Objectives To search for subclinical inflammatory joint disease in patients with psoriasis without psoriatic arthritis (PsA), and to determine whether such changes are associated with the later development of PsA. Methods Eighty-five subjects without arthritis (55 with psoriasis and 30 healthy controls) received high field MRI of the hand. MRI scans were scored for synovitis, osteitis, tenosynovitis and periarticular inflammation according to the PsAMRIS method. Patients with psoriasis additionally received complete clinical investigation, highresolution peripheral quantitative CT for detecting erosions and enthesiophytes and were followed up for at least 1 year for the development of PsA. Results 47% of patients with psoriasis showed at least one inflammatory lesion on MRI. Synovitis was the most prevalent inflammatory lesion (38%), while osteitis (11%), tenosynovitis (4%) and periarticular inflammation (4%) were less frequent. The mean (±SD) PsAMRIS synovitis score was 3.0±2.5 units. Enthesiophytes and bone erosions were not different between patients with psoriasis with or without inflammatory MRI changes. The risk for developing PsA was as high as 60% if patients had subclinical synovitis and symptoms related to arthralgia, but only 13% if patients had normal MRIs and did not report arthralgia. Conclusions Prevalence of subclinical inflammatory lesions is high in patients with cutaneous psoriasis. Arthralgia in conjunction with MRI synovitis constitutes a high-risk constellation for the development of PsA.

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BackgroundMusculoskeletal changes precede the onset of psoriatic arthritis (PsA). A subset of psoriasis patients is characterised by arthralgia as well as inflammatory changes in the joints visible by MRI assessment. These patients have a high risk to progress into PsA.ObjectivesTo test the concept of a very early intervention in PsA we exposed psoriasis patients with subclinical joint inflammation to the anti-interleukin (IL)−17A antibody secukinumab. We hypothesised that IL-17A inhibition disrupted the early link between skin and joint disease in psoriasis.MethodsPsoriasis (but not PsA) patients were included in the open prospective 24 weeks ‘Interception in Very Early PSA’ (IVEPSA) study. To fulfil the inclusion criteria patients had to have a PASI score greater than 6 or nail or scalp involvement as well as inflammatory or erosive changes in MRI or high-resolution peripheral quantitative computed tomography (HRpQCT) at baseline. Patients received treatment with secukinumab 300 mg sc. for 24 weeks. MRI scans and HRpQCT of the dominant hand were performed at baseline and at 24 weeks. MRI was scored according to PsAMRIS. HRpQCT evaluated for erosions and enthesiophytes.Results20 patients (median age 49.5 years (IQR 42.8, 59), 70% males) with a median disease duration of 14 years (IQR 5, 20), were included into the study. At baseline, 85% reported arthralgia assessed by a Visual Analogue Scale (VAS) and 40% had tender joints on examination (TJC78). 83.3% had at least one inflammatory lesion in the MRI, 66.7% synovitis, 55.6% tendinitis/enthesitis, 27.8% osteitis and 16.7% periarticular inflammation. Erosions were present in 72.2% and 58.8% in the MRI and HRpQCT, respectively, while enthesiophytes were found in 33.3% and 41.2%. One patient was discontinued early due to lack of improvement (wk12) and one patient was unable to perform the follow-up MRI. Psoriatic skin disease (total PASI and BSA) significantly improved (both p<0.05) and also arthralgia (VAS pain, tender joint count) significantly declined after secukinumab treatment (both p<0.05). Total PsAMRIS score and synovitis subscore significantly improved at week 24 (p=0.005 and p=0.008, respectively). Importantly, improvement in total PsAMRIS score significantly correlated with the improvement in arthralgia (p<0.05). Finally, neither erosions nor enthesiophytes in MRI and HRpQCT progressed during the 24 weeks of treatment. There was no new safety signal in the study.ConclusionsIL-17 inhibition by secukinumab over 24 weeks led to resolution of inflammation and no progression of bone changes in the joints in psoriasis patients with subclinical peripheral joint involvement. These data suggest that very early disease interception in PsA is a feasible approach. IVEPSA also provides the guide for further very early interventions in PsA providing concepts for imaging-based identification and the sensitivity to change subclinical inflammation through biological disease modifying anti-rheumatic drug therapy.AcknowledgementsThis study was supported by an unrestricted g...

BackgroundPsoriasis is a chronic inflammatory disease affecting 2–3% of the population [1,2]. Up to 30% of psoriasis patients develop psoriatic arthritis (PsA), and usually musculoskeletal symptoms start after the onset of skin disease. Psoriatic skin disease has a higher prevalence than arthritis what raises the question whether psoriasis patients without PsA are indeed spared from joint inflammation [3].Detecting subclinical joint inflammation could help identify which patients with skin disease would benefit of treatment covering both skin and musculoskeletal inflammation.ObjectivesTo search for subclinical inflammatory joint disease in psoriasis patients without arthritis, and to determine whether such changes are associated with the later development of PsA.MethodsEighty-five subjects without arthritis (55 with psoriasis and 30 healthy controls) received high field magnetic resonance imaging (MRI) of the hand. MRI scans were scored according to the PSAMRIS method [4]. Psoriasis patients received complete clinical investigation, high-resolution peripheral quantitative computed tomography (HR-pQCT) to detect erosions and enthesiophytes and were followed up for at least one year for the development of PsA.Results47% of psoriasis patients showed at least one inflammatory lesion on MRI. Synovitis was the most prevalent inflammatory lesion (38%), while osteitis (11%), tenosynovitis (4%) and periarticular inflammation (4%) were less frequent. The mean (±SD) PSAMRIS synovitis score was 3.0±2.5 units. Enthesiophytes and bone erosions were not different between psoriasis patients with or without inflammatory MRI changes. The risk for developing PsA was as high as 55% if patients had subclinical synovitis and symptoms related to arthralgia, but only 15% of patients had normal MRIs and did not report of arthralgia.ConclusionsPrevalence of subclinical inflammatory lesions is high in patients with cutaneous psoriasis. Arthralgia associated with MRI synovitis constitutes a high-risk constellation for the development of PsA.ReferencesMease PJ, Gladman DD, Papp KA, et al. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol 2013;69:729–35.McGonagle D, Ash Z, Dickie L, et al. The early phase of psoriatic arthritis. Ann Rheum Dis 2011;70 Suppl 1:i71–6.Palazzi C, Lubrano E, D'Angelo S, et al. Beyond early diagnosis: occult psoriatic arthritis. J Rheumatol 2010;37:1556–8Ostergaard M, McQueen F, Wiell C, et al. The OMERACT psoriatic arthritis magnetic resonance imaging scoring system (PsAMRIS): definitions of key pathologies, suggested MRI sequences, and preliminary scoring system for PsA Hands. J Rheumatol 2009;36:1816–24.AcknowledgementThis study was supported by the Deutsche Forschungsgemeinschaft (SPP1468, CRC1181), the Marie Curie project OSTEOIMMUNE, the Metarthros project of the German Ministry of Science and Education, the IMI-funded project BTCure and the Pfizer Competitive Grant Award Germany.Disclosure of InterestNone dec...

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