Dermatologists’ Role in the Early Diagnosis of Psoriatic Arthritis: Expert Recommendations

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Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El papel del dermatólogo en el diagnóstico precoz de la artritis psoriásica: recomendaciones de un grupo de expertos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1674 "Ancho" => 2167 "Tamanyo" => 290030 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Clinical management algorithm for PsA in dermatology practices. CRP indicates C-reactive protein; HLA, human leukocyte antigen; RF, rheumatoid factor; PsA, psoriatic arthritis." ] ] ] "textoCompleto" => "IntroductionPsoriatic arthritis (PsA) is a chronic inflammatory disease with an estimated prevalence of 0.05% to 0.25% in the general population and 6% to 41% in patients with psoriasis.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It is a highly heterogeneous disease with a variable course.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> In the joints, it causes inflammation of the synovial membrane and the periosteal insertions of tendons and ligaments, leading to erosions and enthesophytes, respectively.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> PsA causes joint deformity and destruction in approximately 40% to 60% of patients and is therefore associated with functional impairment, reduced quality of life, psychosocial complications, and an increased risk of death compared with the general population.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> The manifestations of PsA are highly variable and can affect any joint; patients may have peripheral, axial, or mixed involvement.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Inflammatory pain, a characteristic feature of joint disease, improves with activity and worsens with rest and is usually accompanied by heat, swelling, morning stiffness, and limited movement.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Other hallmark manifestations of PsA are enthesitis, dactylitis, and nail involvement.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Clinical diagnosis and treatment is complex because of the heterogeneous clinical spectrum of PsA. In addition, other arthropathies must be ruled out (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Early diagnosis is essential to enable early treatment, alter the natural course of disease, and prevent irreversible inflammation-induced structural damage.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a>Several studies have shown that joint damage in patients with PsA occurs within just a few years of disease onset.<a class="elsevierStyleCrossRefs" href="#bib0080">16–18</a> One retrospective study found that a diagnostic delay of just 6 months was associated with worse long-term radiographic and functional outcomes.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>Up to 84% of patients with PsA develop skin manifestations before the joint involvement becomes clinically evident,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> meaning that dermatologists are often faced with the challenge of establishing an early diagnosis. Although dermatologists are very familiar with psoriatic skin lesions, they may have less experience with the musculoskeletal manifestations of PsA.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In addition, most of them do not routinely screen for PsA, increasing the likelihood of diagnostic delays. The prevalence of undiagnosed PsA among psoriasis patients under treatment at dermatology practices has been estimated at between 15% and 40%.<a class="elsevierStyleCrossRefs" href="#bib0100">20,22,23</a> To ensure favorable long-term clinical outcomes, dermatologists need to systematically screen for PsA in patients with psoriasis. To do this, however, they need appropriate training and practice to detect suspicious cases and enable early referral to a rheumatologist to confirm the diagnosis and initiate treatment before permanent joint damage occurs.<a class="elsevierStyleCrossRefs" href="#bib0120">24,25</a>Adequate screening tools for use by both dermatologists and primary care physicians are also lacking. While several tools exist, their usefulness in everyday practice is limited as they are time-consuming, complex, and have a high false-positive rate.The recommendations in this document, which build on and update previous recommendations,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> address several issues related to the early detection of PsA by dermatologists and draw on an updated review of psoriasis treatments and their efficacy in the treatment of joint involvement. We present a concise, systematic, structured overview of potentially useful and practical tools for the early detection of PsA by dermatologists and offer a series of recommendations and a simple, practical algorithm that may be useful for the clinical management of PsA in dermatology practices. Our recommendations are based on an updated review of the evidence and expert opinions.ObjectiveThe main aim of this study was to produce a guide to help dermatologists establish an early diagnosis of PsA in routine clinical practice.MethodsThis document was created by an expert panel formed by 9 dermatologists and 1 rheumatologist, all with extensive experience in psoriasis and PsA. The methodological approach was based on the so-called formal method for developing consensus and recommendations in which an expert panel evaluates scientific evidence and uses clinical experience (expert opinion) to achieve consensus on given clinical problems.<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a>Following the precepts of this approach, the expert panel reviewed the relevant literature and completed a previously designed questionnaire to identify important unresolved issues related to the early diagnosis of PsA and potential diagnostic tools. A face-to-face meeting was then held to analyze and discuss the results of the questionnaire, deliberate on aspects of clinical management related to the early diagnosis of PsA in dermatology practices, and achieve evidence- and experience-based consensus on discrepancies identified. Analysis of the questionnaire results and the most relevant points that emerged in the meeting formed the basis for the management algorithm and other recommendations provided in this document.Section 5 of the results section (treatment) contains a table based on the available scientific evidence that summarizes the efficacy of different psoriasis drugs for the treatment of each of the clinical domains of PsA and axial spondyloarthritis according to clinical trial results. The table also shows the number of phase 3 clinical trials, including head-to-head trials, conducted in white adults that have analyzed the efficacy of the different treatments for each domain. The literature search, performed in clinicaltrials.gov and PubMed, targeted studies published up to June 4, 2020. The references of all the articles and trials used to prepare the table are provided in Appendix A <a class="elsevierStyleCrossRef" href="#sec1035">supplementary material 1</a>.ResultsTo facilitate the early detection of PsA, this section presents a summary of the findings of the literature review and the opinions of the expert panel in 5 sections:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Screening tools</li><li class="elsevierStyleListItem" id="lsti0010">2.History taking and physical examination</li><li class="elsevierStyleListItem" id="lsti0015">3.Additional tests</li><li class="elsevierStyleListItem" id="lsti0020">4.Multidisciplinary care: referral to a rheumatologist</li><li class="elsevierStyleListItem" id="lsti0025">5.Treatment</li></ul>Screening Tools<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030">aLiterature Review</li></ul>Numerous screening tools have been developed and validated to facilitate the early diagnosis and treatment of PsA (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Two recent questionnaires are the Simple Psoriatic Arthritis Screening (SiPAS) questionnaire<a class="elsevierStyleCrossRef" href="#bib0185">37</a> and the Psoriatic arthritis UnclutteRed screening Evaluation (PURE-4) questionnaire.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> The SiPAS is a 5-item questionnaire designed to be completed quickly by the patient. It has a similar sensitivity (79%) and specificity (87%) to other questionnaires.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> The PURE-4 questionnaire has just 4 items based on the 4 domains with the highest diagnostic yield for PsA in patients with psoriasis. The initial results are promising (85.7% sensitivity and 83.6% specificity)<a class="elsevierStyleCrossRef" href="#bib0190">38</a> and the questionnaire was recently validated in Spanish.<a class="elsevierStyleCrossRef" href="#bib0195">39</a><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">bExpert Panel Recommendations</li></ul>The expert panel concluded that currently validated screening questionnaires are not ideal for early PsA detection, mainly due to the time needed for their completion and interpretation in daily practice. Nonetheless, the recently validated Spanish version of PURE-4 is promising because it is short, has high diagnostic sensitivity, and is feasible in routine clinical practice.Patient History and Physical Examination<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040">aLiterature Review</li></ul>Although PsA is a highly heterogeneous disease, its main clinical manifestations are inflammatory arthritis (peripheral), enthesitis, dactylitis, and inflammatory axial pain (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0035">7,40,41</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Nail psoriasis is also common.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> Some authors consider that patients with nail psoriasis are more likely to have enthesitis and distal interphalangeal joint disease.<a class="elsevierStyleCrossRefs" href="#bib0215">43,44</a> Dermatologists should therefore be familiar with these signs, as they may be the only manifestation of PsA during the early phase of disease.Approximately 25% of patients with PsA have inflammatory disease involving the axial skeleton; this causes pain, mainly in the lumbar region and sacroiliac joints (sacroiliitis),<a class="elsevierStyleCrossRef" href="#bib0225">45</a> and mobility limitations.<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0045">bExpert Panel Recommendations</li></ul>Based on the available scientific evidence and their clinical experience, the experts recommend that dermatologists should actively look for signs of PsA in patients with psoriasis at least once a year and ideally every 6 months by taking a complete history and evaluating key manifestations (inflammation of the axial skeleton, dactylitis, enthesitis, and peripheral arthritis) to check for inflammatory pain.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15,19,46</a>During the physical examination, special attention should be paid to the fingers and toes (particularly the distal interphalangeal joints) to check for peripheral inflammation and dactylitis (especially in the toes); the entheses (e.g., Achilles tendon) to check for enthesitis; and the spine to check for inflammatory axial pain.The expert panel also highlighted the importance of informing patients about the signs and symptoms of PsA to raise their awareness about the disease and the possibility of progression to joint disease. Informed patients will be better equipped to identify and consult their dermatologist about the manifestations of PsA, increasing thus the likelihood of an early diagnosis.Additional TestsLaboratory Tests<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0050">aLiterature Review</li></ul>Since the diagnosis of PsA is essentially clinical, it can often be difficult to distinguish between PsA and other conditions with similar manifestations. The availability of specific biomarkers could facilitate a definitive diagnosis. The different laboratory tests and their usefulness in the diagnosis of PsA are described in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0055">bExpert Panel Recommendations</li></ul><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The experts concluded that none of the currently available serum biomarkers provides sufficient information to establish a definitive diagnosis of PsA. Nonetheless, should a dermatologist decide to order blood tests before referring a patient to a rheumatologist, the following biomarkers may complement clinical findings and enable a faster diagnosis: rheumatoid factor (RF), C-reactive protein (CRP), and, in patients with axial pain, human leukocyte antigen B27 (HLA-B27). If it is not possible to request all 3 tests, high-sensitivity CRP is recommended as the test of choice.Diagnostic Imaging<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0060">aLiterature Review</li></ul>Conventional radiography (X-rays), ultrasound, and magnetic resonance imaging (MRI) have been widely used in the evaluation of PsA.A radiograph is the simplest imaging test. Radiographic evidence of juxta-articular new bone formation (not including osteophytes) in the hands or feet is one of the classification criteria for PsA.<a class="elsevierStyleCrossRef" href="#bib0260">52</a> Erosions are also a characteristic feature of joint lesions in PsA. The main purpose of radiography, however, is to identify PsA manifestations specifically present in patients with advanced disease.In recent decades, there has been a substantial increase in the use of ultrasound and MRI for the early diagnosis of PsA. Both techniques provide useful data for determining pathogenicity and level of disease activity.<a class="elsevierStyleCrossRefs" href="#bib0265">53–55</a> The findings of several studies have suggested that by detecting enthesitis and extracapsular inflammation MRI can discriminate between PsA, rheumatoid arthritis, and osteoarthritis.<a class="elsevierStyleCrossRefs" href="#bib0280">56–58</a> Ultrasound is used to detect early lesions (mainly synovitis and enthesitis). Several studies have evaluated the role of ultrasound in patients with psoriasis but without signs of joint disease.<a class="elsevierStyleCrossRefs" href="#bib0295">59,60</a> The predictive value of subclinical enthesitis in the diagnosis of PsA, however, is still unknown.In light of the growing evidence on the value of diagnostic imaging in the treatment of rheumatic diseases, the European League Against Rheumatism (EULAR) published the first recommendations on the use of imaging studies for the diagnosis and treatment of spondyloarthritis, including PsA.<a class="elsevierStyleCrossRef" href="#bib0305">61</a> Radiography, ultrasound, and MRI are recommended for patients with a personal or family history of psoriasis and signs suspicious for peripheral PsA, although MRI is indicated as a second-line option due to its limited availability and relatively high cost. The procedure of choice for the diagnosis of axial PsA is radiographic examination of the pelvis to check for sacroiliitis. An MRI, however, may be required to distinguish old bone lesions from active lesions, which will show evident bone swelling.<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0065">bExpert Panel Recommendations</li></ul>The experts consider that routine imaging tests are not feasible in daily dermatology practice. However, such tests can optimize the care process if ordered in the context of referral to rheumatology. In such cases, the recommendation is to perform a radiographic evaluation of the sacroiliac joints (if there is axial pain) and the most symptomatic joints (especially in the hands and feet). The panel also recommends MRI for patients with axial manifestations. For dermatologists skilled in interpreting images, ultrasound can be a useful tool for identifying musculoskeletal signs of PsA.Multidisciplinary Care: Referral to a Rheumatologist<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0070">aLiterature Review</li></ul>The value of multidisciplinary care is being increasingly recognized.<a class="elsevierStyleCrossRefs" href="#bib0310">62–65</a> Several models have been proposed and evaluated, including a model in which patients are seen by a rheumatologist and a dermatologist on the same day and virtual models in which they are seen by both specialists at the same clinic but at different times.<a class="elsevierStyleCrossRefs" href="#bib0310">62,66</a> Given the current coronavirus disease 2019 (COVID-19) pandemic, teledermatology models are gaining traction as a means of reducing face-to-face consultations and risk of infection.<a class="elsevierStyleCrossRefs" href="#bib0335">67,68</a> Although different teledermatology models exist in Spain, their use is not yet widespread,<a class="elsevierStyleCrossRef" href="#bib0345">69</a> although this is likely to change with the current situation.Multidisciplinary management models have been shown to improve patient care and treatment outcomes, mainly because they facilitate faster and more accurate diagnoses. Other advantages mentioned by specialists include better communication and collaboration and more research opportunities.<a class="elsevierStyleCrossRefs" href="#bib0350">70–73</a> Scheduling visits, however, remains a major challenge, as both rheumatologic and dermatologic evaluations are time consuming and require clinical experience.In light of the heterogeneity of referral criteria and procedures, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has highlighted the need for clear criteria on which patients should be referred to a rheumatologist for a more detailed evaluation.<a class="elsevierStyleCrossRef" href="#bib0370">74</a><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0075">bExpert Panel Recommendations</li></ul>The expert panel considers that dermatologists have a key role in the early diagnosis of PsA because of their involvement in psoriasis management. However, a joint evaluation is recommended to confirm diagnosis.In the event of multidisciplinary care, the experts recommend maintaining fluid, 2-way communication to monitor the patient’s condition, resolve diagnostic uncertainties, and choose an appropriate treatment strategy.In line with the recommendations published by Daudén et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> in 2012, the experts consider that patients with psoriasis and suspected PsA should be referred to a rheumatologist when they have at least 1 of the following signs or symptoms:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0080">•Inflammatory axial pain, including night pain</li><li class="elsevierStyleListItem" id="lsti0085">•Inflammatory peripheral pain or swelling</li><li class="elsevierStyleListItem" id="lsti0090">•Enthesitis or signs of enthesitis (especially in the Achilles tendon and plantar fascia)</li><li class="elsevierStyleListItem" id="lsti0095">•Dactylitis or signs of dactylitis</li></ul>As already mentioned, the expert group recommends that dermatologists should actively look for signs or symptoms of PsA at least once a year and ideally every 6 months.Finally, telemedicine could acquire a key role in the multidisciplinary management of patients with psoriasis, particularly in the current COVID-19 situation.<a class="elsevierStyleCrossRef" href="#bib0335">67</a>A proposed algorithm for the clinical management of PsA in dermatology practices is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Treatment<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0100">aLiterature Review</li></ul>Although immediate referral to a rheumatologist is recommended for patients with rapidly progressive or advanced disease or for those being treated by a dermatologist with less experience in managing PsA, the realities of the healthcare system are such that dermatologists sometimes need to take decisions regarding the treatment of a patient with psoriasis and suggestive signs of PsA.<a class="elsevierStyleCrossRefs" href="#bib0375">75,76</a>Specific treatment guidelines and recommendations for patients with early PsA are lacking. Most of the current guidelines (e.g., GRAPPA, EULAR, ACR) focus on patients with established PsA, that is patients who meet the Classification Criteria for Psoriatic Arthritis (CASPAR).<a class="elsevierStyleCrossRefs" href="#bib0385">77–79</a>Nonsteroidal anti-inflammatory drugs and other conservative strategies are usually indicated for patients with mild clinical manifestations and/or nonerosive disease. In patients with moderate to severe disease, however, first-line treatment with nonbiological disease-modifying antirheumatic drugs (conventional DMARDS) may be considered. Other options include biologic drugs (tumor necrosis factor inhibitors and interleukin [IL] 17 and IL-12/23 inhibitors) and new oral synthetic molecules (phosphodiesterase inhibitors), which have substantially improved the treatment of PsA.<a class="elsevierStyleCrossRef" href="#bib0380">76</a>Evidence on the treatment of early PsA is scarce. Nonetheless, a recent exploratory study showed that early treatment with secukinumab for 24 weeks in psoriasis patients without PsA but with arthralgia and inflammatory joint lesions resolved inflammation and stopped progression of structural changes. These results suggest that early treatment with secukinumab is possible and may lead to improved clinical and radiographic outcomes in patients with early PsA.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Another exploratory study showed that treatment with ustekinumab in patients with psoriasis but not PsA reduced subclinical enthesitis after 12 weeks.<a class="elsevierStyleCrossRef" href="#bib0400">80</a>The efficacy of psoriasis drugs for the treatment of the different clinical domains of PsA and axial spondyloarthritis as shown by clinical trials is summarized in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0105">bExpert Panel Recommendations</li></ul><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>The expert panel recommends a treatment strategy based on the different clinical manifestations of PsA. Specific treatments should be chosen according to efficacy and safety data from clinical trials and real-world experience.ConclusionsEarly diagnosis of PsA is essential, as early treatment and management can alter the natural course of PsA and prevent irreversible joint damage. The lack of adequate screening tools for this purpose, however, constitutes an unmet need addressed in this work. We have analyzed key issues, as well as potential tools and procedures that dermatologists could use for the early detection of PsA.The conclusions of each of the sections are presented below and summarized in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Screening tools. Although screening questionnaires are not useful for the early detection of PsA, the PURE-4 questionnaire, which was recently validated in Spanish, may be a feasible tool for the early detection of PsA by dermatologists in routine clinical practice.Patient history and physical examination. Dermatologists should perform a targeted physical examination to look for signs of PsA at least once a year and ideally every 6 months. In particular, the key signs are inflammatory peripheral arthritis, enthesitis (Achilles tendon and plantar fascia), dactylitis, and axial inflammatory pain.Additional tests. The use of biomarkers and imaging tests, in general, is not recommended by specialists. However, if PsA is suspected and the dermatologist decides to request laboratory tests, the experts consider that RF, CPR, and HLA-B27 could be useful. The experts also recommend requesting a radiograph of the most symptomatic joints and, if there is axial pain, the sacroiliac joints. MRI is recommended for patients with axial symptoms, and ultrasound may be useful for dermatologists who are skilled in reading images to identify musculoskeletal signs of PsA.Multidisciplinary care and referral to a rheumatologist. Dermatologists should refer patients with axial or peripheral inflammatory pain, enthesitis, or dactylitis to a rheumatologist. Fluid communication between dermatology and rheumatology departments is essential for monitoring the status of referred patients, clarifying diagnostic doubts, and making joint treatment decisions. Finally, telemedicine could have a key role in the multidisciplinary management of patients with psoriasis, particularly in the context of the current COVID-19 pandemic.Treatment. Treatment should be adapted to the different clinical manifestations of PsA and based on safety and efficacy findings from clinical trials and clinical experience.FundingNovartis Farmacéutica S.A. funded the meetings and the writing and review of this manuscript.Conflicts of InterestI. Belinchón has served as a consultant and/or speaker and/or participated in clinical trials sponsored by companies that manufacture drugs for the treatment of psoriasis, including Janssen, Almirall, Eli Lilly and Company, AbbVie, Novartis Pharmaceutica S.A., Celgene España S.L., Biogen Inc., Amgen, LEO Pharma, Pfizer-Wieth, UCB, and Merck Sharp & Dohme Española S.A.L. Salgado-Boquete: AbbVie, Almirall, Celgene España S.L., Janssen, LEO Pharma, Eli Lilly and Company, Novartis, MSD, Pfizer, and Reig Jofre.A. López-Ferrer: Novartis Farmacéutica S.A., Janssen, MSD, Eli Lilly and Company, Pfizer, Celgene España S.L., Almirall, LEO Pharma, AbbVie, and Amgen.M. Ferran has served as a speaker and/or consultant and/or participated in clinical trials for Janssen, Eli Lilly and Company, Novartis, Pfizer, MSD, AbbVie, Celgene, and Almirall.P. Coto-Segura has served on advisory committees and as a consultant, participated in clinical trials, and received grants and speaker and research support fees from the following pharmaceutical companies: AbbVie (Abbott), Janssen-Cilag, Novartis Farmacéutica S.A., Pfizer, MSD, UCB, Eli Lilly and Company, and Celgene España S.L.R. Rivera has served as a consultant, researcher and/or speaker for AbbVie, Almirall, Celgene España S.L., GlaxoSmithKline, Janssen-Cilag, Lilly, LEO Pharma, MSD, Novartis, Pfizer, and UCB.D. Vidal has served as a consultant, researcher, and/or speaker for AbbVie, Celgene España S.L., Eli Lilly and Company, Janssen, Novartis Farmacéutica S.A., Laboratorios Gebro Pharma S.A., LEO Pharma, and UCB.L. Rodríguez has served as a consultant and speaker for AbbVie, Janssen, MSD, Pfizer-Wyeth, Novartis Farmacéutica S.A., Celgene España S.L., Almirall, Eli Lilly and Company, and LEO Pharma.P. de la Cueva has served as a consultant and/or researcher, and/or speaker for AbbVie, Almirall, Astellas Pharma, Biogen Inc., Boehringer Ingelheim, Celgene España S.L., Janssen, LEO Pharma, Eli Lilly and Company, Merck Sharp & Dohme Española S.A., Novartis Farmacéutica S.A., Pfizer, and UCB.R. Queiro has served as a consultant, researcher, and/or speaker for AbbVie, MSD, Pfizer, Novartis Farmacéutica S.A., Lilly, Janssen, UCB, and Celgene España S.L. and received unconditional research funds from AbbVie, Novartis Farmacéutica S.A., and Janssen." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1435361" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1310285" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1435360" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1310286" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Methods" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Screening Tools" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Patient History and Physical Examination" ] 2 => array:3 [ "identificador" => "sec0035" "titulo" => "Additional Tests" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Laboratory Tests" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Diagnostic Imaging" ] ] ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Multidisciplinary Care: Referral to a Rheumatologist" ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "Treatment" ] ] ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of Interest" ] 11 => array:2 [ "identificador" => "xack500820" "titulo" => "Acknowledgments" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-12" "fechaAceptado" => "2020-06-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1310285" "palabras" => array:4 [ 0 => "Early diagnosis" 1 => "Psoriatic arthritis" 2 => "Psoriasis" 3 => "Screening" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1310286" "palabras" => array:4 [ 0 => "Diagnóstico precoz" 1 => "artritis psoriásica" 2 => "psoriasis" 3 => "cribado" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Psoriatic arthritis is a common type of inflammatory arthritis found in up to 40% of patients with psoriasis. Because skin involvement usually precedes joint involvement, dermatologists play a key role in early detection. Early diagnosis is important for reducing the risk of irreversible structural damage, attenuating the deterioration of physical function, and improving patients’ quality of life. This consensus statement was drafted by a group of 9 dermatologists and 1 rheumatologist to provide simple recommendations to help dermatologists screen for psoriatic arthritis in patients with psoriasis. The experts offer consensus-based guidelines that draw on a review of available scientific evidence and on experience acquired in routine clinical practice." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La artritis psoriásica (APs) es una forma común de artritis inflamatoria que aparece hasta en el 40% de los pacientes con psoriasis. Dado que la afectación cutánea suele preceder a la afectación articular, los dermatólogos desempeñan un papel fundamental en la detección precoz de la APs. El diagnóstico precoz es importante para reducir el riesgo de daños estructurales irreversibles, limitar el deterioro de la función física y mejorar la calidad de vida de los pacientes. El presente documento ha sido elaborado por un grupo de especialistas (nueve dermatólogos y un reumatólogo) con el objetivo de proporcionar recomendaciones sencillas que ayuden a los dermatólogos en el cribado de la APs en pacientes con psoriasis. Los expertos elaboraron el presente documento ofreciendo unas recomendaciones consensuadas basadas en una revisión descriptiva de la evidencia científica disponible y en la experiencia adquirida en la práctica clínica diaria." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Belinchón I, Salgado-Boquete L, López-Ferrer A, Ferran M, Coto-Segura P, Rivera R et al. El papel del dermatólogo en el diagnóstico precoz de la artritis psoriásica: recomendaciones de un grupo de expertos. Actas Dermosifiliogr. 2020;111:835–846." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec1040" ] ] ] ] "multimedia" => array:13 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1674 "Ancho" => 2167 "Tamanyo" => 290030 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Clinical management algorithm for PsA in dermatology practices. CRP indicates C-reactive protein; HLA, human leukocyte antigen; RF, rheumatoid factor; PsA, psoriatic arthritis." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Psoriatic Arthritis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Arthrosis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Gout \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Chondrocalcinosis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Infectious Arthritis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fibromyalgia \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex, age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male/femaleMiddle-aged \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male/femaleMiddle-aged/elderly \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MaleMiddle-aged/young \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male/femaleElderly \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male/femaleAny age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FemaleMiddle-aged \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gradual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gradual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sudden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sudden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sudden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gradual \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Joint involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PeripheralAsymmetricOligo/polyarticular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Peripheral/axialAsymmetricMono/oligoarticular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PeripheralAsymmetricMono/oligoarticular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VariableKnee in > 50% casesCarpal joints, hip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VariableMonoarticularFrequent joint involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Numerous localized areas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of pain and duration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inflammatory Long-durationHigher intensity or worsening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MechanicalLong-durationHigher intensity or worsening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inflammatory 48-72 h (1-2 wk if not treated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inflammatory Variable (days-weeks) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inflammatory Lasts until treated with antimicrobials \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MultipleContinuous with periodic, fluctuating exacerbations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Axial involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CommonMay be silent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rare (spondylodiscitis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Axial pain common \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enthesitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dactylitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nail psoriasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2469250.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Other entities that might be considered in the differential diagnosis, such as rheumatoid arthritis, systemic lupus erythematosus, and sarcoidosis, have very clear characteristics and classification criteria." ] ] ] "descripcion" => array:1 [ "en" => "Differential Diagnosis of Psoriatic Arthritis<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>: Key Characteristics of Main Arthropathies.<a class="elsevierStyleCrossRefs" href="#bib0050">10–13</a>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Abbreviations: EARP, Early Arthritis for Psoriatic Patients screening questionnaire; PASE, Psoriatic Arthritis screening and Evaluation questionnaire; PASQ, Psoriasis and Arthritis Screening Questionnaire; PsA; psoriatic arthritis; ToPAS, Toronto Psoriatic Arthritis Screening questionnaire." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Screening Tool \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PASE<a class="elsevierStyleCrossRef" href="#bib0140">28</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PEST<a class="elsevierStyleCrossRefs" href="#bib0145">29,30</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ToPAS<a class="elsevierStyleCrossRefs" href="#bib0155">31,32</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PASQ/ePASQ<a class="elsevierStyleCrossRef" href="#bib0165">33</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EARP<a class="elsevierStyleCrossRef" href="#bib0170">34</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advantages \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distinguishes between symptoms of PsA and osteoarthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Simple and quick \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Can be used to screen for psoriasis and PsA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Provides a diagram for assessing joints \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Simple and quick \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drawbacks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complex scoring system \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Does not include questions about cutaneous or axial manifestations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not designed for early detection of PSA (requires symptoms to have been present for ≥3 mo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Does not include questions about cutaneous manifestations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Does not include questions about cutaneous manifestations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sensitivity<a class="elsevierStyleCrossRefs" href="#bib0120">24,33,35,36</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59%–82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68%–97% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70%–86.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86.27%<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a>92.86%<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Specificity<a class="elsevierStyleCrossRefs" href="#bib0120">24,33,35,36</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66%–73% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71%–79% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.89%<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a>75%<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75%–85% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expert opinions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Current validated screening questionnaires are not ideal for early PsA as they have low sensitivity and specificity in routine clinical practice and require time to administer and interpret.</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2469251.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Established disease." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "Early disease." ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of Screening Tools for the Early Detection of PsA." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of Inflammation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Signs and Symptoms \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="fig1005"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Morning stiffness ≥ 30 min; joint swelling; pain that improves with activity and gets worse with rest; limited mobility \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="fig2005"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic back pain; chronic pain involving buttocks, hips, and behind the thighs; morning stiffness; limited mobility and flexibility \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="fig3005"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Swelling; heat; erythema; sensitivity at inflammation site; reduced mobility; sausage-like digits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="fig4005"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain next to the joint; swelling at site of pain; functional limitations; history of plantar fascitis; pain involving the enthesis (Achilles tendon, plantar fascia, quadriceps tendon, patellar ligament, iliac crest); more common in the lower than upper extremities \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2469252.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical Characteristics of Inflammatory Arthritis, Enthesitis, Dactylitis, and Spondylitis or Axial Pain.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>" ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: CASPAR, ClASsification criteria for Psoriatic ARthritis; CCP, cyclic citrullated peptide; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; HLA, human leukocyte antigen; PsA, psoriatic arthritis; RF, rheumatoid factor." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Laboratory test \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Description \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Usefulness for Diagnosing PsA \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESR, CRP<a class="elsevierStyleCrossRef" href="#bib0235">47</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Most common blood abnormalities detected in PsA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elevated in just 50% of patients with PSA; more useful for follow-up than diagnosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RF, CCP antibodies<a class="elsevierStyleCrossRefs" href="#bib0240">48–50</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with PsA are usually seronegative; RF negativity is a CASPAR criterion for the diagnosis of PsA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive in 5% to 20% of patients with PsA; accordingly, seropositivity for RF or CCP antibodies in patients with characteristic manifestations of PsA does not necessarily rule out a diagnosis of PsA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HLA C*06:02, HLA B*08:01, B*27:05, B*38:01, and B*39:01 alleles<a class="elsevierStyleCrossRef" href="#bib0255">51</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HLA C * 06: 02 is strongly associated with psoriasis, while HLA B * 08: 01, B * 27: 05, B * 38: 01, and B * 39: 01 are associated with early-onset PsA and certain specific features of the disease, such as sacroiliitis, enthesitis, and dactylitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low predictive value and of limited use in the diagnosis of PsA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2469247.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Possible Biomarkers for Diagnosing PsA." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: ADA, adalimumab; APR, apremilast; BRO, brodalumab; CER, certolizumab; ETA, etanercept; GUS, guselkumab; IL, interleukin; INF, infliximab; IXE, ixekizumab; NonRx, nonradiographic; PDE4, phosphodiesterase inhibitor 4; PsA, psoriatic arthritis; RIS, risankizumab; Rx, radiographic; SEC, secukinumab; SpA, spondyloarthritis; TIL, tildrakizumab; TNF, tumor necrosis factor; UST, ustekinumab.*The term early PsA refers to exploratory studies in which patients did not have a definitive diagnosis of PsA." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202012160744289801"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2469248.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of Clinical Efficacy of Systemic Biologic Drugs and Oral Small Molecules Approved for Psoriasis in the Treatment of the Clinical Domains of Psoriatic Arthritis and Axial Spondyloarthritis. The number in each circle indicates the number of clinical trials evaluating a given domain. All the references for the articles and clinical trials used to prepare this table are provided in Appendix A supplementary material 1. Supplementary material" ] ] 6 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: CRP, C-reactive protein; HLA, human leukocyte antigen; RF, rheumatoid factor; PSA, psoriatic arthritis; PURE-4, Psoriatic arthritis UnclutteRed screening Evaluation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnostic Tools \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Expert Recommendations \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Screening questionnaires \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not ideal for early PsA detection and time consuming, although the PURE-4 questionnaire appears to be promising \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">History taking and physical examination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Once a year and ideally every 6 monthsLook for:• Peripheral inflammatory arthritis• Dactylitis • Enthesitis (Achilles tendon and plantar fascia)• Inflammatory axial pain \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Additional tests: laboratory tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biomarkers not recommended as a diagnostic tool for PsAUseful laboratory tests:• CRP• HLA-B27 (if inflammatory axial pain)• RF (CASPAR criteria) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnostic imaging \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Radiographs of most symptomatic joints• Ultrasound if dermatologist is skilled at reading images \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multidisciplinary care: referral to a rheumatologist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fluid, 2-way dialogue between dermatologists and rheumatologistsReferral to a rheumatologist is recommended if PsA is suspected and the patient has:• inflammatory or night pain involving the axial skeleton• peripheral inflammatory pain, joint swelling• enthesitis or clinical signs of enthesitis (especially in Achilles tendon and plantar fascia)• dactylitis or suggestive clinical signs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Bear in mind the different possible manifestations of PsA• Choose treatment according to clinical experience and safety and efficacy results from clinical trials \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2469249.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of Recommendations." ] ] 7 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 175958 ] ] 8 => array:5 [ "identificador" => "fig1005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 1568 "Ancho" => 1333 "Tamanyo" => 111694 ] ] ] 9 => array:5 [ "identificador" => "fig2005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx2.jpeg" "Alto" => 1488 "Ancho" => 1333 "Tamanyo" => 100680 ] ] ] 10 => array:5 [ "identificador" => "fig3005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx3.jpeg" "Alto" => 1546 "Ancho" => 1333 "Tamanyo" => 112404 ] ] ] 11 => array:5 [ "identificador" => "fig4005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx4.jpeg" "Alto" => 1483 "Ancho" => 1333 "Tamanyo" => 82309 ] ] ] 12 => array:5 [ "identificador" => "202012160744289801" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx5.jpeg" "Alto" => 1894 "Ancho" => 2917 "Tamanyo" => 474666 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:80 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epidemiology of psoriatic arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rdc.2015.07.001" "Revista" => array:6 [ "tituloSerie" => "Rheum Dis Clin North Am." 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"vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011100000010/v1_202012160744/S1578219020303218/v1_202012160744/en/main.assets" "Apartado" => array:4 [ "identificador" => "6228" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Consensus document" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000011100000010/v1_202012160744/S1578219020303218/v1_202012160744/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219020303218?idApp=UINPBA000044"]

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Dermatologists’ Role in the Early Diagnosis of Psoriatic Arthritis: Expert Recommendations

El papel del dermatólogo en el diagnóstico precoz de la artritis psoriásica: recomendaciones de un grupo de expertos

I Belinchóna, L Salgado-Boqueteb, A López-Ferrerc, M Ferrand, P Coto-Segurae, R Riveraf, D Vidalg, L Rodríguezh, P de la Cuevai,

Corresponding author

pdelacueva@yahoo.com

Corresponding author.

, R Queiroj

a Servicio de Dermatología, Hospital General Universitario de Alicante-ISABIAL-UMH, Alicante, Spain

b Servicio de Dermatología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain

c Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

d Servicio de Dermatología, Hospital del Mar, Barcelona, Spain

e Servicio de Dermatología, Hospital Álvarez-Buylla, Mieres, Asturias, Spain

f Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain

g Servicio de Dermatología, Hospital de Sant Joan Despí Moisès Broggi, Sant Joan Despí, Barcelona, Spain

h Servicio de Dermatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain

i Servicio de Dermatología, Hospital Universitario Infanta Leonor, Madrid, Spain

j Servicio de Reumatología, Hospital Universitario Central de Asturias, Oviedo, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriatic arthritis &#40;PsA&#41; is a chronic inflammatory disease with an estimated prevalence of 0&#46;05&#37; to 0&#46;25&#37; in the general population and 6&#37; to 41&#37; in patients with psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is a highly heterogeneous disease with a variable course&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the joints&#44; it causes inflammation of the synovial membrane and the periosteal insertions of tendons and ligaments&#44; leading to erosions and enthesophytes&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> PsA causes joint deformity and destruction in approximately 40&#37; 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In addition&#44; other arthropathies must be ruled out &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Early diagnosis is essential to enable early treatment&#44; alter the natural course of disease&#44; and prevent irreversible inflammation-induced structural damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Several studies have shown that joint damage in patients with PsA occurs within just a few years of disease onset&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;18</span></a> One retrospective study found that a diagnostic delay of just 6 months was associated with worse long-term radiographic and functional outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Up to 84&#37; of patients with PsA develop skin manifestations before the joint involvement becomes clinically evident&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> meaning that dermatologists are often faced with the challenge of establishing an early diagnosis&#46; Although dermatologists are very familiar with psoriatic skin lesions&#44; they may have less experience with the musculoskeletal manifestations of PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In addition&#44; most of them do not routinely screen for PsA&#44; increasing the likelihood of diagnostic delays&#46; The prevalence of undiagnosed PsA among psoriasis patients under treatment at dermatology practices has been estimated at between 15&#37; and 40&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;22&#44;23</span></a> To ensure favorable long-term clinical outcomes&#44; dermatologists need to systematically screen for PsA in patients with psoriasis&#46; To do this&#44; however&#44; they need appropriate training and practice to detect suspicious cases and enable early referral to a rheumatologist to confirm the diagnosis and initiate treatment before permanent joint damage occurs&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Adequate screening tools for use by both dermatologists and primary care physicians are also lacking&#46; While several tools exist&#44; their usefulness in everyday practice is limited as they are time-consuming&#44; complex&#44; and have a high false-positive rate&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The recommendations in this document&#44; which build on and update previous recommendations&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> address several issues related to the early detection of PsA by dermatologists and draw on an updated review of psoriasis treatments and their efficacy in the treatment of joint involvement&#46; We present a concise&#44; systematic&#44; structured overview of potentially useful and practical tools for the early detection of PsA by dermatologists and offer a series of recommendations and a simple&#44; practical algorithm that may be useful for the clinical management of PsA in dermatology practices&#46; Our recommendations are based on an updated review of the evidence and expert opinions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Objective</span><p id="par0040" class="elsevierStylePara elsevierViewall">The main aim of this study was to produce a guide to help dermatologists establish an early diagnosis of PsA in routine clinical practice&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">This document was created by an expert panel formed by 9 dermatologists and 1 rheumatologist&#44; all with extensive experience in psoriasis and PsA&#46; The methodological approach was based on the so-called <span class="elsevierStyleItalic">formal</span> method for developing consensus and recommendations in which an expert panel evaluates scientific evidence and uses clinical experience &#40;expert opinion&#41; to achieve consensus on given clinical problems&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Following the precepts of this approach&#44; the expert panel reviewed the relevant literature and completed a previously designed questionnaire to identify important unresolved issues related to the early diagnosis of PsA and potential diagnostic tools&#46; A face-to-face meeting was then held to analyze and discuss the results of the questionnaire&#44; deliberate on aspects of clinical management related to the early diagnosis of PsA in dermatology practices&#44; and achieve evidence- and experience-based consensus on discrepancies identified&#46; Analysis of the questionnaire results and the most relevant points that emerged in the meeting formed the basis for the management algorithm and other recommendations provided in this document&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Section 5 of the results section &#40;treatment&#41; contains a table based on the available scientific evidence that summarizes the efficacy of different psoriasis drugs for the treatment of each of the clinical domains of PsA and axial spondyloarthritis according to clinical trial results&#46; The table also shows the number of phase 3 clinical trials&#44; including head-to-head trials&#44; conducted in white adults that have analyzed the efficacy of the different treatments for each domain&#46; The literature search&#44; performed in clinicaltrials&#46;gov and PubMed&#44; targeted studies published up to June 4&#44; 2020&#46; The references of all the articles and trials used to prepare the table are provided in Appendix A <a class="elsevierStyleCrossRef" href="#sec1035">supplementary material 1</a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">To facilitate the early detection of PsA&#44; this section presents a summary of the findings of the literature review and the opinions of the expert panel in 5 sections&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Screening tools</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">History taking and physical examination</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Additional tests</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Multidisciplinary care&#58; referral to a rheumatologist</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Treatment</p></li></ul></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Screening Tools</span><p id="par0090" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">a</span><p id="par0095" class="elsevierStylePara elsevierViewall">Literature Review</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">Numerous screening tools have been developed and validated to facilitate the early diagnosis and treatment of PsA &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Two recent questionnaires are the Simple Psoriatic Arthritis Screening &#40;SiPAS&#41; questionnaire<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> and the Psoriatic arthritis UnclutteRed screening Evaluation &#40;PURE-4&#41; questionnaire&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The SiPAS is a 5-item questionnaire designed to be completed quickly by the patient&#46; It has a similar sensitivity &#40;79&#37;&#41; and specificity &#40;87&#37;&#41; to other questionnaires&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The PURE-4 questionnaire has just 4 items based on the 4 domains with the highest diagnostic yield for PsA in patients with psoriasis&#46; The initial results are promising &#40;85&#46;7&#37; sensitivity and 83&#46;6&#37; specificity&#41;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> and the questionnaire was recently validated in Spanish&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">b</span><p id="par0110" class="elsevierStylePara elsevierViewall">Expert Panel Recommendations</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">The expert panel concluded that currently validated screening questionnaires are not ideal for early PsA detection&#44; mainly due to the time needed for their completion and interpretation in daily practice&#46; Nonetheless&#44; the recently validated Spanish version of PURE-4 is promising because it is short&#44; has high diagnostic sensitivity&#44; and is feasible in routine clinical practice&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Patient History and Physical Examination</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">a</span><p id="par0125" class="elsevierStylePara elsevierViewall">Literature Review</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">Although PsA is a highly heterogeneous disease&#44; its main clinical manifestations are inflammatory arthritis &#40;peripheral&#41;&#44; enthesitis&#44; dactylitis&#44; and inflammatory axial pain &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;40&#44;41</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Nail psoriasis is also common&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Some authors consider that patients with nail psoriasis are more likely to have enthesitis and distal interphalangeal joint disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;44</span></a> Dermatologists should therefore be familiar with these signs&#44; as they may be the only manifestation of PsA during the early phase of disease&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Approximately 25&#37; of patients with PsA have inflammatory disease involving the axial skeleton&#59; this causes pain&#44; mainly in the lumbar region and sacroiliac joints &#40;sacroiliitis&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> and mobility limitations&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">b</span><p id="par0145" class="elsevierStylePara elsevierViewall">Expert Panel Recommendations</p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">Based on the available scientific evidence and their clinical experience&#44; the experts recommend that dermatologists should actively look for signs of PsA in patients with psoriasis at least once a year and ideally every 6 months by taking a complete history and evaluating key manifestations &#40;inflammation of the axial skeleton&#44; dactylitis&#44; enthesitis&#44; and peripheral arthritis&#41; to check for inflammatory pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15&#44;19&#44;46</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">During the physical examination&#44; special attention should be paid to the fingers and toes &#40;particularly the distal interphalangeal joints&#41; to check for peripheral inflammation and dactylitis &#40;especially in the toes&#41;&#59; the entheses &#40;e&#46;g&#46;&#44; Achilles tendon&#41; to check for enthesitis&#59; and the spine to check for inflammatory axial pain&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The expert panel also highlighted the importance of informing patients about the signs and symptoms of PsA to raise their awareness about the disease and the possibility of progression to joint disease&#46; Informed patients will be better equipped to identify and consult their dermatologist about the manifestations of PsA&#44; increasing thus the likelihood of an early diagnosis&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Additional Tests</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Laboratory Tests</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">a</span><p id="par0170" class="elsevierStylePara elsevierViewall">Literature Review</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">Since the diagnosis of PsA is essentially clinical&#44; it can often be difficult to distinguish between PsA and other conditions with similar manifestations&#46; The availability of specific biomarkers could facilitate a definitive diagnosis&#46; The different laboratory tests and their usefulness in the diagnosis of PsA are described in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">b</span><p id="par0180" class="elsevierStylePara elsevierViewall">Expert Panel Recommendations</p></li></ul></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">The experts concluded that none of the currently available serum biomarkers provides sufficient information to establish a definitive diagnosis of PsA&#46; Nonetheless&#44; should a dermatologist decide to order blood tests before referring a patient to a rheumatologist&#44; the following biomarkers may complement clinical findings and enable a faster diagnosis&#58; rheumatoid factor &#40;RF&#41;&#44; C-reactive protein &#40;CRP&#41;&#44; and&#44; in patients with axial pain&#44; human leukocyte antigen B27 &#40;HLA-B27&#41;&#46; If it is not possible to request all 3 tests&#44; high-sensitivity CRP is recommended as the test of choice&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagnostic Imaging</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">a</span><p id="par0195" class="elsevierStylePara elsevierViewall">Literature Review</p></li></ul></p><p id="par0200" class="elsevierStylePara elsevierViewall">Conventional radiography &#40;X-rays&#41;&#44; ultrasound&#44; and magnetic resonance imaging &#40;MRI&#41; have been widely used in the evaluation of PsA&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">A radiograph is the simplest imaging test&#46; Radiographic evidence of juxta-articular new bone formation &#40;not including osteophytes&#41; in the hands or feet is one of the classification criteria for PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Erosions are also a characteristic feature of joint lesions in PsA&#46; The main purpose of radiography&#44; however&#44; is to identify PsA manifestations specifically present in patients with advanced disease&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In recent decades&#44; there has been a substantial increase in the use of ultrasound and MRI for the early diagnosis of PsA&#46; Both techniques provide useful data for determining pathogenicity and level of disease activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53&#8211;55</span></a> The findings of several studies have suggested that by detecting enthesitis and extracapsular inflammation MRI can discriminate between PsA&#44; rheumatoid arthritis&#44; and osteoarthritis&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#8211;58</span></a> Ultrasound is used to detect early lesions &#40;mainly synovitis and enthesitis&#41;&#46; Several studies have evaluated the role of ultrasound in patients with psoriasis but without signs of joint disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59&#44;60</span></a> The predictive value of subclinical enthesitis in the diagnosis of PsA&#44; however&#44; is still unknown&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In light of the growing evidence on the value of diagnostic imaging in the treatment of rheumatic diseases&#44; the European League Against Rheumatism &#40;EULAR&#41; published the first recommendations on the use of imaging studies for the diagnosis and treatment of spondyloarthritis&#44; including PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> Radiography&#44; ultrasound&#44; and MRI are recommended for patients with a personal or family history of psoriasis and signs suspicious for peripheral PsA&#44; although MRI is indicated as a second-line option due to its limited availability and relatively high cost&#46; The procedure of choice for the diagnosis of axial PsA is radiographic examination of the pelvis to check for sacroiliitis&#46; An MRI&#44; however&#44; may be required to distinguish old bone lesions from active lesions&#44; which will show evident bone swelling&#46;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">b</span><p id="par0220" class="elsevierStylePara elsevierViewall">Expert Panel Recommendations</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">The experts consider that routine imaging tests are not feasible in daily dermatology practice&#46; However&#44; such tests can optimize the care process if ordered in the context of referral to rheumatology&#46; In such cases&#44; the recommendation is to perform a radiographic evaluation of the sacroiliac joints &#40;if there is axial pain&#41; and the most symptomatic joints &#40;especially in the hands and feet&#41;&#46; The panel also recommends MRI for patients with axial manifestations&#46; For dermatologists skilled in interpreting images&#44; ultrasound can be a useful tool for identifying musculoskeletal signs of PsA&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Multidisciplinary Care&#58; Referral to a Rheumatologist</span><p id="par0230" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">a</span><p id="par0235" class="elsevierStylePara elsevierViewall">Literature Review</p></li></ul></p><p id="par0240" class="elsevierStylePara elsevierViewall">The value of multidisciplinary care is being increasingly recognized&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#8211;65</span></a> Several models have been proposed and evaluated&#44; including a model in which patients are seen by a rheumatologist and a dermatologist on the same day and virtual models in which they are seen by both specialists at the same clinic but at different times&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#44;66</span></a> Given the current coronavirus disease 2019 &#40;COVID-19&#41; pandemic&#44; teledermatology models are gaining traction as a means of reducing face-to-face consultations and risk of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67&#44;68</span></a> Although different teledermatology models exist in Spain&#44; their use is not yet widespread&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> although this is likely to change with the current situation&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Multidisciplinary management models have been shown to improve patient care and treatment outcomes&#44; mainly because they facilitate faster and more accurate diagnoses&#46; Other advantages mentioned by specialists include better communication and collaboration and more research opportunities&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#8211;73</span></a> Scheduling visits&#44; however&#44; remains a major challenge&#44; as both rheumatologic and dermatologic evaluations are time consuming and require clinical experience&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">In light of the heterogeneity of referral criteria and procedures&#44; the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis &#40;GRAPPA&#41; has highlighted the need for clear criteria on which patients should be referred to a rheumatologist for a more detailed evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">b</span><p id="par0255" class="elsevierStylePara elsevierViewall">Expert Panel Recommendations</p></li></ul></p><p id="par0260" class="elsevierStylePara elsevierViewall">The expert panel considers that dermatologists have a key role in the early diagnosis of PsA because of their involvement in psoriasis management&#46; However&#44; a joint evaluation is recommended to confirm diagnosis&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">In the event of multidisciplinary care&#44; the experts recommend maintaining fluid&#44; 2-way communication to monitor the patient&#8217;s condition&#44; resolve diagnostic uncertainties&#44; and choose an appropriate treatment strategy&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">In line with the recommendations published by Daud&#233;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in 2012&#44; the experts consider that patients with psoriasis and suspected PsA should be referred to a rheumatologist when they have at least 1 of the following signs or symptoms&#58;<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Inflammatory axial pain&#44; including night pain</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Inflammatory peripheral pain or swelling</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Enthesitis or signs of enthesitis &#40;especially in the Achilles tendon and plantar fascia&#41;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Dactylitis or signs of dactylitis</p></li></ul></p><p id="par0295" class="elsevierStylePara elsevierViewall">As already mentioned&#44; the expert group recommends that dermatologists should actively look for signs or symptoms of PsA at least once a year and ideally every 6 months&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">Finally&#44; telemedicine could acquire a key role in the multidisciplinary management of patients with psoriasis&#44; particularly in the current COVID-19 situation&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">A proposed algorithm for the clinical management of PsA in dermatology practices is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment</span><p id="par0310" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">a</span><p id="par0315" class="elsevierStylePara elsevierViewall">Literature Review</p></li></ul></p><p id="par0320" class="elsevierStylePara elsevierViewall">Although immediate referral to a rheumatologist is recommended for patients with rapidly progressive or advanced disease or for those being treated by a dermatologist with less experience in managing PsA&#44; the realities of the healthcare system are such that dermatologists sometimes need to take decisions regarding the treatment of a patient with psoriasis and suggestive signs of PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">75&#44;76</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">Specific treatment guidelines and recommendations for patients with early PsA are lacking&#46; Most of the current guidelines &#40;e&#46;g&#46;&#44; GRAPPA&#44; EULAR&#44; ACR&#41; focus on patients with established PsA&#44; that is patients who meet the Classification Criteria for Psoriatic Arthritis &#40;CASPAR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#8211;79</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">Nonsteroidal anti-inflammatory drugs and other conservative strategies are usually indicated for patients with mild clinical manifestations and&#47;or nonerosive disease&#46; In patients with moderate to severe disease&#44; however&#44; first-line treatment with nonbiological disease-modifying antirheumatic drugs &#40;conventional DMARDS&#41; may be considered&#46; Other options include biologic drugs &#40;tumor necrosis factor inhibitors and interleukin &#91;IL&#93; 17 and IL-12&#47;23 inhibitors&#41; and new oral synthetic molecules &#40;phosphodiesterase inhibitors&#41;&#44; which have substantially improved the treatment of PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">Evidence on the treatment of early PsA is scarce&#46; Nonetheless&#44; a recent exploratory study showed that early treatment with secukinumab for 24 weeks in psoriasis patients without PsA but with arthralgia and inflammatory joint lesions resolved inflammation and stopped progression of structural changes&#46; These results suggest that early treatment with secukinumab is possible and may lead to improved clinical and radiographic outcomes in patients with early PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Another exploratory study showed that treatment with ustekinumab in patients with psoriasis but not PsA reduced subclinical enthesitis after 12 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">The efficacy of psoriasis drugs for the treatment of the different clinical domains of PsA and axial spondyloarthritis as shown by clinical trials is summarized in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">b</span><p id="par0345" class="elsevierStylePara elsevierViewall">Expert Panel Recommendations</p></li></ul></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0350" class="elsevierStylePara elsevierViewall">The expert panel recommends a treatment strategy based on the different clinical manifestations of PsA&#46; Specific treatments should be chosen according to efficacy and safety data from clinical trials and real-world experience&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0355" class="elsevierStylePara elsevierViewall">Early diagnosis of PsA is essential&#44; as early treatment and management can alter the natural course of PsA and prevent irreversible joint damage&#46; The lack of adequate screening tools for this purpose&#44; however&#44; constitutes an unmet need addressed in this work&#46; We have analyzed key issues&#44; as well as potential tools and procedures that dermatologists could use for the early detection of PsA&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">The conclusions of each of the sections are presented below and summarized in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0365" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Screening tools&#46;</span> Although screening questionnaires are not useful for the early detection of PsA&#44; the PURE-4 questionnaire&#44; which was recently validated in Spanish&#44; may be a feasible tool for the early detection of PsA by dermatologists in routine clinical practice&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient history and physical examination&#46;</span> Dermatologists should perform a targeted physical examination to look for signs of PsA at least once a year and ideally every 6 months&#46; In particular&#44; the key signs are inflammatory peripheral arthritis&#44; enthesitis &#40;Achilles tendon and plantar fascia&#41;&#44; dactylitis&#44; and axial inflammatory pain&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Additional tests</span>&#46; The use of biomarkers and imaging tests&#44; in general&#44; is not recommended by specialists&#46; However&#44; if PsA is suspected and the dermatologist decides to request laboratory tests&#44; the experts consider that RF&#44; CPR&#44; and HLA-B27 could be useful&#46; The experts also recommend requesting a radiograph of the most symptomatic joints and&#44; if there is axial pain&#44; the sacroiliac joints&#46; MRI is recommended for patients with axial symptoms&#44; and ultrasound may be useful for dermatologists who are skilled in reading images to identify musculoskeletal signs of PsA&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Multidisciplinary care and referral to a rheumatologist</span>&#46; Dermatologists should refer patients with axial or peripheral inflammatory pain&#44; enthesitis&#44; or dactylitis to a rheumatologist&#46; Fluid communication between dermatology and rheumatology departments is essential for monitoring the status of referred patients&#44; clarifying diagnostic doubts&#44; and making joint treatment decisions&#46; Finally&#44; telemedicine could have a key role in the multidisciplinary management of patients with psoriasis&#44; particularly in the context of the current COVID-19 pandemic&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment</span>&#46; Treatment should be adapted to the different clinical manifestations of PsA and based on safety and efficacy findings from clinical trials and clinical experience&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0390" class="elsevierStylePara elsevierViewall">Novartis Farmac&#233;utica S&#46;A&#46; funded the meetings and the writing and review of this manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of Interest</span><p id="par0395" class="elsevierStylePara elsevierViewall">I&#46; Belinch&#243;n has served as a consultant and&#47;or speaker and&#47;or participated in clinical trials sponsored by companies that manufacture drugs for the treatment of psoriasis&#44; including Janssen&#44; Almirall&#44; Eli Lilly and Company&#44; AbbVie&#44; Novartis Pharmaceutica S&#46;A&#46;&#44; Celgene Espa&#241;a S&#46;L&#46;&#44; Biogen Inc&#46;&#44; Amgen&#44; LEO Pharma&#44; Pfizer-Wieth&#44; UCB&#44; and Merck Sharp &#38; Dohme Espa&#241;ola S&#46;A&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall">L&#46; Salgado-Boquete&#58; AbbVie&#44; Almirall&#44; Celgene Espa&#241;a S&#46;L&#46;&#44; Janssen&#44; LEO Pharma&#44; Eli Lilly and Company&#44; Novartis&#44; MSD&#44; Pfizer&#44; and Reig Jofre&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">A&#46; L&#243;pez-Ferrer&#58; Novartis Farmac&#233;utica S&#46;A&#46;&#44; Janssen&#44; MSD&#44; Eli Lilly and Company&#44; Pfizer&#44; Celgene Espa&#241;a S&#46;L&#46;&#44; Almirall&#44; LEO Pharma&#44; AbbVie&#44; and Amgen&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">M&#46; Ferran has served as a speaker and&#47;or consultant and&#47;or participated in clinical trials for Janssen&#44; Eli Lilly and Company&#44; Novartis&#44; Pfizer&#44; MSD&#44; AbbVie&#44; Celgene&#44; and Almirall&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall">P&#46; Coto-Segura has served on advisory committees and as a consultant&#44; participated in clinical trials&#44; and received grants and speaker and research support fees from the following pharmaceutical companies&#58; AbbVie &#40;Abbott&#41;&#44; Janssen-Cilag&#44; Novartis Farmac&#233;utica S&#46;A&#46;&#44; Pfizer&#44; MSD&#44; UCB&#44; Eli Lilly and Company&#44; and Celgene Espa&#241;a S&#46;L&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">R&#46; Rivera has served as a consultant&#44; researcher and&#47;or speaker for AbbVie&#44; Almirall&#44; Celgene Espa&#241;a S&#46;L&#46;&#44; GlaxoSmithKline&#44; Janssen-Cilag&#44; Lilly&#44; LEO Pharma&#44; MSD&#44; Novartis&#44; Pfizer&#44; and UCB&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">D&#46; Vidal has served as a consultant&#44; researcher&#44; and&#47;or speaker for AbbVie&#44; Celgene Espa&#241;a S&#46;L&#46;&#44; Eli Lilly and Company&#44; Janssen&#44; Novartis Farmac&#233;utica S&#46;A&#46;&#44; Laboratorios Gebro Pharma S&#46;A&#46;&#44; LEO Pharma&#44; and UCB&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">L&#46; Rodr&#237;guez has served as a consultant and speaker for AbbVie&#44; Janssen&#44; MSD&#44; Pfizer-Wyeth&#44; Novartis Farmac&#233;utica S&#46;A&#46;&#44; Celgene Espa&#241;a S&#46;L&#46;&#44; Almirall&#44; Eli Lilly and Company&#44; and LEO Pharma&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">P&#46; de la Cueva has served as a consultant and&#47;or researcher&#44; and&#47;or speaker for AbbVie&#44; Almirall&#44; Astellas Pharma&#44; Biogen Inc&#46;&#44; Boehringer Ingelheim&#44; Celgene Espa&#241;a S&#46;L&#46;&#44; Janssen&#44; LEO Pharma&#44; Eli Lilly and Company&#44; Merck Sharp &#38; Dohme Espa&#241;ola S&#46;A&#46;&#44; Novartis Farmac&#233;utica S&#46;A&#46;&#44; Pfizer&#44; and UCB&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">R&#46; Queiro has served as a consultant&#44; researcher&#44; and&#47;or speaker for AbbVie&#44; MSD&#44; Pfizer&#44; Novartis Farmac&#233;utica S&#46;A&#46;&#44; Lilly&#44; Janssen&#44; UCB&#44; and Celgene Espa&#241;a S&#46;L&#46; and received unconditional research funds from AbbVie&#44; Novartis Farmac&#233;utica S&#46;A&#46;&#44; and Janssen&#46;</p></span></span>"
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            1 => array:2 [
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                0 => array:2 [
                  "identificador" => "sec0040"
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                1 => array:2 [
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              "titulo" => "Multidisciplinary Care&#58; Referral to a Rheumatologist"
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          "identificador" => "xack500820"
          "titulo" => "Acknowledgments"
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        12 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-05-12"
    "fechaAceptado" => "2020-06-29"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:4 [
            0 => "Early diagnosis"
            1 => "Psoriatic arthritis"
            2 => "Psoriasis"
            3 => "Screening"
          ]
        ]
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Diagn&#243;stico precoz"
            1 => "artritis psori&#225;sica"
            2 => "psoriasis"
            3 => "cribado"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Psoriatic arthritis is a common type of inflammatory arthritis found in up to 40&#37; of patients with psoriasis&#46; Because skin involvement usually precedes joint involvement&#44; dermatologists play a key role in early detection&#46; Early diagnosis is important for reducing the risk of irreversible structural damage&#44; attenuating the deterioration of physical function&#44; and improving patients&#8217; quality of life&#46; This consensus statement was drafted by a group of 9 dermatologists and 1 rheumatologist to provide simple recommendations to help dermatologists screen for psoriatic arthritis in patients with psoriasis&#46; The experts offer consensus-based guidelines that draw on a review of available scientific evidence and on experience acquired in routine clinical practice&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La artritis psori&#225;sica &#40;APs&#41; es una forma com&#250;n de artritis inflamatoria que aparece hasta en el 40&#37; de los pacientes con psoriasis&#46; Dado que la afectaci&#243;n cut&#225;nea suele preceder a la afectaci&#243;n articular&#44; los dermat&#243;logos desempe&#241;an un papel fundamental en la detecci&#243;n precoz de la APs&#46; El diagn&#243;stico precoz es importante para reducir el riesgo de da&#241;os estructurales irreversibles&#44; limitar el deterioro de la funci&#243;n f&#237;sica y mejorar la calidad de vida de los pacientes&#46; El presente documento ha sido elaborado por un grupo de especialistas &#40;nueve dermat&#243;logos y un reumat&#243;logo&#41; con el objetivo de proporcionar recomendaciones sencillas que ayuden a los dermat&#243;logos en el cribado de la APs en pacientes con psoriasis&#46; Los expertos elaboraron el presente documento ofreciendo unas recomendaciones consensuadas basadas en una revisi&#243;n descriptiva de la evidencia cient&#237;fica disponible y en la experiencia adquirida en la pr&#225;ctica cl&#237;nica diaria&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Belinch&#243;n I&#44; Salgado-Boquete L&#44; L&#243;pez-Ferrer A&#44; Ferran M&#44; Coto-Segura P&#44; Rivera R et al&#46; El papel del dermat&#243;logo en el diagn&#243;stico precoz de la artritis psori&#225;sica&#58; recomendaciones de un grupo de expertos&#46; Actas Dermosifiliogr&#46; 2020&#59;111&#58;835&#8211;846&#46;</p>"
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          0 => array:4 [
            "apendice" => "<p id="par1085" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec1040"
          ]
        ]
      ]
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      0 => array:8 [
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical management algorithm for PsA in dermatology practices&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CRP indicates C-reactive protein&#59; HLA&#44; human leukocyte antigen&#59; RF&#44; rheumatoid factor&#59; PsA&#44; psoriatic arthritis&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Psoriatic Arthritis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Arthrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Gout&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Chondrocalcinosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Infectious Arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fibromyalgia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&#44; age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&#47;femaleMiddle-aged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&#47;femaleMiddle-aged&#47;elderly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MaleMiddle-aged&#47;young&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&#47;femaleElderly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&#47;femaleAny age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FemaleMiddle-aged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gradual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gradual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sudden&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sudden&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sudden&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gradual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Joint involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PeripheralAsymmetricOligo&#47;polyarticular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Peripheral&#47;axialAsymmetricMono&#47;oligoarticular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PeripheralAsymmetricMono&#47;oligoarticular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VariableKnee in &#62; 50&#37; casesCarpal joints&#44; hip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VariableMonoarticularFrequent joint involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Numerous localized areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type of pain and duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inflammatory Long-durationHigher intensity or worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MechanicalLong-durationHigher intensity or worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inflammatory 48-72&#8239;h &#40;1-2 wk if not treated&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inflammatory Variable &#40;days-weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inflammatory Lasts until treated with antimicrobials&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MultipleContinuous with periodic&#44; fluctuating exacerbations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axial involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CommonMay be silent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rare &#40;spondylodiscitis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Axial pain common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Enthesitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dactylitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nail psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Other entities that might be considered in the differential diagnosis&#44; such as rheumatoid arthritis&#44; systemic lupus erythematosus&#44; and sarcoidosis&#44; have very clear characteristics and classification criteria&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Differential Diagnosis of Psoriatic Arthritis<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#58; Key Characteristics of Main Arthropathies&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;13</span></a></p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; EARP&#44; Early Arthritis for Psoriatic Patients screening questionnaire&#59; PASE&#44; Psoriatic Arthritis screening and Evaluation questionnaire&#59; PASQ&#44; Psoriasis and Arthritis Screening Questionnaire&#59; PsA&#59; psoriatic arthritis&#59; ToPAS&#44; Toronto Psoriatic Arthritis Screening questionnaire&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Screening Tool&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PASE<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PEST<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ToPAS<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PASQ&#47;ePASQ<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EARP<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Distinguishes between symptoms of PsA and osteoarthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Simple and quick&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Can be used to screen for psoriasis and PsA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Provides a diagram for assessing joints&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Simple and quick&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Drawbacks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complex scoring system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does not include questions about cutaneous or axial manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not designed for early detection of PSA &#40;requires symptoms to have been present for &#8805;3 mo&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does not include questions about cutaneous manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does not include questions about cutaneous manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sensitivity<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;33&#44;35&#44;36</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#37;&#8211;82&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#37;&#8211;97&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#37;&#8211;86&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#46;27&#37;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>92&#46;86&#37;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Specificity<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;33&#44;35&#44;36</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#37;&#8211;73&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#37;&#8211;79&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;89&#37;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>75&#37;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#37;&#8211;85&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Expert opinions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Current validated screening questionnaires are not ideal for early PsA as they have low sensitivity and specificity in routine clinical practice and require time to administer and interpret&#46;</td></tr></tbody></table>
                  """
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            1 => array:3 [
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Early disease&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Screening Tools for the Early Detection of PsA&#46;</p>"
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      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
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            "identificador" => "at0020"
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        "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of Inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Signs and Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="fig1005"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Morning stiffness &#8805; 30&#8239;min&#59; joint swelling&#59; pain that improves with activity and gets worse with rest&#59; limited mobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="fig2005"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic back pain&#59; chronic pain involving buttocks&#44; hips&#44; and behind the thighs&#59; morning stiffness&#59; limited mobility and flexibility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="fig3005"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Swelling&#59; heat&#59; erythema&#59; sensitivity at inflammation site&#59; reduced mobility&#59; sausage-like digits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="fig4005"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pain next to the joint&#59; swelling at site of pain&#59; functional limitations&#59; history of plantar fascitis&#59; pain involving the enthesis &#40;Achilles tendon&#44; plantar fascia&#44; quadriceps tendon&#44; patellar ligament&#44; iliac crest&#41;&#59; more common in the lower than upper extremities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Clinical Characteristics of Inflammatory Arthritis&#44; Enthesitis&#44; Dactylitis&#44; and Spondylitis or Axial Pain&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p>"
        ]
      ]
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        "etiqueta" => "Table 4"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; CASPAR&#44; ClASsification criteria for Psoriatic ARthritis&#59; CCP&#44; cyclic citrullated peptide&#59; CRP&#44; C-reactive protein&#59; ESR&#44; erythrocyte sedimentation rate&#59; HLA&#44; human leukocyte antigen&#59; PsA&#44; psoriatic arthritis&#59; RF&#44; rheumatoid factor&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Laboratory test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Usefulness for Diagnosing PsA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ESR&#44; CRP<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Most common blood abnormalities detected in PsA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Elevated in just 50&#37; of patients with PSA&#59; more useful for follow-up than diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RF&#44; CCP antibodies<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#8211;50</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with PsA are usually seronegative&#59; RF negativity is a CASPAR criterion for the diagnosis of PsA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Positive in 5&#37; to 20&#37; of patients with PsA&#59; accordingly&#44; seropositivity for RF or CCP antibodies in patients with characteristic manifestations of PsA does not necessarily rule out a diagnosis of PsA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HLA C&#42;06&#58;02&#44; HLA B&#42;08&#58;01&#44; B&#42;27&#58;05&#44; B&#42;38&#58;01&#44; and B&#42;39&#58;01 alleles<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HLA C &#42; 06&#58; 02 is strongly associated with psoriasis&#44; while HLA B &#42; 08&#58; 01&#44; B &#42; 27&#58; 05&#44; B &#42; 38&#58; 01&#44; and B &#42; 39&#58; 01 are associated with early-onset PsA and certain specific features of the disease&#44; such as sacroiliitis&#44; enthesitis&#44; and dactylitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low predictive value and of limited use in the diagnosis of PsA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Possible Biomarkers for Diagnosing PsA&#46;</p>"
        ]
      ]
      5 => array:8 [
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ADA&#44; adalimumab&#59; APR&#44; apremilast&#59; BRO&#44; brodalumab&#59; CER&#44; certolizumab&#59; ETA&#44; etanercept&#59; GUS&#44; guselkumab&#59; IL&#44; interleukin&#59; INF&#44; infliximab&#59; IXE&#44; ixekizumab&#59; NonRx&#44; nonradiographic&#59; PDE4&#44; phosphodiesterase inhibitor 4&#59; PsA&#44; psoriatic arthritis&#59; RIS&#44; risankizumab&#59; Rx&#44; radiographic&#59; SEC&#44; secukinumab&#59; SpA&#44; spondyloarthritis&#59; TIL&#44; tildrakizumab&#59; TNF&#44; tumor necrosis factor&#59; UST&#44; ustekinumab&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#42;The term <span class="elsevierStyleItalic">early PsA</span> refers to exploratory studies in which patients did not have a definitive diagnosis of PsA&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t"><elsevierMultimedia ident="202012160744289801"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Summary of Clinical Efficacy of Systemic Biologic Drugs and Oral Small Molecules Approved for Psoriasis in the Treatment of the Clinical Domains of Psoriatic Arthritis and Axial Spondyloarthritis&#46; The number in each circle indicates the number of clinical trials evaluating a given domain&#46; All the references for the articles and clinical trials used to prepare this table are provided in Appendix A supplementary material 1&#46; Supplementary material</p>"
        ]
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      6 => array:8 [
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; CRP&#44; C-reactive protein&#59; HLA&#44; human leukocyte antigen&#59; RF&#44; rheumatoid factor&#59; PSA&#44; psoriatic arthritis&#59; PURE-4&#44; Psoriatic arthritis UnclutteRed screening Evaluation&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnostic Tools&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Expert Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Screening questionnaires&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not ideal for early PsA detection and time consuming&#44; although the PURE-4 questionnaire appears to be promising&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">History taking and physical examination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Once a year and ideally every 6 monthsLook for&#58;&#8226; Peripheral inflammatory arthritis&#8226; Dactylitis &#8226; Enthesitis &#40;Achilles tendon and plantar fascia&#41;&#8226; Inflammatory axial pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Additional tests&#58; laboratory tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Biomarkers not recommended as a diagnostic tool for PsAUseful laboratory tests&#58;&#8226; CRP&#8226; HLA-B27 &#40;if inflammatory axial pain&#41;&#8226; RF &#40;CASPAR criteria&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diagnostic imaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Radiographs of most symptomatic joints&#8226; Ultrasound if dermatologist is skilled at reading images&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multidisciplinary care&#58; referral to a rheumatologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fluid&#44; 2-way dialogue between dermatologists and rheumatologistsReferral to a rheumatologist is recommended if PsA is suspected and the patient has&#58;&#8226; inflammatory or night pain involving the axial skeleton&#8226; peripheral inflammatory pain&#44; joint swelling&#8226; enthesitis or clinical signs of enthesitis &#40;especially in Achilles tendon and plantar fascia&#41;&#8226; dactylitis or suggestive clinical signs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Bear in mind the different possible manifestations of PsA&#8226; Choose treatment according to clinical experience and safety and efficacy results from clinical trials&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Summary of Recommendations&#46;</p>"
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Article information

ISSN: 15782190
Original language: English

DOI:10.1016/j.adengl.2020.10.025

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2024 November	7	1	8
2024 October	163	106	269
2024 September	216	69	285
2024 August	193	88	281
2024 July	196	70	266
2024 June	227	59	286
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2024 April	161	53	214
2024 March	149	47	196
2024 February	174	66	240
2024 January	180	52	232
2023 December	166	54	220
2023 November	198	70	268
2023 October	208	53	261
2023 September	165	60	225
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2023 July	139	67	206
2023 June	138	62	200
2023 May	167	60	227
2023 April	168	48	216
2023 March	148	60	208
2023 February	113	51	164
2023 January	97	43	140
2022 December	113	45	158
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2022 October	79	52	131
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2021 July	148	46	194
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2021 April	285	139	424
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