antirheumatic drug (DMARD), the clinical pattern of the condition worsens over time 8 . Indeed, more than 60% of patients who start with monooligoarthritis develop polyarthritis during followup 8 . In addition, although patients with polyarthritis are more frequently treated with traditional DMARD, the number of their involved joints is a function of disease duration 8 . Therefore, there is a consistent rationale towards early effective treatment of PsA patients in order to avoid joint damage. HOW CAN WE DETECT PsA EARLIER? The diagnosis of early PsA requires extremely careful attention to recognition of skin and joint involvement. We know that skin involvement can be clinically more or less evident. Apart from the case of patients with overt skin and/or nail psoriasis or those in whom disease has been present in their medical history, we have to consider patients with barely evident cutaneous involvement (min- imal lesions) and those with preclinical evidence (skin xerosis). Moreover, we need to emphasize the usefulness of magnetic resonance imaging in classifying the disease by demonstrating nail abnormalities in psoriatic patients even in the absence of overt onycopathy 9 . Finally, we also have to consider the case of patients in whom classic skin disease is present only in the family medical history. Emphasized by the ClASsification of Psoriatic ARthritis (CASPAR) criteria 10 , the latter clinical category supports the so-called subset of PsA sine psoriasis, which we previously detailed 11 . With regards to joint evaluation, today, traditional physical examination can no longer be considered an exhaustive system for complete detection of articular involvement. Indeed, detection of synovitis and particu- larly enthesitis by physical examination, apart from having suboptimal reproducibility, has a low sensitivity. Recent evidence shows that sonography detects more synovitis than clinical examination in patients with oligoarthritis 12 . Moreover, in almost two-thirds of patients screened, subclinical disease was demonstrated and, in one third, oligoarthritis was reclassified as pol- yarthritis. More recently, entheseal abnormalities were At the end of the last century, clinical studies on patients with rheumatoid arthritis (RA), conducted with new imaging modalities, increased our ability to recognize soft tissue swelling and erosions that were too small to be seen on traditional plain radiographs 1,2 . This evidence con- firmed that RA is an aggressive condition and supported the concept that the degree of inflammation correlates with structural damage, which is irreversible over time. Consequently, the rapid recognition of inflammatory arthritides became a crucial medical subject and the con- cept of “early arthritis” was developed to assure rapid referral to rheumatologists of all patients with articular involvement of recent onset 3 . COMPARISON OF EARLY RHEUMATOID AND EARLY PSORIATIC ARTHRITIS In recent years, a large body of evidence has demonstrat- ed that psoriatic arthritis (PsA), as with RA, is a severe disease that produces progressive and irreversible joint damage 4,5 . Stable radiographic changes are detectable within 2 years of clinical onset 6 . Therefore, its recognition at early clinical stages is crucial to prevent progression of articular damage. Unfortunately, this point raises several difficulties, the most important of which is that, using a traditional clinical approach, the real severity of joint inflammation may be underestimated. Compared with RA patients, those with PsA show an articular and nonarticular tenderness that is significantly reduced, with a threshold of tenderness that is significantly increased 7 . Despite treatment with a traditional disease modifying ABSTRACT. Early detection of psoriatic arthritis (PsA) can effectively help in reducing the risk of joint damage and disability. Accordingly, the authors offer diagnostic insights in order to improve the approach to the patient’s medical history, clinical examination, and the imaging modalities. Early PsA is a condition with a consistent risk of clinical progression. Marked entheseal involvement is a distinctive clinical aspect that helps discrim- inate early PsA from other conditions observed at their onset, in particular rheumatoid arthritis. (J Rheumatol 2009;36 Suppl 83:26-27; doi:10.3899/jrheum.090217) Key Indexing Terms: EARLY PSORIATIC ARTHRITIS PSORIATIC ARTHRITIS EARLYARTHRITIS Early Psoriatic Arthritis RAFFAELE SCARPA, MARIANGELA ATTENO, LUISA COSTA, ROSARIO PELUSO, SALVATORE IERVOLINO, FRANCESCO CASO, and ANTONIO DEL PUENTE Personal non-commercial use only. The Journal of Rheumatology Copyright © 2009. All rights reserved. From the Department of Clinical and Experimental Medicine, RheumatologyResearchUnit,EarlyPsoriaticArthritisClinic,University Federico II, Naples, Italy. R. Scarpa, MD, Associate Professor of Rheumatology; M. Atteno, MD; R. Peluso, MD, Researcher; L. Costa, MD; S. Iervolino, MD; F. Caso, MD; A. Del Puente, MD, Researcher. Address correspondence to Prof. R. Scarpa, Department of Clinical and Experimental Medicine, Rheumatology Research Unit, Early Psoriatic Arthritis Clinic, University Federico II, via Sergio Pansini 5, 80131 Naples, Italy. E-mail: rscarpa@unina.it 26 The Journal of Rheumatology 2009;36 Suppl 83; doi:10.3899/jrheum.090217 www.jrheum.org Downloaded on February 17, 2022 from