Comprehensive Treatment of Dactylitis in Psoriatic Arthritis

Abstract

Dactylitis, a hallmark clinical feature of psoriatic arthritis (PsA) and other spondyloarthropathies, may also be a severity marker for PsA and psoriasis. Traditionally, clinicians have used nonsteroidal antiinflammatory drugs and local corticosteroid injections to treat dactylitis, although conventional disease-modifying antirheumatic drugs are also used. We performed a systematic literature review to determine the most efficacious current treatment options for dactylitis in PsA. Effect sizes were greatest for the biologic agents ustekinumab, certolizumab, and infliximab, suggesting that therapy with one of these agents should be initiated in patients with dactylitis. However, the limited data highlight the need for randomized, placebo-controlled trials, with dactylitis as a primary outcome, to determine a valid, reliable, and responsive clinical outcome measure for PsA patients with dactylitis.

European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update

“…In this patient population, no data-driven definition of ‘active’ disease (relative to enthesitis/dactylitis) exists and the Task Force considered at least one active localisation as active disease, taking into account quality of life consequences as most relevant in these patients. In these patients, after failure of local or non-specific anti-inflammatory therapy, bDMARDs may be applied even if no csDMARDs have been tried, since the latter have not been proven efficacious in treating these aspects of PsA, especially enthesitis 94 95. The experts felt the data did not allow a definitive primary choice between a TNFi or bDMARDs targeting IL-12/23 or IL-17 pathways, since there are no head-to-head comparisons and based on the available data all these agents appear to have similar efficacy on enthesitis and dactylitis.…”

Measuring psoriatic disease in clinical practice. An expert opinion position paper

“…Dactylitis describes a uniform swelling of a digit with inflammation causing a sausage digit (87,88). Dactylitis can be further characterized as acute/tender dactylitis where the digit is tender, often erythematous and warm, or as chronic/sub-acute/non-tender dactylitis where the digit is swollen but non-tender.…”

Severe psoriatic dactylitis: when psoriasis involves beyond the skin

“…However, controlling symptoms cannot be achieved in all cases and the introduction of anti-tumor necrosis factor (TNF)-alpha therapies is required. Treatment with TNF-alpha inhibitors may result in not only substantial improvements in signs and symptoms of skin and nail diseases, but also improvements in all distinct sites of joint diseases such as axial arthritis, enthesitis and dactylitis (10). Since metotrexate was not effective in our patient, it was discontinued and azathioprine 1 mg/ kg was initiated.…”

“…Traditionally, therapeutic approaches are not based on well-designed trials, but on empirical experiences. Physicians use drugs such as non-steroidal antinflammatory drugs, local corticosteroid injections, metotrexate, cyclosporine and azathioprine (10). However, controlling symptoms cannot be achieved in all cases and the introduction of anti-tumor necrosis factor (TNF)-alpha therapies is required.…”