John Tesser, MD: I would like to now bring into the discussion my colleagues. Let me launch into this by asking you, Nehad, can you give a sense of what risk factors, signs, and symptoms help us understand the disease a little better?

Nehad Soloman, MD: Certainly. Thank you, John. First of all, you did a brilliant job underscoring and outlining the variability in presentations of this condition. You mentioned the genetic factors. You mentioned both skin as well as peripheral and axial involvement, and so all of that is very important to understand the domains that are involved in this disease process. When we think about it, years ago when you and I trained, we had learned about the Moll and Wright classification criteria, where we divided it up based on the distribution of joint symptomatology and features. But it left out some of the critical pieces that you underscored. It left out the idea behind the whole patient, the systemic nature of this disease. Patients with systemic disease may also have what we call extra-articular manifestations. They may present with uveitis, which is an inflammation in the eye. They may have a comorbid condition with inflammatory bowel disease, for example. Not everybody has an HLA-B27 component. As you mentioned, there are other genetic factors as well.

But even more than that, as a patient, all of this is rather overwhelming and sometimes obtuse when we talk to them in scientific terms. For the patient, it’s about their quality of life, which includes pain, fatigue, stiffness, swelling, and skin manifestations. And I can’t underscore how important that is. When somebody is riddled with psoriasis all over his or her body, it has a psychological effect. Many of these folks have depression. Many of these folks don’t have a social life as a result of the proverbial alligator skin, if you will. So, in thinking about treatment for these folks and how to approach them, it’s important to employ a multifaceted approach. But we’re going to get into treatment a little later, so we’re sticking to the idea of presentation and thinking about domains now as opposed to the prior classification criteria.

Now we think about the CASPAR criteria that you mentioned, which is the classification criteria for psoriatic arthritis. Although this is really meant for research purposes, I think in the clinic it’s very useful, especially when we have APCs [advanced practice clinicians], advanced practice providers, medical students, and the like, in thinking about how to approach the disease. I think the 2 critical pieces include dactylitis and enthesitis, and those were things that we hadn’t really thought much about in the past. But they seem to be pretty unique and specific for this condition in particular, or this family of conditions in particular. They’re also the most difficult aspects of the disease to really get under control. So you’ll see many of the studies will specifically call out percentage improvement of dactylitis, percentage improvement of enthesitis, and in what timeframe, because of how debilitating those 2 aspects may be.

John Tesser, MD: Excellent comments, Nehad. I think what you have underscored very well is the holistic concept. This is a psoriatic disease, and we need to understand all of these other organ systems that you would think would be separate from this inflammatory disease, but like others, we see it’s a systemic autoimmune inflammatory disease affecting multiple organ systems. I don’t want to leave out the nails. The nails are very important. Interestingly enough, the nails are really an extension of the tendons as they go through the rays of the fingers and the toes

This transcript has been edited for clarity.