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Psoriatic juvenile idiopathic arthritis: Management and prognosis

Psoriatic juvenile idiopathic arthritis: Management and prognosis
Literature review current through: Jan 2024.
This topic last updated: Nov 29, 2022.

INTRODUCTION — Psoriatic juvenile idiopathic arthritis (psJIA), or alternately juvenile psoriatic arthritis (JPsA), is a condition that can range widely in presentation and severity. Frank cutaneous psoriasis is not always evident, and the extent of articular involvement may vary from mild enthesitis (inflammation of sites at which ligaments, tendons, and other fibrous structures insert into bone) to polyarticular involvement of multiple axial (spine, sacroiliac joints) and peripheral joints.

The treatment and prognosis of psJIA are discussed here. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of psJIA are discussed separately, as is psoriatic arthritis in adults. (See "Psoriatic juvenile idiopathic arthritis: Pathogenesis, clinical manifestations, and diagnosis" and "Clinical manifestations and diagnosis of psoriatic arthritis" and "Treatment of psoriatic arthritis" and "Pathogenesis of psoriatic arthritis".)

MONITORING — Laboratory tests and imaging studies are of limited value in the management of psJIA. As in other subtypes of JIA, destructive arthritis may continue in the face of normal laboratory studies. Similarly, as with JIA generally, the role of conventional radiography in the day-to-day management of arthritis also is small since bony changes take months or years to become evident. Treatment should not be withheld because radiologic changes are not yet evident. Rather, careful clinical monitoring of the physical exam remains of paramount importance in following children with psoriatic arthritis. Monitoring for uveitis is discussed separately. (See "Psoriatic juvenile idiopathic arthritis: Pathogenesis, clinical manifestations, and diagnosis", section on 'Laboratory findings' and "Psoriatic juvenile idiopathic arthritis: Pathogenesis, clinical manifestations, and diagnosis", section on 'Radiologic studies' and "Oligoarticular juvenile idiopathic arthritis", section on 'Uveitis'.)

TREATMENT — Treatment recommendations for psJIA are derived from trials in other JIA subtypes and from adult psoriatic arthritis since few randomized controlled trials (RCTs) have been conducted specifically in psJIA [1]. Management should be conducted in consultation with a pediatric rheumatologist and pediatric ophthalmologist whenever possible.

Peripheral arthritis — The treatment priority in psJIA, as in other types of JIA, is to extinguish synovitis in order to avoid damage to cartilage and bone. This imperative is particularly critical for the growing skeleton, where injury to growth plates and growth centers can cause permanent derangement of bone shape and length [2,3]. Absence of reported pain and lack of functional impairment are imperfect guides to successful therapy since children may adapt remarkably well to ongoing arthritis [4]. Such children may still go on to experience substantial joint injury, developing functional impairment later in childhood or as young adults [5].

The basic treatment algorithm of psJIA is similar to that employed in other subtypes of JIA (table 1) [1]. More than 80 percent of psJIA patients are treated with methotrexate, and more than half receive tumor necrosis factor (TNF) antagonists over the course of their illness [6].

Nonsteroidal antiinflammatory drugs (NSAIDs) are employed initially as the sole therapy by some rheumatologists but typically do not induce remission and are inappropriate as monotherapy for synovitis that persists beyond two months of treatment [1]. Initiation of methotrexate at diagnosis is preferable to delaying therapy while awaiting the result of an NSAID trial in patients presenting with moderate or severe arthritis, erosive disease, or arthritis of multiple joints [1]. NSAIDs are used to help control swelling and pain while awaiting the onset of antirheumatic activity of disease-modifying antirheumatic drugs (DMARDs).

Individual large joints can be treated effectively with intraarticular (IA) glucocorticoid injection. psJIA has not been specifically studied, but decision analysis in oligoarticular JIA suggests that a strategy of upfront IA glucocorticoid injection is preferable to a trial of NSAIDs followed by IA for refractory disease due to the low probability (approximately 16 percent) that NSAIDs will induce remission within two months [7].

Dactylitis in psoriatic arthritis reflects a composite of arthritis of the finger or toe joints, tenosynovitis, and, in particular, enthesitis of the many attachments of ligaments, tendons, and joint capsules in the digit [8]. Scintigraphic studies confirm the presence of TNF localized to the dactylitic digit [9]. Psoriatic dactylitis can be treated effectively with glucocorticoid injection into the digital flexor tendon sheath, with a response rate of 87 percent in one adult observational series [10]. Traditional DMARDs such as methotrexate generally appear to have limited utility, although improvement of dactylitis with treatment has been reported [11]. By contrast, dactylitis in adult psoriatic arthritis responds well to therapy with TNF inhibitors, interleukin (IL) 12/23 blockade (ustekinumab), IL-17 blockade, phosphodiesterase-4 (PDE4) inhibition (apremilast), and Janus kinase (JAK) inhibitors [12-16]. In children, TNF inhibitors are typically the first biologic selected for this purpose.

DMARDs are indicated at diagnosis in patients with involvement of multiple joints [1]. The most commonly used DMARD is methotrexate. Methotrexate is associated with a higher risk of hepatotoxicity in adults with psoriatic arthritis than in those with rheumatoid arthritis, possibly because of the higher prevalence of obesity and associated steatohepatitis in adult psoriasis, but methotrexate is typically well tolerated in children with psJIA [17]. Sulfasalazine is an alternative, especially for lower-extremity large-joint arthritis, although trial data in adult psoriatic arthritis provide conflicting evidence of efficacy [18-21].

Failure to achieve remission is addressed by substitution or addition of a second oral DMARD, such as leflunomide, or more commonly by institution of anti-TNF therapy with any of the available agents [1]. TNF blockade is particularly useful when there is axial disease since conventional DMARDs are not effective for inflammation of the spine and sacroiliac joints. Anti-TNF agents are also effective for dactylitis and enthesitis [1]. (See "Overview of biologic agents in the rheumatic diseases", section on 'TNF inhibition'.)

Secukinumab (a human IL-17A antagonist) exhibits efficacy in adult psoriatic arthritis comparable with TNF inhibition and is superior in improvement of associated skin psoriasis, with comparable safety [22]. Secukinumab is also effective with respect to axial arthritis [23]. A randomized withdrawal trial of secukinumab in children with psJIA and enthesitis related arthritis (ERA) showed efficacy, with safety generally comparable with that reported in adult disease [24]. Secukinumab is approved for psJIA in children ≥2 years of age.

Clinical similarities between adult and pediatric psoriatic arthritis suggest that they form a spectrum of disease, a possibility supported by genetic evidence [25-27]. Based upon this similarity, agents useful in adult psoriatic arthritis are likely to be effective in psJIA efficacy, including apremilast (a PDE4 inhibitor) and abatacept (a T cell costimulatory blocker), the latter only modestly effective for psoriatic arthritis but effective and well tolerated in polyarticular-course JIA [28-30]. The IL-12/23 inhibitor ustekinumab has efficacy in adult psoriatic arthritis and, based upon extrapolation from studies in pediatric psoriasis and in adult psoriatic arthritis, is approved for use in pediatric psoriasis and psoriatic arthritis for patients age six years and older [31-33]. (See "Treatment of psoriatic arthritis".)

Some rheumatologists believe that psoriatic arthritis is less responsive to systemic glucocorticoids than other types of arthritis, but this observation has yet to be rigorously tested. Systemic glucocorticoids can provoke a flare of cutaneous psoriasis when tapered [34]. Some data also suggest a risk for worsening psoriasis with antimalarials such as hydroxychloroquine [35]. These agents are therefore avoided when possible, although low-to-moderate-dose systemic glucocorticoids are sometimes employed as short-term "bridge" therapy while awaiting the effect of slower-acting DMARDs in highly symptomatic patients.

Spondylitis — Treatment of psoriatic spondylitis in children is based primarily upon experience with ankylosing spondylitis (AS) [36-38]. Based upon observational data, our practice is to initiate anti-TNF therapy in all children with confirmed sacroiliitis, employing NSAIDs as adjuvant therapy if needed to provide complete symptomatic relief. (See "Spondyloarthritis in children" and "Treatment of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults".)

Axial disease in psJIA tends to run a milder course than in AS [39]. Treatment should be initiated in patients with psJIA who experience axial symptoms or show limitation of spinal mobility, even if changes have not yet developed on plain radiograph [36]. Of note, spinal radiographs are much less sensitive in detecting early sacroiliitis than magnetic resonance imaging (MRI), and, therefore, we typically avoid plain radiographs and instead employ noncontrast MRI as the preferred mode of imaging in children with symptoms suggestive of sacroiliitis [40].

The benefit of continuous NSAID therapy is uncertain. In one adult trial, standing-dose versus as-needed NSAIDs resulted in measurable radiographic improvement, but the effect was small, and the finding was not replicated in a second comparably sized RCT [41,42]. In one observational study, standing-dose NSAIDs were associated with a 12 percent increase in incident hypertension [43]. There are no data that evaluate the role of NSAIDs in the setting of anti-TNF therapy. Standard DMARDs, including sulfasalazine, methotrexate, and leflunomide, are of minimal benefit. Anti-TNF therapy is highly effective for axial disease in JIA [44]. Studies in adults with longstanding disease have not shown reduced radiographic progression, although data do support the possibility that early initiation of therapy may result in a more favorable outcome [45-49]. Early initiation may be particularly important in young people because early-onset spondyloarthropathies may run a more destructive course than later-onset disease [50].

Evidence from adult patients confirms that therapy directed against IL-17 can benefit axial disease, including patients whose disease has not responded to TNF inhibitors [51-55]. Secukinumab (anti-IL-17A) has been tested in psJIA and in the pediatric equivalent of AS, ERA, and is approved for used in psJIA in children ≥2 years of age [24]. JAK inhibitors such as upadacitinib have clinical efficacy in adults with active AS [56]. Ustekinumab is not typically effective for axial disease [57].

Uveitis — Treatment for uveitis in psJIA is similar to that in other subtypes of JIA. Chronic anterior uveitis is treated initially with topical corticosteroids, usually together with oral or subcutaneous methotrexate. Resistant disease often responds to an anti-TNF antibody such as infliximab or adalimumab (the anti-TNF receptor fusion protein etanercept is less effective for uveitis). Third-line agents include mycophenolate mofetil and cyclosporine. Acute anterior uveitis may also occur, typically in children with axial disease; this form of uveitis is less frequently sight threatening than chronic anterior uveitis and typically responds to topical corticosteroids or oral glucocorticoids. These options are discussed separately. (See "Uveitis: Treatment" and "Oligoarticular juvenile idiopathic arthritis", section on 'Uveitis'.)

Cutaneous disease — Cutaneous manifestations of pediatric psoriasis are phenotypically similar to skin involvement in adults regardless of whether there is concomitant arthritis. The only exception is a higher prevalence of nail changes in psJIA [58]. Conventional psoriasis treatment is appropriate for skin disease associated with psJIA, although articular manifestations favor use of systemic agents that are also effective for skin disease, including methotrexate, TNF blockers, ustekinumab, and the IL-17 antagonist secukinumab. Data from adult psoriasis and psoriatic arthritis suggest that therapy directed against IL-17 is likely to provide the best relief for resistant cutaneous psoriasis. (See "Psoriatic juvenile idiopathic arthritis: Pathogenesis, clinical manifestations, and diagnosis", section on 'Skin and nail disease' and "Treatment of psoriasis in adults" and "Treatment of psoriatic arthritis".)

IMMUNIZATIONS — The administration of live-virus vaccines and other standard childhood immunizations in patients with JIA is discussed in detail separately. (See "Oligoarticular juvenile idiopathic arthritis", section on 'Immunizations'.)

PROGNOSIS — The long-term outcome of children with psJIA has improved with the expanding repertoire of agents available. Clinical remission (on medication) is achieved in the majority of patients in both older and younger subgroups [59,60]. Nevertheless, compared with other patients with JIA, observational data suggest that those with psoriatic arthritis accumulate more inflamed joints and are less likely to enter sustained remission [61].

Among patients with psJIA followed for at least five years, from the prebiologic era (before approximately 2000 in pediatric rheumatology), persistently active disease was found in 70 percent and physical activity limitations in one-third [62]. In another series of children with JIA first admitted between 1980 and 1985 and followed for at least 15 years, 33 percent of patients with psJIA still required disease-modifying antirheumatic drug (DMARD) therapy [63]. Poor outcomes and long-term disability were seen principally in patients who experienced a long delay in diagnosis or in whom effective therapy was not instituted, often through clinician or caregiver reluctance to take the steps necessary to induce remission. In contrast, 91 percent of patients with psJIA in a large cohort of children diagnosed with JIA from 2005 to 2010 attained inactive disease within two years, and 47 percent achieved remission (defined as inactive disease >12 months after discontinuing treatment) within five years [64].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Juvenile idiopathic arthritis" and "Society guideline links: Uveitis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Psoriatic arthritis in children (The Basics)")

SUMMARY

Psoriatic juvenile idiopathic arthritis (psJIA), or alternately juvenile psoriatic arthritis (JPsA), is a relatively common subtype of JIA, but its clinical presentation can be highly variable. (See "Psoriatic juvenile idiopathic arthritis: Pathogenesis, clinical manifestations, and diagnosis" and "Classification of juvenile idiopathic arthritis".)

Laboratory tests and radiologic studies are of limited value in the management of psJIA, aside from the confirmation of suspected sacroiliitis with noncontrast magnetic resonance imaging (MRI). (See 'Monitoring' above.)

The treatment priority in psJIA, as in other types of JIA, is to extinguish all clinical, laboratory, and radiographic manifestations of synovitis in order to avoid damage to cartilage and bone. (See 'Treatment' above.)

The basic treatment algorithm of psJIA is similar to that employed in other subtypes of JIA, with a few exceptions (table 1). Nonsteroidal antiinflammatory drugs (NSAIDs) are used as initial monotherapy by some rheumatologists. However, NSAIDs typically do not induce remission and, therefore, are generally better used as adjuncts to DMARDs in patients with widespread or moderate-to-severe disease. Arthritis in individual large joints, as well as dactylitic digits, may be treated with glucocorticoid injections. Disease-modifying antirheumatic drugs (DMARDs) are indicated at diagnosis in patients with involvement of multiple joints and in those whose disease does not go into remission with intraarticular (IA) glucocorticoids. Continued disease activity is addressed by addition of a second DMARD or, more commonly, by institution of anti-tumor necrosis factor (TNF) therapy. Patients with disease resistant to TNF inhibitors are treated with secukinumab or ustekinumab, agents that can be especially helpful in the setting of resistant cutaneous psoriasis. Systemic glucocorticoids are employed less commonly, and antimalarial agents are generally avoided due to a risk of worsening the psoriatic rash. (See 'Peripheral arthritis' above.)

Axial disease in psJIA is phenotypically similar to ankylosing spondylitis (AS). Treatment should be initiated in patients with psJIA who experience axial symptoms or show limitation of spinal mobility, even if changes have not yet developed on plain radiograph. Anti-TNF agents are generally the most effective, while NSAIDs can provide relief to some patients. Blockade of interleukin (IL) 17 as well as Janus kinase (JAK) inhibition (though not IL-12/23 blockade) have documented efficacy for axial disease in adults and are increasingly used in children, although given the extensive track record with TNF inhibitors, we reserve these newer agents for refractory disease. (See 'Spondylitis' above.)

Monitoring for and treatment of uveitis in psJIA are similar to that in other subtypes of JIA. (See 'Uveitis' above.)

Conventional psoriasis treatment is appropriate for skin disease associated with psJIA. Frequently, this is not an issue, since articular manifestations may drive early use of systemic agents that are highly effective for skin disease, including methotrexate and TNF blockers. (See 'Cutaneous disease' above.)

Poor outcomes and long-term disability are seen principally in patients who had a long delay in diagnosis and/or in whom effective therapy was not instituted, often through clinician or caregiver reluctance to take the steps necessary to induce remission. (See 'Prognosis' above.)

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Topic 16366 Version 19.0

References

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