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Chapter: Paediatrics: Bones and joints

Paediatrics: Psoriatic arthritis

Recently recognized, underdiagnosed subset of JIA; 2–15% of children with JIA; unknown aetiology on a background of strong genetic predisposition (up to 50%).

Psoriatic arthritis

 

Recently recognized, underdiagnosed subset of JIA; 2–15% of children with JIA; unknown aetiology on a background of strong genetic predisposition (up to 50%).

 

ILAR criteria for diagnosis of psoriatic arthritis1

Inflammatory arthritis in presence of psoriasis, or inflammatory arthritis with dactylitis or psoriatic nail changes plus a first-degree relative with psoriasis.

Exclusions: RF +ve; HLA-B27 +ve in male >6yrs; any enthesitis-related arthritis or uveitis in first-degree relative; systemic arthritis.

 

Clinical features

 

Arthritis and rash rarely present simultaneously. Rash usually precedes arthritis.

Arthritis: commonest is asymmetrical large joint (knees or ankles). Small joint polyarthritis of fingers and toes (metacarpal phalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints) and dactylitis are also common. Some children have tendonitis or tenosynovitis, especially around the ankles.

 

Skin: predominantly plaque psoriasis (examine extensor surfaces of elbows and knees, hairline, behind the ears, around the umbilicus, groin, and natal cleft;).

 

Nails: pitting, ridging, onycholysis, subungual hyperkeratosis.

 

Uveitis: needs regular screening as can potentially blind.

 

Psoriasis affects up to 3% of normal population; the association with inflammatory arthritis may be coincidental.

 

Investigations

 

No specific tests: need exclusion bloods.

 

Often evidence of chronic inflammation: raised CRP; thrombocytosis; and low grade normocytic anaemia.

 

Radiographs

 

Periarticular osteopenia and soft tissue swelling.

 

Periosteal new bone formation, particularly in dactylitis.

 

Treatment

 

Important to diagnosis dactylitis. NSAIDs are the mainstay of treat-ment. Intra-articular steroid injections often help settle inflammation. Methotrexate and ant-TNF agents are effective for persistent disease.

 

Prognosis 

Arthritis can be episodic and continue into adult life. A few patients have a very destructive course with arthritis mutilans.

 

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Paediatrics: Bones and joints


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