PracticalDermatology

Celebrity stories often help raise awareness about medical conditions and can open the door for important conversations regarding treatment. This phenomenon is called the “Couric-Jolie effect.” When Katie Couric underwent a colonoscopy on TV to call attention to the need for such screening exams following her first husband’s death from colon cancer, Americans scheduled their colon cancer screening tests en masse.

When Angelina Jolie revealed she tested positive for the breast cancer gene and underwent a prophylactic double mastectomy and salpingo-oophorectomy, many opted for genetic counseling and testing.

Most recently, celebrity dancer, singer, and founding member of NSYNC Lance Bass revealed that he has psoriatic arthritis (PsA) after dismissing the debilitating symptoms for years. Despite the evolution and revolution of highly effective systemic and biologic therapies for psoriatic disease over the last 15 years, his story (and others) suggests there is still a lack of awareness on effective treatments. Bass is working with Amgen on their Double Take campaign to empower people to take action when it comes to PsA. As part of the campaign, Mr. Bass created a dance to help make it easy for everyone to recognize the early signs and symptoms of PsA. (PsADoubleTake.com)

Lance Bass

PsA is a comorbid chronic inflammatory disorder that affects approximately 20 to 30% of psoriasis patients, causes deformities and joint damage, impairs quality of life, and can cause long-term functional disability. Many patients like Mr. Bass have skin and joint symptoms for a long time before making this connection. We need to do better. More than 80 percent of the time PsA develops after psoriasis, thus it is important to screen psoriasis patients for early signs and symptoms of PsA. Dermatologists can help patients better understand the connection between skin and joints.

Diagnosing PsA Early

PsA is a highly heterogeneous disease, and the clinical features may overlap with other diseases such as reactive arthritis, osteoarthritis, and ankylosing spondylitis. The common and overlapping features of these diseases make the differential diagnosis challenging and may delay the diagnosis, resulting in poor physical function and permanent disability.

Rheumatologists coined the term early psoriatic arthritis (ePsA).¹ It refers to inflammatory joint symptoms and signs compatible with PsA of less than 24 months of duration. The clinical signs and symptoms of ePsA often fluctuate. Some ePsA patients rapidly progress to severe disease, while others develop clinical symptoms that remain mild or spontaneously resolve. Rheumatologists recognize that it is not easy to determine when exactly PsA begins in an individual. Currently, no biomarkers have been identified, and imaging techniques such as ultrasonography are being explored to detect subclinical synovitis and enthesitis in PsA.

Because there are no diagnostic tests for PsA, validated screening tools help identify signs and symptoms of the disease. In my practice, I find the Psoriasis Epidemiology Screening Tool (PEST) to be the most efficient and easy to use. This instrument consists of five questions with a picture of a manikin for patient markup. (See Figure 1) Furthermore, the questionnaire has shown a sensitivity of 0.94 and a specificity of 0.78. A score of ≥3 identifies psoriatic arthritis at an early stage.²

Figure 1. The Psoriasis Epidemiology Screening Tool (PEST)

A recent analysis of the Corrona Psoriasis Registry showed that the PEST questions identified more than one-tenth of registry patients as having scores ≥3 who were not thought to have PsA.³ Appropriate, earlier identification and care of PsA is important because these patients were more likely to have nail PsO, worse health status, pain, fatigue, and Dermatology Life Quality Index and activity impairment. There are multiple systemic and/or biologic treatment options that can achieve high skin clearance along with improvement in the other signs and symptoms of PsA. Mr. Bass’s dance video is another way for us to educate patients and ultimately diagnose PsA earlier.

1. Hioki T, Komine M, Ohtsuki M. Diagnosis and Intervention in Early Psoriatic Arthritis. J Clin Med. 2022;11(7):2051. Published 2022 Apr 6. doi:10.3390/jcm11072051

2. Ibrahim GH, Buch MH, Lawson C, et al. Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire. Clin Exp Rheumatol. 2009;27(3):469-74. PMID: 19604440.

3. Mease PJ, Palmer JB, Hur P, Strober BE, Lebwohl M, Karki C, Reed GW, Etzel CJ, Greenberg JD, Helliwell PS. Utilization of the validated Psoriasis Epidemiology Screening Tool to identify signs and symptoms of psoriatic arthritis among those with psoriasis: a cross-sectional analysis from the US-based Corrona Psoriasis Registry. J Eur Acad Dermatol Venereol. 2019 May;33(5):886-892. doi: 10.1111/jdv.15443. Epub 2019 Mar 5. PMID: 30663130; PMCID: PMC6593969.