Psoriatic arthritis

• General Rheumatology consultations (consultants, specialty doctors, specialist nurses, ANP, senior Pharmacist)
• AHP (Rheumatology Physiotherapy, Podiatry, Occupational Therapy)
• US scan of the joints (for internal referrals only)
• Intraarticular steroid injections (for internal referrals only or performed by Rheumatology Physiotherapist)
• Training for self-delivered subcutaneous injections (internal use only)
• Medical Day Unit (internal service for delivery of intravenous medication, subcutaneous medication, Short Synacthen test)
• Rheumatology on-call (quick access to the service, prompt reply to enquiries via email)
• Rheumatology page 1439 – covered by resident doctor
• Rheumatology helpline  - 01292513316 – Service run by Rheumatology Specialist nurses.

Suspected psoriatic arthritis and other peripheral sondylarthritis.

History

• Joint pain, stiffness and swelling affecting the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the hands, feet and large joints, symmetrical/asymmetrical.
• Early morning stiffness (typically >30 minutes)
• Inactivity gelling (stiffness after a period of inactivity)
• Presence or history of psoriasis/family history of psoriasis
• May have inflammatory spinal pain symptoms
• May have IBD/uveitis/iritis.

Examination

• Joint swelling and tenderness
• Nail changes e.g. pitting
• Lower back or thoracic-lumbar junction pain on palpation or mobilisation
• Psoriasis or psoriatic nails.

Refer to Rheumatology with urgent priority if the patient displays persistent symptoms as above, by using SCI OP Gateway

Do not send new referrals only for updates or to ask for urgent review do to flares for patients already known to Rheumatology, being on the list waiting for reviews, as we cancel such referrals to avoid duplication.

Please do not hesitate to keep in touch with us regarding your patients with any updates, symptom changes or flare ups using the Rheumatology Clinical email inbox: clinicalr@aapct.scot.nhs.uk

Investigations

• FBC, U&Es, LFTs, CRP/ESR (may be normal)
• Rheumatoid arthritis factor typically negative
• X-ray of hands or feet (extra bone formation, erosions)
• X-ray lumbar spine or pelvis – square vertebra, extra bone formation (Romanus’ lesions), demineralization, aspect of sacroiliitis uni or bilateral asymmetrical.

Please do not check rheumatoid factor and ANA for patients with back pain as they have no relevance for diagnosis or disease management, but they can generate unnecessary referrals, misinterpretations and stress to patients.

Initial management

Treat symptoms with NSAID and/or analgesics pending clinic review.

Please avoid giving corticosteroids as they will mask the clinical examination, do not help for diagnosis and can worsen psoriasis after discontinuation.

Main differential diagnosis

Rheumatoid arthritis

Osteoarthritis - there is bony swelling of the distal interphalangeal (DIP) and proximal interphalangeal (PIP) and 1^st carpometacarpal (CMC) joints of the hands rather than synovitis. Morning stiffness is not prominent. Radiographs show OA change. 

Mechanical back pain

1. British Society for Rheumatology Adult Rheumatology Referral Guidance. September 2021. Accessed at: https://www.rheumatology.org.uk/Portals/0/Documents/Policy/Adult-rheumatology-referral-guidance.pdf?ver=2022-08-04-104812-413
2. NHS Lanarkshire Rheumatology referral guidelines. March 2022. Accessed at: https://rightdecisions.scot.nhs.uk/media/2014/ebooklet-rheumatology-referrals-2022.pdf
3. NHS Lothian. RefHep. Accessed at:RefHelp – Instant Acces s to Referral Guidelines for Lothian