Number
26860
Common Procedure Name
26860
CPT Description
Primary repair collateral ligament metacarpophalangeal joint
CPT Code Number
26542
Common Procedure Name
Ulnar collateral ligament repair
CPT Description
Repair of collateral ligament metacarpophalangeal or interphalangeal joint
CPT Code Number
26540
Common Procedure Name
PIP joint arthroplasty
CPT Description
Arthroplasty, metacarpophalangeal joint with prosthetic implant, each joint
CPT Code Number
26536
Common Procedure Name
MP joint arthroplasty
CPT Description
Arthroplasty, metacarpophalangeal joint, each joint
CPT Code Number
26530
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

CPT QuickRef App.  For Apple devices: App Store. For Android devices: Google Play

CPT 2021 Professional Edition: Spiralbound

Complications
  • Gout, arthritis mutilans, methotrexate toxicity, general side effects associated with immunosuppression such as increased infections and malignancies, uveitis that can lead to blindness (psoriatic JIA)
  • Operative: infections, malalignment, further joint deterioration despite surgical treatment like MP arthroplasty, delayed- or non-union
Outcomes
  • Reduction in joint swelling and pain
  • Increased joint mobility
  • Slow disease progression
Key Educational Points
  • Extra-articular features such as psoriatic skin lesions, and finger deformities
  • Asymmetric distribution frequently involving distal interphalangeal (DIP) joints
  • Dactylitis
  • Presence of sacroiliitis and spondylitis
  • Pain and stiffness increased by prolonged immobility and alleviated by physical activity
  • Lack of RF in blood, lack of uric acid in joint fluid
References
  1. De Simone C, Caldarola G , D’Agostino M, et al. Usefulness of ultrasound imaging in detecting psoriatic arthritis of fingers and toes in patients with psoriasis. Clin Develop Immunol 2011 ePub. PMID: 21461353
  2. Raven EEJ, Ottink KD, Doets KC. Radiolunate and radioscapholunate arthrodeses as treatments for rheumatoid and psoriatic arthritis: long-term follow-up. J Hand Surg Am 2012;37:55-62. PMID:22137064
  3. Tan AL, Fukuba E, Halliday NA, et al. High-resolution MRI assessment of dactylitis in psoriatic arthritis shows flexor tendon pulley and sheath-related enthesitis. Ann Rheum Dis 2015;74:185–189. PMID:
  4. Choo AD, Middleton G, Wilson RL.  Nonrheumatoid inflammatory arthrosis of the hand and wrist.  J Hand Surg Am. 2015; 40:2477-2487.
  5. Nalebuff EA.  Surgery of psoriatic arthritis of the hand.  Hand Clin 1996; 12(3):603-614.
  6. Coates LC, Kavanaugh A, et al.  Group for research and assessment of psoriasis and psoriatic arthritis 2015 treatment recommendations and psoriatic arthritis.  Arth & Rheum 2016; 68(5):1060-1071.

Reviews

  1. Day MS, Nam D, Goodman S, et al. Psoriatic arthritis. J Am Acad Ortho Surg 2012;20(1):28-37. PMID: 22207516
  2. Mease P. Methotrexate in psoriatic arthritis. Bull Hosp Joint Dis 2013;71(Suppl 1):S41-5. PMID: 24219040
  3. Mease P. Update on treatment of psoriatic arthritis. Bull NYU Hosp Jt Dis 2012;70(3):167-71. PMID: 23259623
  4. Veale DJ. Psoriatic arthritis: recent progress in pathophysiology and drug development. Arthritis Res Ther 2013;15:224-9. PMID: 24611179

Classics

  1. Wright V. Psoriatic arthritis: A comparative radiographic study of rheumatoid arthritis and arthritis associated with psoriasis. Ann Rheum Dis 1961;20:123-132. PMID: 13786830
  2. Wright V, Moll JMH. Psoriatic arthritis. In: Seronegative polyarthritis. Amsterdam: North Holland Publishing, 1976, pp. 169-223.
Subscribe to PSORIATIC ARTHRITIS
⇡