Histology of psoriasis-like eczema in untreated mice characterized by keratinocyte hyperproliferation.

Histology of psoriasis-like eczema in mice treated with active compound (a vitamin D analogue). The psoriasis-like eczema and keratinocyte hyperproliferation is normalised following treatment.

Inflammation. Hyperproliferation of the epidermis Altered maturation of the epidermis (resulting in scaling) Vascular alterations (which add to redness).

Histology of psoriasis 1. 2. 3. 4. Marked hyperkeratosis with parakeratosis (abnormal maturation) Loss of granular layer Epidermal acathosis and elongation of rete ridges (reflecting hyperproliferative state) Vascular dilatation (these vessels are abnormal as well). Generalised inflammation can also be seen, with T-lymphocytes in the dermis and epidermis.

Complete resolution of the histologic features of psoriasis following treatment with K252a therapy. (a) Histology of the plaque before treatment demonstrates the characteristic morphologic features of psoriasis. (b) The lesion 1 wk after completion of intralesional treatment with K252a demonstrates significant reduction of acanthosis and reduced amount of infiltrates. (c) At the end of 2 wk after treatment complete resolution of hyperkeratosis, acanthosis and barely any dermal infiltrate can be noticed. Magnification 160.

There are no specific clinical, laboratory or radiographic criteria for the diagnosis of psoriatic arthritis. Rather, the diagnosis should be considered in any patient with psoriasis who presents with inflammatory arthritis:

If, as is typical, the patient is rheumatoid factor-negative, the diagnosis is relatively straightforward. If rheumatoid factor is present at a significant titer, the situation likely represents the coincident occurrence of psoriasis and rheumatoid arthritis. Given that hyperuricemia may be found in psoriasis, due to increased cell turnover, gout may also need to be considered and Unlike rheumatoid arthritis, both osteoarthritis and psoriatic arthritis may affect the DIP joints. Therefore, these two entities may need to be distinguished. The 15% of patients who present with joint disease before developing the cutaneous manifestations of psoriasis may also prove diagnostically challenging. Thus, any patient in whom the clinical presentation or pattern of disease suggests the possibility of psoriasis warrants a detailed exam of the nails, as well as for occult plaques on the scalp, behind the pinnae, in the umbilicus and in the inter-gluteal crease. There are no specific laboratory findings in psoriatic arthritis, although laboratory markers of inflammation may track with the activity of disease. Radiographically, psoriatic arthritis is a unique blend of bone destruction & proliferation. Manifestations may include erosive arthritis giving rise to the classic "pencil-in-cup" (image below)

deformity in the phalanges, osteolysis, articular ankylosis, sacroiliitis (two images below)

spondylitis (image below), enthesitis and periostitis.

References

1. Willkens RF, Williams HJ, Ward JR, et al: Randomized, double blind, placebo-controlled trial of low dose pulse methotrexate in psoriatic arthritis. Arthritis Rheum 27:376, 1984.

Carriage rate of TNFA 308*A is increased in patients with severe psoriatic arthritis. Carriage of TNFA -308 * A in patients with psoriasis with (PsA pos.) or without (PsA neg.) a confirmed diagnosis of psoriatic arthritis, as well as in patients with PsA with or without clinical deformities or bone erosions of the hands and/or feet. Bars represent the percentage of carriers of TNFA -308*A in each of these groups and in control subjects. n, number of individuals investigated in each group.