Psoriatic and Reactive Arthritis: A Companion to Rheumatology

242 Pages·2007·4.76 MB·English

by  Christopher Ritchlin MD

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PSORIATIC AND REACTIVE ARTHRITIS ISBN-13: 978-0-323-03622-1
A COMPANION TO RHEUMATOLOGY ISBN-10: 0-323-03622-8
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Library of Congress Cataloging-in-Publication Data
Psoriatic and reactive arthritis: a companion to rheumatology /
[edited by] Christopher T. Ritchlin, Oliver FitzGerald.–1st ed.
p.; cm.
Includes bibliographical references and index.
ISBN 0-323-03622-8
1. Psoriatic arthritis. 2. Infectious arthritis. I. Ritchlin, Christopher T. II. FitzGerald, Oliver.
[DNLM: 1. Arthritis, Psoriatic. 2. Arthritis, Reactive. WE 344 P9734 2007]
RC931.P76P75 2007
616.7’227–dc22
2006050135
Acquisitions Editor: Kimberly Murphy
Publishing Services Manager: Frank Polizzano
Project Manager: Lee Ann Draud
Design Direction: Steve Stave
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To our patients and mentors
Contributors
Firas Alkassab, MD Stephanie Diamantis, MD
Clinical Fellow, Division of Rheumatology and Fellow, Mount Sinai School of Medicine, New York,
Clinical Immunogenetics, University of Texas New York
Health Science Center at Houston, Houston, Texas Dermatologic Management of Psoriasis
Spectrum of Reactive Arthritis
James T. Elder, MD, PhD
Dominique Baeten, MD, PhD Professor, Department of Dermatology, University of
Associate Professor of Clinical Immunology and Michigan Medical School; Physician, University of
Rheumatology, Academic Medical Center, Michigan Health System and Ann Arbor Veterans
University of Amsterdam, Amsterdam, The Netherlands Administration, Ann Arbor, Michigan
Synovial Immunopathology in Spondyloarthropathy Psoriasis: Etiopathogenesis
Juergen Braun, MD Luis R. Espinoza, MD
Professor, Ruhr University, Bochum; Medical Professor and Chief, Section of Rheumatology,
Director, Rheumazentrum Ruhrgebiet, Herne, Department of Internal Medicine, Louisiana State
Germany University Health Sciences Center, New Orleans,
Imaging in Reactive Arthritis Louisiana
Historical Aspects of the Disease
Antoni Chan, MB ChB, MRCP
ARC Clinical Research Fellow, Nuffield Orthopaedic Ursula Fearon, PhD
Centre and MRC Human Immunology Unit, Newman Fellow, University College Dublin; Senior
Weatherall Institute of Molecular Medicine, John Scientist, St. Vincent’s University Hospital, Dublin,
Radcliffe Hospital, Oxford, United Kingdom Ireland
Genetics of Reactive Arthritis Angiogenesis in Psoriasis and Psoriatic Arthritis
Daniel O. Clegg, MD Oliver FitzGerald, MD, FRCP
Professor of Medicine; Chief, Division of Consultant Rheumatologist and Newman Clinical
Rheumatology; and Harold J., Ardella T., and Helen T. Research Professor, St. Vincent’s Hospital and
Stevenson Presidential Chair in Rheumatology, Conway Institute, University College Dublin,
University of Utah School of Medicine; Chief, Dublin, Ireland
Rheumatology Section, Salt Lake City Veterans Affairs Pathogenesis of Psoriatic Arthritis
Medical Center, Salt Lake City, Utah
Management of Reactive Arthritis Tracy M. Frech, MD
Rheumatology Fellow, University of Utah School
Filip De Keyser, MD, PhD of Medicine, Salt Lake City, Utah
Professor of Rheumatology, Department of Management of Reactive Arthritis
Rheumatology, University Hospital Ghent, Ghent,
Belgium
Enteric Infections and Arthritis; Natural History,
Prognosis, Socioeconomic Aspects, and Quality vii
of Life
C Dafna D. Gladman, MD, FRCPC Gabrielle H. Kingsley, MB ChB, PhD, FRCP
O
N Professor of Medicine, University of Toronto Faculty Reader in Rheumatology, King’s College London;
T
RIB of Medicine; Senior Scientist, Division of Outcomes Consultant Rheumatologist, University Hospital
U and Population Health, Toronto Western Research Lewisham, London, United Kingdom
T
O
R Institute, Toronto Western Hospital, Toronto, Historical Aspects of Reactive Arthritis
S
Ontario, Canada
Clinical Features of Psoriatic Arthritis Elli Kruithof, MD, PhD
Physician, Department of Rheumatology, University
Johann E. Gudjonsson, MD, PhD Hospital Ghent, Ghent, Belgium
Resident/Research Fellow, Department of Synovial Immunopathology in Spondyloarthropathy
Dermatology, University of Michigan Medical School;
Resident, Department of Dermatology, University of Mark Lebwohl, MD
Michigan Health System, Ann Arbor, Michigan Professor and Chairman, Department of
Psoriasis: Etiopathogenesis Dermatology, Mount Sinai School of Medicine,
New York, New York
Shahir Hamdulay, BSc, MRCP Dermatologic Management of Psoriasis
Specialist Registrar, Department of Rheumatology,
Hammersmith Campus, Imperial College School of Marjatta Leirisalo-Repo, MD
Medicine, London, United Kingdom Professor of Rheumatology, Department of Medicine,
Outcomes in Reactive Arthritis Helsinki University Central Hospital, Kasarmikatu,
Finland
Philip S. Helliwell, MD, PhD Epidemiology of Reactive Arthritis
Senior Lecturer in Rheumatology, University of
Leeds, Leeds; Attending Physician, Bradford Teaching Dennis McGonagle, PhD, FRCPI
Hospitals NHS Trust, Bradford, West Yorkshire, Academic Unit of Musculoskeletal Diseases, Chapel
United Kingdom Allerton Hospital, University of Leeds, Leeds;
Natural History, Prognosis, and Socioeconomic Aspects Consultant Rheumatologist, Calderdale Royal
of Psoriatic Arthritis Hospital, Halifax, West Yorkshire, United Kingdom
Imaging in Psoriatic Arthritis
Robert D. Inman, MD
Professor of Medicine and Immunology, University Neil McHugh, MB ChB, FRCP
of Toronto Faculty of Medicine; Senior Scientist, Consultant Rheumatologist, Royal National Hospital
Consultant, and Rheumatologist, Toronto Western for Rheumatic Diseases, Bath, United Kingdom
Hospital, Toronto, Ontario, Canada Clinical Outcome Measures in Psoriatic Arthritis
Chlamydia-Induced Arthritis
Philip Mease, MD
David John Kane, PhD, MB BCh, MRCPI Clinical Professor, University of Washington School
Honorary Senior Lecturer, Newcastle University, of Medicine; Head, Seattle Rheumatology Associates;
Northumbria Division, Newcastle upon Tyne, Chief, Rheumatology Clinical Research, Swedish
England; Consultant Rheumatologist, Adelaide & Hospital Medical Center, Seattle, Washington
Heath Hospital, Dublin, Ireland Management of Psoriatic Arthritis: Biologic Agents in
Imaging in Psoriatic Arthritis Psoriatic Arthritis
Arthur Kavanaugh, MD Herman Mielants, MD, PhD
Division of Rheumatology, Allergy, and Immunology, Professor of Rheumatology, Ghent University; Head,
University of California, San Diego, School of Department of Rheumatology, University Hospital
Medicine, La Jolla, California Ghent, Ghent, Belgium
Clinical Outcome Measures in Psoriatic Arthritis Enteric Infections and Arthritis
Andrew Keat, MD, FRCP Peter Nash, MD
Consultant Physician and Rheumatologist, Northwick Director, Rheumatology Research Unit, Department
Park Hospital, Harrow, Middlesex, United Kingdom of Medicine, University of Queensland, Queensland,
Outcomes in Reactive Arthritis Australia
viii Management of Psoriatic Arthritis: Traditional Disease-
Modifying Antirheumatic Drug Therapies for Psoriatic
Arthritis
Finbar D. O’Shea, MB, MRCPI Ai Lyn Tan, MRCP C
o
Research Fellow, Spondylitis Clinic, Toronto Western Specialist Registrar in Rheumatology, Academic Unit n
Hospital, Toronto, Ontario, Canada of Musculoskeletal Disease, Chapel Allerton Hospital, trib
u
Chlamydia-Induced Arthritis Leeds, United Kingdom to
Imaging in Psoriatic Arthritis rs
Proton Rahman, MD, MSc, FRCPC
Professor of Medicine, Memorial University of William J.Taylor, MB ChB, FRACP, FAFRM
Newfoundland Faculty of Medicine; Staff Senior Lecturer, Department of Medicine, Wellington
Rheumatologist, St. Clare’s Mercy Hospital, School of Medicine and Health Sciences, University of
St. John’s, Newfoundland, Canada Otago; Consultant Rheumatologist, Hutt Valley
Epidemiology of Psoriatic Arthritis District Health Board, Wellington, New Zealand
Diagnostic Criteria of Psoriatic Arthritis
John D. Reveille, MD
Director, Division of Rheumatology, University of Auli Toivanen, MD
Texas Health Science Center at Houston, Houston, Professor of Medicine Emerita, Turku University,
Texas Turku, Finland
Spectrum of Reactive Arthritis Clinical Picture and Diagnostic Criteria of Reactive
Arthritis
Christopher T. Ritchlin, MD
Associate Professor of Medicine, University of Bert Vander Cruyssen, MD, PhD
Rochester School of Medicine and Dentistry; Department of Rheumatology, University Hospital
Director, Clinical Immunology Research Center, Ghent, Ghent, Belgium
Allergy, Immunology, and Rheumatology Division, Natural History, Prognosis, Socioeconomic Aspects, and
University of Rochester Medical Center, Rochester, Quality of Life
New York
Pathogenesis of Psoriatic Arthritis Douglas J.Veale, MD, FRCPI, FRCP (Lon)
University College Dublin; Consultant, St. Vincent’s
Eric Ruderman, MD University Hospital, Dublin, Ireland
Associate Professor of Medicine, Division of Angiogenesis in Psoriasis and Psoriatic Arthritis
Rheumatology, Northwestern University Feinberg
School of Medicine; Attending Physician, Robert Winchester, MD
Northwestern Memorial Hospital, Chicago, Illinois Professor of Medicine, Pediatrics, and Pathology,
Natural History, Prognosis, and Socioeconomic Aspects Columbia University College of Physicians and
of Psoriatic Arthritis Surgeons, New York, New York
Genetics of Psoriatic Arthritis
David L. Scott, MD, BSc, FRCP
Professor of Clinical Rheumatology, King’s College Paul Wordsworth, PhD
London and King’s College Hospital Trust, London, Professor of Clinical Rheumatology, University of
United Kingdom Oxford; Honorary Consultant in Rheumatology,
Historical Aspects of Reactive Arthritis Nuffield Orthopaedic Centre, Oxford,
United Kingdom
Joachim Sieper, MD Genetics of Reactive Arthritis
Charité Universitätsmedizin Berlin, Campus
Benjamin Franklin, Berlin, Germany
Pathogenesis of Reactive Arthritis
ix
Foreword
Psoriatic and reactive arthritis, long-neglected though The section on reactive arthritis is similarly struc-
valued siblings, have assumed their rightful places at tured. Scott and Kingsley discuss the historical aspects,
the arthropathy family table. The chairs were shifted as while Leirisalo-Repo and Chan and Wordsworth
the clinical criteria were affirmed, outcomes better describe the epidemiologic and genetic characteristics.
appreciated, and pathophysiologic mechanisms more Insightful discussions of selected pathophysiologic
clearly understood. This altered status is, in many mechanisms are provided by De Keyser and Mielants,
ways, due to previous scientific contributions from the O’Shea and Inman, Kruithof and Baeten, and Sieper.
esteemed authors of this excellent book. The spectrum of clinical features and diagnostic crite-
There are two sections. In the section that addresses ria, natural history and prognosis, outcome measures,
psoriatic arthritis, Espinoza outlines interesting and imaging modalities is elegantly outlined by
historical misunderstandings, summarizes current Toivanen and Reveille and Alkassab, Vander Cruyssen
thinking, and surmises on future directions. The and De Keyser, Keat and Hamdulay, and Braun,
distinctive epidemiology and novel genetic associations respectively. Finally, Frech and Clegg summarize the
are eloquently detailed by Rahman and Winchester, evidence for employing both traditional and novel
respectively. Gudjonsson and Elder, Ritchlin and therapeutic approaches.
FitzGerald, and Veale and Fearon each elucidate current As with other categories of inflammatory arthritis,
knowledge of pivotal pathophysiologic mechanisms. there is still much to learn about psoriatic and reactive
Gladman; Taylor; Helliwell and Ruderman; Kavanaugh arthritis, and further therapeutic advances are eagerly
and McHugh; and Kane, Tan, and McGonagle sepa- awaited. This timely volume provides a comprehensive
rately describe the clinical features, natural history and outline of our collected knowledge as it currently
outcomes, diagnostic criteria, and emerging imaging stands in the early twenty-first century.
modalities. Finally, Mease and Nash summarize
therapeutic advances in the use of targeted therapies Barry Bresnihan, MD
for arthritis, and Diamantis and Lebwohl outline a Dublin, Ireland
systematic, evidence-based approach to the manage-
ment of psoriasis of the skin.
xi
Preface
It is instructive to note that less than 50 years have improved treatment for this disorder in the near
passed since psoriatic and reactive arthritis were recog- future.
nized as distinct forms of joint disease and not “atypi- The topics of psoriatic and reactive arthritis are usu-
cal” variants of rheumatoid arthritis. Despite this ally covered in both medicine and rheumatology texts,
recognition, both reactive arthritis, originally labeled but in-depth presentations have been precluded by
Reiter’s syndrome, and psoriatic arthritis have lan- space considerations and a dearth of new information.
guished in relative obscurity. Clinical studies of these The marked increase in new knowledge from both
disorders were hampered by a striking heterogeneity in ascientific and clinical perspective, however, has kindled
disease manifestations and course coupled with the great interest in these diseases. Thus, we thought it
absence of a defining marker such as rheumatoid appropriate to provide an authoritative and compre-
factor or HLA B27. Moreover, investigations of disease hensive volume to serve as a resource for health care
mechanisms were relatively rare compared with the professionals and biomedical scientists. The material
prodigious efforts made by those studying rheumatoid for this text has been provided by investigators and
arthritis. clinicians from around the world in order to provide
Over the past several years, significant advances have atruly global perspective. The style and format of the
taken place in the classification and treatment of pso- book are the same as the user-friendly and easily acces-
riatic arthritis. These advances are due in large part to sible parent textbook, Rheumatology. It is our sincere
the development of effective biologic agents and hope and expectation that this resource will contribute
improved clinical trial design and implementation. to improved care for patients and spark scientific
In parallel, mechanistic investigations based on tissue investigators to focus attention on these two fascinating
analysis, genetic studies, and novel imaging modalities inflammatory disorders.
have provided new insights into disease pathogenesis.
In reactive arthritis, the recognition of the role of the Christopher T. Ritchlin
innate immune response combined with improved Oliver FitzGerald
epidemiologic methods and pathogen detection holds
great promise for increased understanding and
xiii
PSORIATIC ARTHRITIS
1
Epidemiology of Psoriatic Arthritis
Proton Rahman
HISTORICAL PERSPECTIVE dence of PsA. There is also a wide range in the reported
prevalence and incidence rates of PsA related, in part,
The first widely cited depiction of arthritis associated to the lack of a widely accepted classification or diag-
with psoriasis was reported by Alibert in the early 1800s.1 nostic criteria. Until recently, there were seven classifi-
Despite recognition of this association, there was a long- cation schemes proposed for PsA, six of which were
standing impression that psoriatic arthritis (PsA) was a based on clinical experience.8 Historically, the most
variant of rheumatoid arthritis (RA). It was not until the widely cited classification criteria were developed by
emergence of epidemiologic studies that PsA surfaced as Wright and Moll.9
a unique disease entity separate from RA, and it was rec-
ognized as a specific rheumatic entity by the American Prevalence
Rheumatology Association in 1964.2 This, in part, was The reported prevalence of PsA varies from 0.056% to
due to population studies demonstrating an increased 0.28%, and PsA affects men and women equally.10-13
frequency of inflammatory arthritis among patients with The most recent population-based study, by Gelfand
psoriasis and an increased prevalence of arthritis among and colleagues, reported a PsA prevalence of 0.25%
patients with psoriasis. The prevalence of psoriasis in (95% confidence interval [CI]: 0.18%, 0.31%).10This
subjects with arthritis was found to be 2.6% to 7.0%, prevalence was estimated in a U.S. population by ran-
whereas the prevalence of psoriasis in the general popu- domly interviewing 27,220 subjects.10 Cases were
lation was estimated as 0.1% to 2.8%.3,4 On the other defined as patients who reported a physician diagno-
hand, the prevalence of arthritis in subjects with psoria- sis of psoriasis and PsA. In this survey, 601 subjects
sis varies from 7% to 25% and the prevalence of arthritis stated that they had psoriasis and 71 had PsA. The
in the general population is estimated as 2% to 3%.3,4 prevalence of PsA in Gelfand’s study was substantially
Historically, the rheumatoid factor further defined PsA, higher than that calculated using the Rochester
as subjects with PsA tended to be seronegative. It is now Epidemiological Project computerized medical sys-
apparent that 10% to 15% of patients with PsA are in fact tem. In the latter study, Shbeeb and associates
seropositive for rheumatoid factors, albeit in a low titer.3 screened the records of all Olmsted County residents
The entity of PsA is now well characterized and with a diagnosis consistent with psoriasis or PsA over
encompasses unique clinical features including distinct a 10-year period.11 This screening identified 1844
patterns of peripheral joint involvement, periarticular patients with a diagnosis of psoriasis, of whom 1056
manifestations, and axial involvement.3 The delin- had the diagnosis of psoriasis confirmed by a derma-
eation of PsA and RA is validated by responses to con- tologist. Among these individuals, 66 cases of PsA
comitant human immunodeficiency virus infections, were identified, resulting in a prevalence of PsA of
as symptoms of PsA worsen5and symptoms attributa- 0.1% (95% CI: 0.081% to 0.121%).
ble to RA improve.6Furthermore, the genetic epidemi- Kay and coauthors carried out a similar study and
ology of these two inflammatory arthropathies appear determined the prevalence of PsA in northeast
to be distinct as noted by multiple disease-specific England by evaluating records from six general prac-
associations within and more recently outside the tices.12One practice was used for the pilot study (5842
major histocompatibility complex region (e.g., associ- individuals) and five practices were used for the main
ation of PTPN22and seropositive RA).7 study (29,348 individuals). A questionnaire, which was
validated in the pilot study, was used to identify
EPIDEMIOLOGY inflammatory arthritis in patients with psoriasis. Data
determined from this evaluation showed that 81 of 772
There is a paucity of well-designed population-based psoriasis subjects had inflammatory arthritis, with a 1
studies that have estimated the prevalence and inci- crude prevalence of 0.28%.
E In another population-based study, Alamanos and axial inflammatory symptoms. Two European studies
P
ID colleagues investigated the frequency and distribution that included assessments by dermatologists and
E
M of PsA in a defined area of northwest Greece with rheumatologists from outpatient clinics estimated a
IO
L a population of 500,000.13 All inpatient and outpa- prevalence of inflammatory arthritis of 30% and 31%
O
G tient PsA cases, diagnosed using the European in patients with psoriasis.16,17These estimates are simi-
Y
O Spondyloarthropathy Study Group criteria and lar to those reported in the mid-1980s by Scarpa and
F
P referred from rheumatology clinics in two hospitals, coauthors, who noted the prevalence of inflammatory
S
O were identified over a 9-year period. The age-adjusted arthritis to be 30%.18
R
IA prevalence of PsA in this study was 0.056%.
T Pattern of Inflammatory Arthritis
IC
A Incidence andPsoriasis
R
T
H The reported incidence of PsA has varied from 3 to 23 Moll and Wright described five clinical patterns of
R
IT per 100,000.10-15 From the Rochester Epidemiological PsA and estimated the frequency of these subgroups
IS Project, the average age- and sex-adjusted incidence on the basis of their own clinical observations.19The
rate was 6.59 per 100,000 U.S. population (95% CI: five clinical patterns and their estimated frequencies
4.99 to 8.19). Alamanos and co-workers from northern are (1) “classical” PsA confined to distal interpha-
Greece reported an age-adjusted mean incidence rate langeal (DIP) joints of the hands and feet (5%),
of 3.02 per 100,000. No difference was noted between (2)arthritis mutilans with sacroiliitis (5%), (3) sym-
males and females in the latter study, and the peak metric polyarthritis indistinguishable from RA
incidence was observed between 45 and 64 years. (15%), (4) asymmetric oligoarthritis (70%), and
Savolainen and colleagues systematically collected (5) spondyloarthropathy (15%). Subsequent reports
data on a population of 87,000 inhabitants of Kuopio, validated these subgroups; however, there is consid-
Finland.14 PsA was diagnosed as peripheral arthritis erable overlap and evolution of these subgroups.20At
with psoriasis in the absence of rheumatoid factor– present, there is an ongoing debate about the most
positive polyarthritis or spondylitis with psoriasis. prevalent subgroup of PsA (most acknowledge that
Sixteen new cases of PsA were identified, resulting in a the polyarticular variant is probably the most fre-
mean incidence rate of 23 per 100,000. Furthermore, quent) and the existence of pure DIP involvement.
Soderlin and coauthors performed a prospective popula- These issues are addressed in detail in Chapter 3.
tion-based study on the annual incidence of early arthri- The majority of patients with PsA have the classical
tis in Kronoberg County in southern Sweden.15 The form of psoriasis vulgaris, although pustular psoriasis
patients were referred from primary health care centers and erythredema have also been reported.3In approx-
to the rheumatology department in the central hospital imately 70% of cases, psoriasis precedes the onset of
or to private clinics participating in the study. Additional arthritis, but the interval in between is extremely vari-
hospital records were checked. The patients were regis- able. In approximately 15% of cases, arthritis precedes
tered as incident cases if the onset of the joint inflamma- the onset of psoriasis. In another 15% of cases, the pso-
tion was between May 1, 1999 and May 1, 2000. In total, riasis and inflammatory arthritis are diagnosed
11 patients presented with PsA, corresponding to an together. There appears to be no clear relationship
annual incidence of 8 per 100,000 for PsA. between the extent of psoriasis and the severity of
inflammatory arthritis.4
Prevalence of Psoriatic Arthritis among
Psoriasis Subjects Genetic Epidemiology of Psoriatic Arthritis
The estimated prevalence of inflammatory arthritis Moll and Wright estimated the strength of familial clus-
among patients with psoriasis has varied widely from tering of PsA.19 Evaluation of the first- and second-
6% to 42%.4 Historically, however, a value of 7% to degree relatives of 88 consecutive PsA probands
10% for the prevalence of inflammatory arthritis in showed that 12.5% had at least one relative with con-
psoriasis patients was most often cited.4The U.S. study firmed PsA. Of the 181 first-degree relatives assessed, 10
by Gelfand and colleagues noted a self-reported inci- relatives had PsA, including 5 siblings. Thus, the over-
dence of inflammatory arthritis of 11% (95% CI: 9% to all prevalence of PsA among first-degree relatives was
14%). This may be an underestimate as the diagnosis of 5.5%. Using the calculated prevalence of PsA in the
psoriasis is often overlooked because it may not be in United Kingdom population of 0.1%, the risk for
direct view of patients and physicians (such as scalp, affected first-degree relatives (λ) is 55, a heritability
1
buttocks). Also, there is a lower level of tenderness of substantially greater than those obtained for psoriasis.21
inflammatory arthritis among PsA patients. Thus, ide- In the mid-1980s, Henseler and Christophers noted
2 ally, patients with psoriasis should be carefully exam- that type I psoriasis, defined by the onset of psoriasis
ined and questioned specifically about peripheral and prior to age 40, had a stronger genetic basis (defined by
a family history of psoriasis) and exhibited stronger affected mother.25Interestingly, a linkage study in PsA R
e
human leukocyte antigen (HLA) associations.22 Two noted significant linkage only when assessing the fe
re
independent groups noted a similar trend for PsA transmission of alleles of paternal origin.26 n
c
when PsA was stratified according to the age of onset In summary, the exact prevalence and incidence of es
of psoriasis.23,24PsA patients with early-onset psoriasis PsA are not known. There is a large variance in the
(onset of psoriasis prior to age 40) were more likely to reported prevalence and incidence rates of PsA, in part
have a family history of psoriasis and PsA and exhib- because of a lack of widely accepted diagnostic criteria.
ited differential expression of HLA antigens. When the Classification of Psoriatic Arthritis (CASPAR)
A parent-of-origin effect has also been demonstrated group arrives at a valid set of diagnostic-classification cri-
in PsA as there appears to be a greater proportion of teria, a proper prospective epidemiologic study may pro-
PsA probands with an affected father than with an vide better estimates regarding the epidemiology of PsA.
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