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Original article
a r t i c l e
i n f o
Article history:
Accepted 19 January 2015
Available online 13 April 2015
Keywords:
Subclinical enthesitis
Psoriasis
Psoriatic arthritis
Ultrasonography
Biological therapies
a b s t r a c t
Objective: To estimate the prevalence of ultrasonographic enthesitis in psoriasis patients with or without
musculoskeletal symptoms and to investigate their evolution under systemic treatments given for the
cutaneous symptoms.
Patients and methods: Prospective bi-centre (rheumatology and dermatology) study over 6 months,
including psoriasis pts requiring systemic treatment, with or without musculoskeletal symptoms and/or
psoriatic arthritis (PsA). Clinical assessment (M0 and M6) included: BASDAI, HAQ, SPARCC, PASI and nail
disease. US assessment (M0 and M6) with Grey Scale and PD of 10 entheses was performed by one trained
rheumatologist blinded to clinical and biological data, scoring morphological, structural lesions and PD
signal.
Results: Complete data were obtained on 340 entheses in 34 patients. Twenty-two were asymptomatic
(PsO) and 12 symptomatic (PsA). They received conventional treatment and/or biologics.
At baseline: US abnormalities were found in 97.1% total population and in 86.4% PsO patients. 95/340
enthesitis were observed, 57/220 in PsO vs 38/120 in PsA (P = 0.258). Neither group had PD signal. Presence
of 24/90 enthesitis in patients with nail disease vs 33/130 without (P = 0.831).
At M6: Twenty-three patients were assessed. US morphological (thickness and hypoechogenicity) abnormalities were improved in PsO (n = 13) (P = 0.021) and PsA patients (n = 10) (P = 0.164) with a signicant
decrease of BASDAI, HAQ, SPARCC.
Conclusion: We observed a high frequency of US enthesitis in psoriasis patients, with or without musculoskeletal symptoms, requiring systemic treatment. At 6 months, US morphological abnormalities were
likely to improve. Further studies would be interesting to validate our data and to assess their potential
impact on PsA development.
2015 Socit francaise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction
Enthesitis is a distinctive feature in the pathogenesis of spondyloarthritis (SA), group of diseases, including psoriatic arthritis (PsA)
[1,2]. PsA occurs in a variable percentage of psoriasis patients
http://dx.doi.org/10.1016/j.jbspin.2015.01.016
1297-319X/ 2015 Socit francaise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
268
involved in the treatment decisions. US examination was performed in a darkened room. The patients were asked not to discuss
their clinical symptoms to avoid the possibility of bias. In each
patient, 5 entheses were scanned bilaterally with a systematic
longitudinal and transverse PDUS examination: Achilles tendon,
plantar fascia insertion, quadriceps insertion, patellar proximal and
brachial triceps tendon insertion. Entheses with previous surgical
procedures were not evaluated. Power Doppler (PD) assessment
was performed at the bony margins and entheseal site with a
Doppler frequency of 8.3 MHz. Pulse repetition frequency of 500 Hz
was adjusted to the lowest permissible value to maximize sensitivity. A low-wall lter was used. Flow was additionally demonstrated
in 2 planes and conrmed by pulse wave Doppler spectrum to
exclude artefacts.
Patients were placed in a supine decubitus position to assess
entheses of knee (quadriceps tendon insertion and patella ligament origin) exed at 45 for gray scale (GS) and power doppler
(PD); to assess the entheses of feet (Achilles tendon and plantar aponeurosis): prone decubitus with the feet hanging outside
the examination table in slight at 90 dorsal of exion for GS
and in neutral position for PD; to assess brachial triceps enthese:
sitting facing the examiner with armed exed at 90 and palmar surfaces on a table. US enthesitis were identied according
to the outcome measures in rheumatoid arthritis clinical trials
(OMERACT) denition: abnormally hypoechogenicity (loss of normal brillar architecture) and/or thickened tendon or ligament at
its bone attachment (may occasionally contain hyperechogenicity
foci consistent with calcication), seen in two perpendicular planes,
which may exhibit Doppler signal and/or bony changes, including
enthesophytes, erosions or irregularity [12]. The following elementary lesions were assessed for each enthesis with a binary score
(presence/absence): morphological (i.e. hypoechogenecity and/or
thickening at the body of the tendon) and structural abnormalities
(entheseal calcic deposits, bone erosion and/or enthesophytes) in
GS and intra-enthesis PD signals at the cortical bone insertion. We
took as reference value the tendinous thicknesses used in the MASEI
score [22].
2.3. Statistical analysis
Categorical data are expressed as frequencies, and continuous
variables are given as means (SD). The Wilcoxon signed-rank test
was used to compare changes in clinical and functional scores, from
baseline to the end of the study (M6). The rates of overall and
individual lesions by ultrasound in PsO and PsA patients and in subgroups with or without nail disease were compared by using a 2
test. Changes in US morphological abnormalities between baseline
and M6 were studied using the Mc Nemars test for paired binary
data. All tests were two sided and the signicance level was set to
5%. We used SPSS software, version 11.0 (Chicago, IL, USA) for the
statistical analyses.
3. Results
3.1. Patients characteristics
PDUS were performed on 34 patients (Table 1) who were starting a rst systemic therapy with methotrexate (MTX) (n = 23, 67.6%)
or biologic therapy (n = 11, 32.4%), (etanercept, iniximab, ustekinumab, and adalimumab).
We included:
22 PsO patients: 19 starting conventional systemic treatment
(MTX) and 5 biologics (iniximab n = 1, adalimumab n = 1, ustekinumab n = 3);
34 (20 M; 14 W)
43.45 12.3
Patients (n)
Disease duration, mean (years)
Nail disease (n)
BSA (%)
PASI
DLQI
BASDAI
SPARCC
HAQ
Mean CRP (mg/L)
Treatments
Methotrexate (n)
Biologics (n)
PsO
PsA
22
16.7 9.7
9
5 22.9
15.8 9.9
9.8 3.9
NA
NA
NA
4.25
12
14.4 6
8
269
46.4 16.7
6.73 2.6
1.1 0.5
23 (67.6%)
11 (32.4%)
Table 2
Baseline PDUS ndings in PsO and PsA patients.
Hypoechogenicity
Thickening
Erosion
Calcication
Power Doppler
Morphological lesions
Structural lesions
All lesion
P values
53
69
46
98
0
95
116
167
15.6
20.3
13.5
28.8
0
27.9
34.1
49.1
27
43
26
57
0
57
69
102
12.3
19.5
11.8
25.9
0
25.9
31.4
46.4
26
26
20
41
0
38
47
65
21.7
21.7
16.7
34.2
0
31.7
39.2
54.2
0.022
0.642
0.212
0.108
0.258
0.147
0.169
270
Table 3
Ultrasonography morphological lesion from baseline to 6 months.
M0
Total population
PsO
PsA
M6
P values
Enthesitis
Total enthese
Enthesitis
Total enthese
72
39
46
230
130
100
31.3
30
33
47
23
24
230
130
100
20.4
17.7
24
0.006
0.021
0.164
Disclosure of interest
The authors declare that they have no conicts of interest concerning this article.
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