Clinician Education is Crucial for the Early Recognition of Psoriatic Arthritis

Current unmet needs in the early recognition of psoriatic arthritis (PsA) included improving the use of screening instruments, increasing the education of community-based dermatologists and primary care physicians (PCPs), and utilizing a combination of patient-reported and physician-confirmed findings in the screening approach, according to study results published in The Journal of Rheumatology.

The early recognition of PsA is essential for improving long-term physical function; however, the screening tools developed to identify PsA among patients living with psoriasis are not frequently used. Investigators aimed to explore the views and practices of rheumatologists and dermatologists regarding PsA screening, diagnosis, and care. Additionally, clinicians’ use of screening tools, their opinions on the optimal method to confirm PsA diagnosis, and the greatest unmet needs that currently impede early PsA recognition were examined.

A 24-question survey was sent to all 927 members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). Members of GRAPPA included rheumatologists, dermatologists, and Patient Research Partners (PRPs).

A total of 149 GRAPPA members completed the survey between October 3 and October 16, 2022, including 113 rheumatologists, 26 dermatologists, 7 PRPs, 2 other physicians, and 1 nonphysician.

For the initial referral and assessment, dermatologists reported that 24.0% of their patients with psoriasis also have PsA, and 96.0% indicated they evaluate musculoskeletal (MSK) symptoms among patients with psoriasis. Most (77.0%) assessed for these symptoms among all patients with psoriasis, but 19.0% only did so when MSK symptoms were reported by the patient.

To identify patients with psoriasis with an increased likelihood of having PsA, physical examination was the most common method, with 89.0% of dermatologists relying on the presence of arthritis, enthesitis, and dactylitis, while 85.0% used patient-reported MSK symptoms such as joint and back pain.

Screening questionnaires were also commonly used, with 74.0% of dermatologists utilizing this method. The Psoriasis Epidemiology Screening Tool (PEST) was the most widely used screening instrument (81.0%), followed by The Psoriatic Arthritis Screening and Evaluation Tool (24.0%).

Dermatologists referred an average of 85.0% of patients with suspected PsA to rheumatology, with 67.0% of referrals eventually receiving diagnostic confirmation.

Rheumatologists reported that 42.9% (standard deviation [SD], 24.9%) of patients with psoriasis had seen a dermatologist within a year prior to diagnosis (range, 0.10%-99.0%). PEST was the most widely used screening instrument (60.0% of patients). A total of 47.9% (SD, 24.2%) of referred patients were eventually diagnosed with PsA (range, 0.50-100.0%).

Interspecialty differences in therapeutic decision-making for patients with psoriasis and PsA who required treatment escalation were investigated. Dermatologists most commonly adopted an interdisciplinary approach (54.0%), while rheumatologists relied most often on clinical manifestation to determine therapeutic decisions (40.4%).

In response to optimizing the screening process, 78.2% of clinicians believed that a combination of patient-reported and physician-confirmed findings represents the most effective means of screening patients.

Regarding opinions of unmet needs, dermatologists pointed out a lack of education among their own specialty (85.0%) and PCPs (65.0%), while rheumatologists highlighted the education of PCPs (79.8%) and dermatologists (62.4%). All respondents raised concern over other unmet needs, including long waiting times (46.3%), lack of rheumatologists/available appointments (42.9%), poor performance of screening instruments (37.4%), and education of rheumatologists (22.4%).

Study limitations included survey distribution restricted to GRAPPA members, a low survey-response rate, and potential subjectivity and recall bias.

The study authors concluded, “The education of PCPs and dermatologists regarding early PsA recognition in psoriasis patients was identified as the biggest current unmet need, above long waiting times and poor performance of screening tools. We suggest that such education should focus on identifying the early signs and symptoms, especially clinical manifestations that differentiate PsA from osteoarthritis and rheumatoid arthritis.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.