银屑病关节炎中国医学科学院北京协和医院张奉春脊柱关节病包括的疾病强直性脊柱炎是本组疾病的
原型反应性关节炎（ReA）/Reiter综合征（RS）银屑病关节炎（PsA）炎性肠病相关的关节病（IBDA）幼年发病的脊柱
关节病（JSpA）分类未定的脊柱关节病（USpA）定义：因银屑病而引发的关节炎，属血清阴
性脊柱关节病的范畴。历史：1818年（法国）Alibert报道1860年Bazin命名20世纪
60年代：独立疾病流行病学发病：世界范围患病率：美国0.1%在银屑病中5%~
7%专科医院：7%~49%我国：银屑病0.123%
15%PsA发生在银屑病之前年龄：32~45岁性别：男:女为1:1.
04~1:1.4NPFBenchmarkSurveyforPsoriasisandPsoriaticArthr
itis(N=27,000)PsoriaticArthritisStatisticsAmericansaffec
ted:1millionadultsImpactonpatients’lives:84%reportmoder
atetosignificantimpactonday-to-dayactivities75%losesleep
orsleeppoorly69%reportdiseaseinterfereswitheducational,
vocational,andsocialactivitiesSatisfactionwithtreatment:5
0%reportedseeing?3physiciansfordiseaseinpast2years1i
n4weredissatisfiedwithtreatmentFamilialPredisposition（倾向、
易患病的体质）1stdegreerelativewithpreviousdiseasehistory:40%
ConcordanceratesMonozygotic单卵twins:65%–72%Dizygotictwins:1
5%–30%病因遗传：1/3有家族史银屑病第一代亲属中：银屑病16.9%，PsA
3.3%寻常型银屑病：HLA-B13，-B17，-A1，-CW6PsA：HLA-B2746%~78%脊柱炎
周围型HLA-B38，-B39免疫异常免
疫球蛋白：IgA升高60%PsAIgG免疫复合物升高,IgA免疫复合物升高补体：CH50C3可升高
细胞因子：IL-6IL-8,转化因子-α（TGF-α）……Immunologicbasisofpsoriasis
代谢障碍酶代谢cAMP↓cGMP↑c
AMP/cGMP失调……结果：表皮皮损周期缩短，表皮增生
感染链球菌感染，葡萄球菌α抗毒素滴度其他：精神因素、外伤、内分泌改变……
PathogenesisofPsoriaticArthritisEtiologyunk
nownMultifactorialSkinandjointchangesdonotoccurinparall
el病理炎症性滑膜炎——类似类风湿关节炎骨破坏、吸收肌腱附着处骨质增生临床表现（
一）多数缓慢发病，1/3急性起病伴发热远端指间关节最易受累，不对称无类风湿结节，RF（-）2/3银屑病后5
~10年出现关节炎15%~20%先关节炎再皮疹10%同时出现临床表现（二）关节炎
分型不对称性关节炎（70%）对称性关节炎（15%）远端指间关节型（5%）残毁性关节炎型（5
%）银屑病脊柱炎（5%）Psoriaticarthritis:jointinfla
mmationArthritismutilans(telescoping)临床表现（三）皮肤病变寻常型，红皮
病、脓疱型指甲80%PsA有甲损害：增厚、浑浊、失去光泽白甲、凹凸不平、角质增生甲剥离，匙型甲，顶针状凹陷
Psoriaticarthritis:cutaneousfeatures临床表现（四）眼
（1/3）结膜炎，虹膜炎，巩膜炎其他：心脏、肺纤维化少见临床表现（五）实验室PsoriaticA
rthritis-LaboratoryFeaturesNosinglebio-markerwithhighsen
sitivityorspecificityAcutephasereactantsvariableelevatedC
RPmoreusefulthanESRElevatedIgAin40%PositiveRFinupto
10%PositiveCCPinupto10%PositiveANAinupto25%Anti-Glia
din,transglutimaseABmaybeseen临床表现（六）影像学各关节均可受累，远端指间
关节为主骨破坏与增生共存骨远端骨质溶解——铅笔头征
铅笔帽征脊柱骨桥——不对称，椎体中部Psoriaticar
thritis:radiologicfeaturesJuxta-articularperiostitis7R17:Ps
oriaticarthritis:feet(radiograph)诊断
银屑病+关节炎关节炎+甲改变典型PsA+家族史银屑病关节炎的治疗指南银屑病及银屑病关节炎研究评估
小组（GroupforResearchandAssessmentofPsoriasisandPs
oriaticArthritis,GRAPPA）循证来源和治疗推荐的分级AHCPR推荐的循证来源1a随机对照
试验的Meta分析1b≥1次随机对照试验2a≥1次对照试验（无随机）2b其他类似的精心设计的
研究3非实验性研究（如病例对照试验等）4专家委员会的临床经验、意见关节的评估关节评估可用
RADAS28评价，然后再使用ACR20、50、70评价治疗推荐治疗推荐治疗推荐治疗推荐
治疗推荐治疗推荐不推荐常规系统性应用糖皮质激素。亦不推荐使用金制剂、羟氯喹、氯喹。氨甲喋呤、来氟米特、柳氮磺胺砒啶的
有效性目前尚无法证明。预后关节与皮损一致病程良性部分患者关节畸形5%严重功能障碍无法根治谢谢!
PeripheralradiographicfeaturesMeasePJ,vanderHeijd
eD.IntJAdvRheumatol4(2):38-48,2006周围关节炎中轴关节炎
AxialradiographicmanifestationsMeasePJ,vanderHeijde
D.IntJAdvRheumatol4(2):38-48,2006PsoriaticArthritis:Cl
assification/DiagnosisMoll&WrightCriteriaMoll&Wrightcriter
iadevelopedinmid-70sInflammatoryarthritis+psoriasis+nega
tiveRFandoneofthefollowingsubsets:炎性关节炎银屑病RF阴性及下列项目中任一条
Oligoarticular(<5involvedjoints),asymmetric不对称的寡关节炎Polyarti
cular(oftensymmetric)多关节炎（多对称）DIPpredominant远端指间关节为主Spondyli
tispredominant脊柱炎为主Arthritismutilans残毁型关节炎WrightV,MollJM
H.Psoriaticarthritis.In:WrightV,MollJMH.SeronegativePoly
arthritis.Amsterdam,NY:NorthHollandPublishingCo.;1976:169-2
23.MollJ,WrightV.SemArthRheum.1973;3:55-78.银屑病关节炎治疗的最佳推
荐A.证据来源1B.证据来源2，或加证据1C.证据来源3，或加证据1或2D.证据来源3，或加证据2或
3适用于至少一种DMARD治疗无效的患者。目前市场上的三种TNF抑制剂（依那西普、英夫利昔单抗、阿达木单抗）疗效大致相同。预后
不良的患者即使DMARDs治疗有效，也可考虑使用TNF抑制剂。ATNF抑制剂中或重度适用于所有中重度周
围关节炎的患者，轻度患者若NSAIDS及关节腔内注射无效也可考虑。TNF抑制剂的起效剂量明显大于传统的DMARDs，但尚无证据支
持DMARDs优于TNF抑制剂。AABBDMARDs:柳氮磺胺砒啶来氟米特氨甲喋呤环胞菌素
中或重度如能避免从皮肤病变处注射，对治疗持续性发炎的关节或许有效，并可根据情况反复注射。D关节腔内激素注射无法
分级能控制关节症状，但对皮肤病变无效。90.9%ANSAIDS轻度周围关节
评论认同度循证分级治疗推荐疾病分级A环胞菌素A依法利珠A
TNF抑制剂A延胡索酸酯A氨甲喋呤A光疗光疗包括UVB
/nbUVB,口腔及全身PUVA。如果没有禁忌，病变又不在非照射区（如头皮、腹股沟、腋窝），光疗应作为起始治疗。各种光疗中，PUV
A常被认为具有潜在致皮肤癌的作用。由于提高了患皮肤癌的几率，光疗后（尤其是PUVA）不推荐使用免疫抑制剂。TNF抑制剂包括依
那西普、英夫利昔单抗、阿达木单抗由于环胞菌素会累积毒性，其连续应用不应超过12个月69.2%中
到重度皮肤病变评论认同度循证分级治
疗推荐疾病分级三线治疗方案
二线治疗方案A柳氮磺胺砒啶A阿法赛特
A依曲替酸C硫脲嘌呤C麦考酚酸莫酯A来氟米特69.2%C羟基尿中到
重度皮肤病变评论认同度循证分级治疗推荐疾病
分级英夫利昔单抗、益赛普在脊椎关节病中的疗效已被证实。重度中度已获得一些研究证据DMARDs顽固型许多临床医生接来下
很快会采用注射用激素。糖皮质激素无法分级英夫利昔单抗无法分级总是用于共存的活动性疾病中87.9%DNSAI
DS,理疗轻度附着点炎DDMARDsATNF抑制剂常被用于初始治疗。ADD90.2%
DNSAIDS无法分级指趾炎评论认同度循证分级
治疗推荐疾病分级适用于轻中度疾病治疗失败的患者。英夫利昔单抗、阿达木单抗和益赛普已被证实治疗强直性脊柱炎有效，统计显示银屑病
关节炎和强直性脊柱炎治疗反应相似。TNF抑制剂中到重度TNF抑制剂包括英夫利昔单抗、阿法赛特69.2%
C类维生素A无法分级指甲病变C口腔PUVAC环胞菌素CTNF抑制剂
AAA86.4%ANSAIDS理疗止痛和骶髂关节注射轻到中度脊柱病变
评论认同度循证分级治疗推荐疾病分级EtanerceptinPsAPha
se3-2YearOpenLabelExtensionSustainedACRResponse60666
3374746151618010203040506070%PatientsACR20ACR50
ACR70MeasePJ,etal.JRheum.2006;33:712-72136Weeks1year
2years(48wkOLE)n=168n=168n=145ADEPTWe
ek24and48ACRResponsesMeaseP,etal.ArthritisRheum2005;5
8:3279-89;MeaseP,etal.AnnRheumDis2009;68:702-9PBO→ADA,p
lacebotreatmentduringdouble-blindperiod,convertedtoadalimu
mabduringopen-labelperiod;ADA→ADA,treatedwithadalimumabdu
ringdouble-blindandopen-labelperiodsWeek24Week48ACR20AC
R50ACR70n=147n=151ADAADA→ADAPBOPBO→ADAn=162n=151p<0.
001vsplaceboatWeek24Randomized,placebo-controlled,double
-blind,24-weekstudy;313PsApatientsreceivedadalimumab40mg
eoworplaceboeow24-weekopen-labelextension(n=285)Marzo-Or
tegaH,etal.ArthRheum.2002;46:3396-8.Enthesitis,boneedem
a,andsynovitisbyMRI–resolutionofinflammationpostanti-TN
FtherapyControlledTrialsofDMARDsinPsACompoundArth
ritisSkinSulfasalazine(5)Methotrexate(1)Cyclosporine(abs
.)Gold(1)Azathioprine(1)Leflunomide(1)MarginalImprovement
inPhysicianGlobalAssessmentonlyMarginalMarginal微小的Margina
lPsARC59%ACR2036.3%NoneImprovementinareaofskininvolve
mentonlyGoodNoneNoneMedianPASIimprovement23.8%1.Palit
J.BrJRheumatol.1990;29:280.2.CleggDO.ArthritisRheum.199
6;39:2013.3.WillkinsRF.ArthritisRheum.1984;27:376.4.Spada
roA.ClinExpRheumatol.1995;13:589.5.KaltwasserP.ArthRhe
um.2004;50:1939-50MorbidityandMortality发病率和死亡率Associ
atedWithPsA17%have?5deformedjoints1,2变形/畸形40%-57%havede
formingarthritis120%-40%havespinalinvolvement1,2,3脊柱受累11%-1
9%aredisabled1,2残疾Increasedriskofdeath:standardizedincid
enceratioof1.624死亡风险增加1.TorreAlonsoetal.BrJRheumatol
.1991;30:245.2.GladmanDDetal.QJMed.1987;62:127.3.Hanly
JG,RussellML,GladmanDD.AnnRheumDis.1988;47:386-393.4.G
ladmanDDetal.AnnRheumDis.2005Mar;64Suppl2:ii14-7.Key
QuestionsandExamExamineforAsymmetricinflammatoryarthritis
“Sausagedigits”ordactylitisEnthesitisTenderand/orswollenj
ointsAskAboutMorningstiffness晨僵Persistentjointpainoro
therarthriticsymptoms持续到关节痛或其他关节症状FamilyhistoryofPsA,psori
asis银屑病或银屑病关节炎家族史DifferentialDiagnosisofPsARheumatoidArth
ritisOsteoarthritisOtherSpondyloarthropathiesAnkylosingspond
ylitisReactivearthritisArthritisassociatedwithIBDUndiffere
ntiatedCrystallinearthritis:gout,CPPDTendonitisPsATreatme
ntAxialDiseasePeripheralArthritisSkinandNailDiseaseDac
tylitisEnthesitisMTX,methotrexate;CsA,cyclosporin;SSZ,sulf
asalazine;Lef,leflunomideNSAIDsxxIntra-articularsteroidsx
TopicalsxPhysiotherapyxPsoralenUVA/UVBxDMARDS(MTX,CsA,
SSZ,Lef)xxBiologics(anti-TNFantagonists)xxxxxKavanaug
hA,RitchlinC(eds).JRheum.33;1417-1456外周关节皮肤和指甲病变
中轴疾病趾炎眼炎AssessmentofPsoriaticArth
ritisDomainsInstrumentsJointassessmentT/Sjointcount,ACR,
DAS,PsARCAxialassessmentBASDAI,BASFI,BASMISkinassessment
PASI,Targetlesion,GlobalPainVASPatientglobalVAS(global,
skin+joints)PhysicianglobalVAS(global,skin+joints)Funct
ion/QOLHAQ,SF-36,PsAQoL,DLQIFatigueFACIT,Krupp,MFI,VASE
nthesitisassessmentMander,SPARCC,Leeds,MASES,Berlin,presen
t/absentDactylitisassessmentLeeds,present/absent,acute/chron
icAcutephasereactantESR,CRPImagingXray(modifiedSharp,va
nderHeijde-Sharp),MRI,USMeaseP,etal.AnnRheumDis.2005;
64:ii49-ii54MeaseP,vanderHeijdeD.IntJAdvRheum.2006;4:3
8-48脊柱关节病之间的重叠ASReAIBDAPsAUSpA急性虹膜炎其它寡关节炎、JSpA
NationalPsoriasisFoundation(2002).Presskitforpsoriaticart
hritissurvey.January2002.Availableat:www.psoriasis.org/ima
ges/papresskit.pdf.AccessedNovember13,2002.2/24/00
GladmanDD.RheumDisClinNorthAm.1992;18(1):247-256.
GladmanDD.UpToDate.1997;7(1):1-8.
Sources:MeaseP.AnnRheumDis20
04;63:755-758K
ruegerJG.JAmAcadDermatol2002;46:1-23T-cellsarecontinuous
lyactivatedinlymphnodes淋巴结byunidentifiedantigens未识别的抗原Ac
tivatedT-cellsmigrateintoskinandinducemacrophages巨噬细胞t
oproduceTNF-aandotherpro-inflammatorycytokinesGladmanDD.
RheumDisClinNAmer1992;18:247-56.GeneticsImmune
SystemEnvironmentPsoriaticArthritisInflammatoryEnthesopathySubchondralBoneInflammationandResorption软骨下骨炎症和吸收PeriostealNewBoneFormation骨膜新骨形成BoneEnthesitisMcGonagleD,etal.ArthrRheum1999.42:1080-86.BoneMcGonagleD.ArthritisRheum.1999.42:1080-1086.EnthesitisinPsATendonCourtesyofLesterMillerMDCourtesyofPhilipMeaseMDAsymmetricoligoarthritisDIPsynovitisPIPandDIPsynovitisDactylitisDIP=distalinterphalangeal;PIP=proximalinterphalangealPsoriaticplaquesFingernailpitting指甲顶针样凹陷CourtesyofLesterMillerMDCourtesyofHellerupjenklinikWebsite.Availableat:www.hellerupeye.suite.dk/.AccessedSeptember2004.ArthritismutilansIritisProductive“pencilincup”jointerosionsSacroiliitis |
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