Psoriatic Arthritis
Psoriatic Arthritis
Table Of Content:
- Definition of the disease. Causes of the disease
- Symptoms of psoriatic arthritis
- Pathogenesis of psoriatic arthritis
- Classification and stages of psoriatic arthritis development
- Complications of psoriatic arthritis
- Diagnosis of psoriatic arthritis
- Treatment of psoriatic arthritis
- Forecast. Prevention
- Sources
Psoriatic arthritis Symptoms and treatment
What is psoriatic arthritis? What are the causes, diagnosis, and treatment of psoriatic arthritis? All the methods will be discussed in the article below.
Definition of the disease. Causes of the disease
Psoriatic arthritis is a chronic immune, mediated inflammatory disease of the musculoskeletal system that develops in patients with psoriasis.
Psoriatic arthritis mainly affects the joints and tendons of
the hands and feet, as well as the entheses (places where tendons attach).
Sometimes the process involves the spine with the development of spondylitis
and sacroiliac joints with the development of sacroiliitis.
In the psoriatic arthritis clinic, symptoms of inflammation predominate: pain, swelling, redness, fever in the affected joint area with a gradual decrease in its function.
Prevalence rate
Psoriasis affects between 1 and 3% of the world's
population. The disease affects men and women equally often. Of all patients
with psoriasis, 5-7 % develop psoriatic arthritis. At the same time, some
researchers indicate that the symptoms of arthritis in patients with psoriasis
occur in 46-61 % of cases.
Most often, psoriatic arthritis occurs between the ages of
20 and 60, but its symptoms can appear at any other age. Psoriatic arthritis is
rare in children, usually appearing at 1-2 years of age or at 6-16 years of age.
Causes of psoriatic arthritis
Psoriasis is a systemic process that can involve joint
tissues. The disease is not fully understood. The exact causes of psoriasis and
psoriatic arthritis are unknown.
There is evidence of a hereditary predisposition: approximately 40 % of patients with psoriasis or psoriatic arthritis have first-degree relatives with these pathologies. In this case, the relationship with the HLA system is noted. HLA (Human Leukocyte Antigens, human leukocyte antigens) is a group of protein molecules on the surface of cells that allow the body to recognize its own and other cells (bacteria, viruses, cancer cells, etc.) and, if necessary, trigger an immune response.
A hereditary predisposition is manifested under the influence
of unfavorable environmental factors that change the state of the body's immune
system. These factors include:
Infections — bacterial, viral, or fungal.
Immunodeficiency — congenital or acquired, including AIDS.
Endocrine factors. Their impact on the onset or progression
of psoriatic arthritis is not fully understood. It is known that puberty
(puberty) and the onset of menopause exacerbate the course of the disease, and
during pregnancy, it proceeds more gently.
Diseases of the gastrointestinal tract — gastritis,
cholecystitis, intestinal dysbiosis.
Psychoemotional stress contributes to the onset of the
disease in 70% of cases and exacerbation of the process in 65 %.
Medications — lithium preparations, beta-blockers,
isoquinolines, and sometimes nonsteroidal anti-inflammatory drugs (NSAIDs).
These medications increase the level of pro-inflammatory enzymes in the blood,
which, in the presence of a genetic predisposition, trigger a pathological
process.
Injuries.
Symptoms of psoriatic arthritis
The main symptom of psoriatic arthritis is joint damage,
which is characterized by the typical manifestations of arthritis: pain,
swelling, and limited joint mobility. A characteristic feature of this disease
is the asymmetry and randomness of joint inflammation.
Sometimes psoriatic arthritis occurs in the form of
symmetrical polyarthritis. Such arthritis resembles the rheumatoid nature of
joint syndrome: the patient has pain, swelling, restricted movement, and morning
stiffness in more than four symmetrical joints of the hands and feet (mainly
the joints of the hands, feet, and knees).
Psoriatic arthritis is typical:
simultaneous inflammation of several joints of the same finger (axial arthritis);
inflammation of the distal (distant) and interphalangeal joints of the hands and feet, I carpocarpal joints, and metatarsophalangeal joints of the feet, i.e. joints-exceptions for rheumatoid arthritis.
Arthritis of the knee joints in psoriasis is accompanied by
a large amount of effusion (fluid).
When the axial skeleton is involved, the patient is
concerned about inflammatory back pain, mainly in the cervical and lumbar
regions. This pain occurs or worsens at night, in the morning, or when a person
is in one position for a long time. In the morning, patients usually feel joint
stiffness; after a warm-up session, it decreases or goes away. Chest pain may
also occur when breathing. Sacroiliitis is manifested by intermittent pain in
the gluteal muscles.
Dactylitis (inflammation of the phalanges of the fingers or toes) is found in 48% of patients with psoriatic arthritis. In acute dactylitis, the entire finger becomes sharply painful, evenly swollen, swollen and reddened. A "sausage-like" deformity of the finger develops. Chronic dactylitis causes swelling and swelling of the finger without pain.
Enthesitis
Another common clinical manifestation of psoriatic arthritis is enthesitis, inflammation at the attachment points of muscle tendons to bone. Most often, the heel area is affected: the place where the plantar fascia and Achilles tendon attach to the heel bone. The spinous processes of the vertebrae, the upper edge of the patella, the wings of the iliac bones, etc. may also be affected.
With a high degree of arthritis activity, fever with a temperature rises up to 38-39 °C can join the clinical picture.
Pathogenesis of psoriatic arthritis
Psoriatic arthritis is part of the psoriasis symptom
complex. In addition to joints and connective tissue, psoriasis affects the
skin, internal organs, and lymph nodes, and also disrupts microcirculation.
It was found that 30 % of the genetic predisposition of
psoriatic arthritis is associated with HLA, which is a significant part of the
chromosome. Different antigens of this system determine the development of
different types of psoriatic arthritis. For example, the B17 antigen is associated
with the development of oligoarthritic or spondyloarthritis variants of
psoriatic arthritis, B27-with damage to the axial skeleton, and B38 antigen -
with asymmetric arthritis.
The pathogenesis of psoriatic arthritis is associated with the interaction of cellular and humoral (fluid) factors of the immune system.
The main role in this process belongs to pro-inflammatory
cytokines. These are information molecules that are synthesized by activated
immunocytes and epidermal cells and provide an inflammatory response of the
body.
In psoriatic arthritis, the amount of pro-inflammatory cytokines increases. Under their influence, at the initial stages, capillaries expand in the synovial membranes of joints, edema and infiltration around blood vessels appear. Infiltration involves soaking the tissue with an inflammatory fluid. The basis of this fluid in the skin in psoriasis and in the synovial membranes of the joints in psoriatic arthritis are activated T-lymphocytes together with tissue macrophages and dendritic cells. I.e., psoriasis and psoriatic arthritis are a T-cell-mediated process.
In recent studies, angiogenesis, i.e. the formation of new
blood vessels, is increasingly important in the development and progression of
psoriatic arthritis. This occurs under the influence of pro-inflammatory
cytokines that have a pro-angiogenic character: endothelial growth factor,
tumor necrosis factor α (TNF-α), interleukin 8, etc. They provoke the
formation of new blood vessels, which increases synovial infiltration and
hyperplasia (tissue overgrowth) and increases the synthesis of cytokines and
growth factors, and a vicious circle occurs.
Pro-inflammatory cytokines also cause hypersensitivity of
the sensing nerve fibers. As a result, the excited pain receptors begin to
respond to the usual non-painful effects, and the person feels pain in the
joint with light pressure and movement.
Classification and stages of psoriatic arthritis development
Clinical variants of psoriatic arthritis:
Distal shape. The distal (distant) interphalangeal joints of
the hands and feet are mainly affected. In the classic distal form, isolated
arthritis of these joints occurs. But they can also be involved in the
pathological process in other clinical forms of psoriatic arthritis.
Asymmetric mono-or oligoarthritis. This type of psoriatic
arthritis is the most common. The knee, elbow, wrist, ankle, and interphalangeal
joints may be affected, but the number of joints involved does not exceed four.
Symmetrical polyarthritis (rheumatoid-like form).
Symmetrical joints (paired joint areas) are affected, as in rheumatoid
arthritis. Asymmetric pathology in this form is also possible, but the number
of joints involved in the pathological process should be at least five.
Psoriatic spondylitis. In an isolated form, it is rare, more
often combined with peripheral arthritis. Psoriatic spondylitis is accompanied
by an inflammatory lesion of the intervertebral joints, as well as the
sacroiliac joint.
Mutating arthritis. It is characterized by widespread osteolysis (destruction) of the articular surfaces. This is a rare form of psoriatic arthritis, in which the fingers of the hands and feet are shortened and deformed due to the destruction of the articular surface, and multiple multidirectional subluxations of the fingers appear
In children, there are two clinical variants of the disease
that do not exclude each other:
The first variant develops mainly in girls aged 1-2 years
and is characterized by damage to no more than four joints, dactylitis, chronic
uveitis, and a positive test for antinuclear antibodies.
The second variant of children's psoriatic arthritis usually
makes its debut in 6-12 years. It is equally common in boys and girls. Any
number of joints can be affected, sometimes the axial skeleton is involved, and dactylitis and enthesitis occur. Antinuclear antibodies are usually absent, but
there is an association with HLA-B27.
Forms of psoriatic arthritis that reflect the main features
of the pathological process, its severity, the degree of progression of bone
and joint destruction, the presence and severity of systemic manifestations,
and so on.:
The usual form. It progresses slowly. Inflammation develops in a limited number of joints, such as the sacroiliac joints or the spine. There is no functional insufficiency. Destructions are noted in individual joints.
Severe form. It is characterized by generalized arthritis,
spondylitis with pronounced spinal deformity, multiple joint erosions,
functional insufficiency of joints of II-III degrees, pronounced general and
visceral manifestations, and progressive course of exudative or atypical psoriasis.
Malignant form. It is characterized by a particularly severe
course: hectic fever with changes in body temperature by 3-5 °C, which can be
repeated 2-3 times a day; generalized arthritis with pronounced exudative
manifestations-develops only in men with pustular or erythrodermic psoriasis.
With pustular psoriasis, the patient develops rashes — pustules filled with
fluid. An erythrodermic psoriasis is a severe form of the disease with the spread
of psoriatic rashes throughout the body. In this case, the rash becomes bright
red and covered with white scales. The malignant form of psoriatic arthritis is
very difficult to treat.
Degrees of activity:
Minimal activity. The patient is concerned about minor joint
pain when moving, morning stiffness is absent or does not exceed 30 minutes.
The body temperature in this case is normal, and the erythrocyte sedimentation rate
(ESR) in the general blood test does not exceed 20 mm/h.
Moderate activity. Joint pain occurs not only when moving,
but also at rest. At this stage, morning stiffness lasts up to three hours,
body temperature rises to 38 °C, and ESR — is up to 40 mm/h. Leukocytosis and a shift
of the leukocyte formula to the left (an increase in the number of young
immature neutrophils) are possible.
Maximum activity. It is characterized by severe joint pain
during movement and at rest, as well as significant and persistent swelling
around the joints. Body temperature rises to 39 °C, and laboratory parameters are
significantly changed.
Complications of psoriatic arthritis
Complications of psoriatic arthritis can be divided into
articular and systemic.
Articular complications are primarily associated with
erosion of the articular surfaces, and destruction of the bones of the terminal
phalanges. As a result, functional insufficiency of the joints progresses, up
to the fourth degree, in which the joints are completely immobile due to bone
ankylosis (fusion of the articular ends of the bones).
If persistent dactylitis is not treated, flexion contracture of the fingers (shortening and compaction of the tendons of the palmar surface) and functional insufficiency of the hands and feet develop quite early
Systemic manifestations of psoriatic arthritis include
damage to the following organs::
eye (conjunctivitis, iridocyclitis, uveitis, rarely
episcleritis);
kidney diseases (glomerulonephritis, amyloidosis of the
kidneys, tubulopathy);
heart disease (myocarditis, endocarditis with damage to the
valvular apparatus of the heart, more often the aortic valve with the
development of aortitis);
liver disease (hepatitis);
peripheral nervous system (polyneuritis), etc.
The cause of systemic manifestations of psoriatic arthritis
is considered to be progressive disorganization of connective tissue, complex
disorders in the system of cellular and humoral immunity, as well as systemic
proliferative-destructive vasculitis (vascular inflammation).
In psoriatic arthritis, metabolic disorders occur, such as
dyslipidemia — a change in the level of lipids in the blood with an increase
in" harmful " low-density lipoproteins. In combination with advanced
atherosclerosis, this increases the risk of cardiovascular death in these patients.
Atherosclerosis progresses due to an increase in
pro-inflammatory cytokines in the blood, which disrupt the function of the
endothelium (the inner wall of blood vessels). At the same time, the
endothelium produces proatherogenic and procoagulant mediators, under the
influence of which lipids are deposited in the vascular wall, atherosclerotic
plaques are "destabilized", and blood clots occur.
Diagnosis of psoriatic arthritis
The diagnosis of psoriatic arthritis is made based on the
clinical picture, laboratory tests, and radiological data.
Clinical manifestations
In the clinical picture, there are two main symptom
complexes: joint syndrome and the presence of characteristic psoriatic rashes
on the skin.
Inflammatory damage to the musculoskeletal system
(arthritis, spondylitis, enthesitis) develops in 60-70% of cases against the
background of already existing skin manifestations. However, in some cases,
psoriatic arthritis begins with the joint syndrome in the absence of changes in the
skin.
Damage to the axial skeleton is possible even without
concomitant arthritis, but it is more often observed with inflammation in the
peripheral joints. Psoriatic sacroiliitis is usually unilateral. Often this is
the only manifestation of damage to the axial skeleton (isolated psoriatic
sacroiliitis).
The joint syndrome usually develops acutely, less often
subacutely in the form of persistent arthralgia (joint pain). The pain is
intense, often accompanied by stiffness. In rare cases, pain and stiffness
immobilize the patient.
Psoriasis of the skin can be both common and limited — in the form of single plaques. Rashes usually appear on the scalp, behind the ears, on the elbow and knee joints, in the navel, and intervertebral fold. Sometimes the only manifestation of pathology is nail psoriasis in the form of digitalis psoriasis, onycholysis, subungual hyperkeratosis, etc.
Laboratory diagnostics
Laboratory manifestations in psoriatic arthritis are
non-specific and are associated with the activity of the inflammatory joint
process. At the moderate and maximum activity, there is an increase in ESR,
leukocytosis with a shift in the leukocyte formula, an increase in the level of
C-reactive protein (CRP), dysproteinemia (a violation of the content of
proteins in blood plasma). The higher the activity of the inflammatory process,
the more pronounced these changes are.
In 5-10% of patients in small concentrations (titer not
higher than 1/64), rheumatoid factor is detected — antibodies that mistakenly
attack the body's own tissues. 20 % of patients have elevated uric acid levels,
and gout symptoms are almost never detected.
To clarify the diagnosis of psoriatic arthritis, the HLA-B27
histocompatibility system gene is also determined using a polymerase chain
reaction. A third of the patients tested positive.
Instrumental diagnostics
The radiological picture of psoriatic arthritis has its own characteristics. In the first stages, the narrowing of the articular slits is visible. As the disease progresses, erosive changes develop in the distal interphalangeal joints. Erosion first affects the edges of the joints, then spreads to the center. There may also be the destruction of the terminal phalanges, resulting in a bone deformity of the "pencil in a glass" type.
Psoriatic arthritis can also be suspected in a patient.:
bone proliferation (overgrowth): enthesophytes (bony
protrusions at the site of attachment of a tendon or ligament) and marginal
bone growths;
bone ankylosis (splices);
changes in the spine: paravertebral ossifications (foci of
pathological ossification near the spine); marginal syndesmophytes (bone
growths of the vertebrae);
periostitis (inflammation of the periosteum);
unilateral or asymmetric bilateral sacroiliitis
(inflammation of the sacroiliac joint);
The diagnosis of psoriatic arthritis is made in the presence
of inflammatory joint syndrome, as well as three or more points according to
the CASPAR criteria (ClASsification criteria for Psoriatic Arthritis, 2006).
The CASPAR criteria include:
The presence of skin psoriasis (both at the time of
examination and in the anamnesis, including family).
Psoriatic nail changes.
A negative test for rheumatoid factor.
Dactylites.
Radiological signs of extra-articular bone proliferation.
Differential diagnosis
Psoriatic arthritis is difficult to distinguish from other
diseases if the joint syndrome occurs before the development of skin
manifestations.
Differential diagnosis is performed with the following diseases:
Rheumatoid arthritis. Psoriatic arthritis differs from
rheumatoid arthritis by the asymmetric nature of the joint process and the
absence of rheumatoid factor in blood serum and synovial fluid.
Reiter's disease. In psoriatic arthritis, unlike Reiter's
disease, there is no association of joint syndrome with urogenital infection.
Idiopathic ankylosing spondylitis (ankylosing spondylitis).
This pathology is characterized by more pronounced stiffness and pain of the
spine, as well as the absence of radiological features of psoriatic
spondylitis.
Gout.
Osteoarthritis.
Treatment of psoriatic arthritis
Therapeutic goals of psoriatic arthritis treatment:
Achieve remission or minimal activity of clinical
manifestations if remission is not possible.
Prevent or slow the progression of the disease, including
X-rays.
Increase the patient's life expectancy and improve its
quality.
Reduce the risk of comorbid diseases.
Non-steroidal anti-inflammatory drugs (NSAIDs),
glucocorticoids (corticosteroids), synthetic and targeted synthetic basic
anti-inflammatory drugs, as well as genetically engineered biological drugs with
different mechanisms of action, are used in the treatment.
NSAIDs and corticosteroids are "symptom-modifying
drugs" that reduce pain, swelling, and other symptoms of arthritis,
enthesitis, and dactylitis. When prescribing NSAIDs, the patient's comorbidities
are taken into account. In diseases of the gastrointestinal tract, selective
COX-2 inhibitors are mainly prescribed, and in diseases of the cardiovascular
system, non-selective COX inhibitors are prescribed. In some cases, special
protective drugs (Nolpaza, Omez, etc.) are prescribed to prevent complications
from the gastrointestinal tract.
Corticosteroids are mainly administered intra-articularly.
Systemic use (i.e. for the whole body) in psoriatic arthritis is impractical,
as it can cause an exacerbation of psoriasis, up to pustular forms.
If NSAID and corticosteroid therapy is ineffective,
synthetic and targeted synthetic basic anti-inflammatory drugs, as well as
genetically engineered biological drugs, are used for treatment. All of them
have a "disease-modifying effect", i.e. they affect the mechanism of
disease development.
Synthetic basic anti-inflammatory drugs (DMARDs) include
Methotrexate, Sulfasalazine, Leflunomide, and Cyclosporine. They suppress
inflammation in the musculoskeletal system and in the skin and also delay
structural damage to the joints. Indications for HDL therapy: persistent
activity of psoriatic arthritis, high ESR and C-reactive protein levels, severe
psoriasis, and presence of joint surface erosions. However, these drugs are ineffective
for spondylitis and enthesitis.
Among hDLSS, Methotrexate is the first to be prescribed,
starting with a minimum dosage of 10 mg/week. Methotrexate has many side
effects, so before prescribing it, the patient is examined: the level of liver
enzymes, creatinine, and glucose is determined, a general clinical blood test is
performed, an analysis for HIV and viral hepatitis is performed, and a chest
X-ray is performed. When prescribing Methotrexate, it is necessary to take
folic acid in a dose of at least 5-10 mg/week. If the patient has contraindications
to taking Methotrexate, other drugs of this group are prescribed.
Targeted synthetic basic anti-inflammatory drugs (tsBAPS)
are a new group of drugs for the treatment of psoriatic arthritis. Apremilast
and Tofacitinib belong to this group. These drugs effectively suppress
inflammation in the skin and joints, slow down the radiological progression of
the disease, and they are also effective against dactylitis, enthesitis, and spondylitis.
Among the genetically engineered biological drugs (GBPS),
tumor necrosis factor-alpha inhibitors (Infliximab, Adalimumab, etc.),
monoclonal antibodies to interleukin 12 and 23 (Ustekinumab) and to interleukin
17 (Secukinumab) are used.
GIBPS reduces the activity of arthritis,
enthesitis, and dactylitis and slows the radiological progression of arthritis.
Tumor necrosis factor α inhibitors are used both in monotherapy (single drug
therapy) and in combination with Methotrexate. Before prescribing the GIBP, the
patient should be examined for tuberculosis. For this purpose, a Mantoux test,
a disk-in test, a chest X-ray, and a phthisiatrician's consultation are
prescribed.
Forecast. Prevention
Psoriasis is a chronic progressive disease that leads to
functional insufficiency of the joints and disability of the patient. The unfavorable development of psoriatic arthritis is more often observed in men
and young people.
The prognosis is worse if a high degree of functional joint
failure develops early. Provoking factors for this may be polyarthritis, joint
erosion, previous intake of glucocorticoids, and an increase in ESR and C-reactive
protein.
If left untreated, erosions, mutating arthritis, and
sacroiliitis can develop within 6 months of the onset of the disease, which
worsens the further prognosis of the disease.
With psoriatic arthritis, the patient loses his ability to
work within 5 years from the onset of the disease. Mortality in this group is
higher than in the general population (65% for women, 59 % for men). This is
due to extra-articular systemic manifestations of psoriatic arthritis:
obstructive vascular diseases of the heart and brain;
kidney failure, which subsequently leads to amyloid
nephropathy;
diseases of the respiratory system;
malignant tumors;
complications from ongoing treatment.
Early diagnosis and treatment of psoriatic arthritis slow
down joint damage, and reduce the risk of exacerbations and complications, which
improves the patient's quality of life. Therefore, it is important to consult a
doctor in time and follow all his prescriptions.
Prevention
Primary prevention of psoriatic arthritis has not yet been
developed, i.e. there are no measures that would help prevent the development
of this disease.
Secondary prevention is aimed at reducing the activity of
the process, slowing the rate of progression of arthritis, and preserving joint
function. The main role among secondary prevention measures is assigned to the
selection of adequate standard therapy, as well as the inclusion of genetically
engineered basic drugs in treatment. It is also advisable to conduct a
screening diagnosis of arthritis in patients with psoriasis or with a family
history of psoriasis and psoriatic arthritis. Such patients are recommended to
be examined by a rheumatologist, and if there are joint complaints, the doctor
should prescribe an additional diagnosis.: Ultrasound or X-ray of the joints,
blood tests.
Prevention
Primary prevention of psoriatic arthritis has not yet been
developed, i.e. there are no measures that would help prevent the development
of this disease.
Secondary prevention is aimed at reducing the activity of the process, slowing the rate of progression of arthritis, and preserving joint function. The main role among secondary prevention measures is assigned to the selection of adequate standard therapy, as well as the inclusion of genetically engineered basic drugs in treatment. It is also advisable to conduct a screening diagnosis of arthritis in patients with psoriasis or with a family history of psoriasis and psoriatic arthritis. Such patients are recommended to be examined by a rheumatologist, and if there are joint complaints, the doctor should prescribe an additional diagnosis.: Ultrasound or X-ray of the joints, blood tests.
List of literature
Diseases of joints: a guide for doctors / ed. by V. I. Mazurov. Saint Petersburg: SpetsLit Publ., 2008, 397 p. (in Russian) Nasonov E. L., Nasonova V. A. Rheumatology: a national guide, Moscow: GEOTAR-Media, 2008, 738 p. Zabolotnykh I. I. Diseases of joints: a guide for doctors. Saint Petersburg: SpetsLit Publ., 2013, 270 p. (in Russian) Russian Society of Dermatovenereologists and Cosmetologists, Association of Rheumatologists of Russia. Psoriatic arthritis: federal clinical guidelines. - 2016. - 41 p. Garaeva Z. Sh., Yusupova L. A., Mavlyutova G. I., Yunusova E. I. Psoriatic arthritis. Sovremennye aspekty diagnostiki i lecheniya [Modern aspects of diagnosis and treatment]. Lechashchiy vrach, 2015, no. 4, pp. 36-38. Korotaeva T. V., Korsakova Yu. L., Loginova E. Yu. and others. Psoriatic arthritis: clinical guidelines for diagnosis and treatment // Modern rheumatology. - 2018. - Vol. 12, No. 2. - pp. 22-35. Troshkina I. A., Badokin V. V., Guseva I. A. The role of HLA-system class I antigens in the development of psoriatic arthritis and its clinical presentation. 2012, no. 4, pp. 34-39. Korotaeva T. V. Angiogenesis in psoriasis and psoriatic arthritis: cellular and humoral mechanisms, role in pathogenesis and search for promising solutions in therapy. 2014, No. 2, pp. 60-64. Korotaeva T. V., Korsakova Yu. L. Psoriatic arthritis: classification, clinical picture, diagnosis and treatment / / Scientific and practical rheumatology. - 2018. - No. 1. - pp. 60-69. Batkaeva N. V., Donchenko I. Yu., Batkaev A. E. Diagnosis of psoriatic arthritis without skin manifestations of the disease. Medical review. - 2019. - No. 12. - pp. 36-38. Yusupova L. A., Filatova M. A. Sovremennoe sostoyanie problemy psoriaticheskogo artrita [Current state of the problem of psoriatic arthritis]. — 2013. — № 1-4 (73). — P. 24-28. Yanysheva A.V. Metabolic disorders in psoriatic arthritis / / Siberian Medical Journal, 2009, no 2, pp. 25-28. Bakulev A. L., Shagova Yu. V., Kozlova I. V. Psoriasis as a systemic pathology // Saratov Scientific and Medical Journal. — 2008. — № 1 (19). — P. 13-20. Yanysheva A.V., Badokin V. V. Psoriatic arthritis and the risk of developing cardiovascular pathology / / Siberian Medical Journal, 2008, no. 6, pp. 8-13. Gaidukova I. Z., Rebrov A. P., Lebedinskaya O. A. et al. Cardiovascular morbidity and mortality in ankylosing spondylitis and psoriatic arthritis — results of a single-center, four-year follow-up// Practical medicine. 2015, vol. 88, no. 3, pp. 120-129. Badokin V. V. Therapy of peripheral joint lesions in psoriatic arthritis. Rheumatology. - 2012. - No. 7. - P. 354. Chandran V., Raychaudhuri S. P. Geoepidemiology and environmental factors of psoriasis and psoriatic arthritis // J Autoimmun. - 2010. - Vol. 34, No. 3. - p. J314-321. link Nograles K. E., Brasington R. D., Bowcock A. M. New insights into the pathogenesis and genetics of psoriatic arthritis // Nat Clin Pract Rheumatol. - 2009. - Vol. 5, No. 2. - p. 83-91. link
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