**3. How can patients with PsA be identified in daily clinical routine?**

In clinical practice, psoriatic patients with a dominant skin manifestation primarily consult dermatologists and patients with a dominant peripheral or spinal manifestation primarily

Detecting Psoriasis Arthritis Early in the Disease Course – Why This

detect PsA in Ps patients (Härle, 2010).

of arthritic manifestation.

8%

 Arthritis <1 year Arthritis >1<2 years Arthritis >2<3 years Arthritis >3<4 years Arthritis >4 years

9%

early arthritis.

is Important and How Dermatologists and Rheumatologists Can Successfully Cooperate? 71

question related to the time period since the first occurrence of complaints lasting from one week up to more than 5 years in order to detect early PsA manifestations. In the statistical evaluation of the study, we calculated a cut-off value of greater than or equal to 4 positive answered questions. This cut-off showed a sensitivity of 89% and a specificity of 73% to

In the final evaluation, we clinically evaluated 54 patients. These patients were selected by the GEPARD questionnaire from dermatology outpatient clinics. We found 43 patients who had some arthritic manifestations according to clinical examination, ultrasound, x-ray, MRI, and Technecium-Szintigraphy. This accounts for 79,6% patients being positive for PsA manifestation. This percentage of PsA among patients with Ps is in line with earlier publications (Sadek, 2007). Furthermore, 23 patients were first diagnosed as having PsA.

According to the time duration of arthritic complaints we found 57% suffering over 4 years but 43% of patients below 4 years (figure 4) which may still be considered as being early arthritis. From these patients with complaints of less than 4 years 80% could be classified for PsA just by clinical examination according the CASPAR criteria without the use of sonography, x-ray, MRI, or szintigraphy (figure 5). Considering that the initial screening process was exclusively based on patients' answers, without evaluation by a physician, the GEPARD patient - questionnaire is well suited for routine clinical usage. In addition, the screening tool does not consume additional time from the dermatologist but still enables him to identify patients who need to be referred to a rheumatologist for further evaluation

57%

Fig. 4. Pie chart of arthritis duration according to the GEPARD patient-questionnaire. Fortythree percent suffered of symptoms of less than 4 years. Less than 4 years is considered to be

11% 15%

consult rheumatologists or orthopedics. However, the vast majority of Ps patients gather within the dermatology setting. Therefore, it seems rational to screen patients for arthritic manifestations in the dermatology setting.

From July 2005 until October 2008, we validated and established the self-administered patient-screening questionnaire GEPARD (GErman Psoriasis ARthritis Diagnostic questionnaire) to detect PsA in psoriatic patients seeking primarily dermatologic care (Härle, 2010) (Tab. 2 and www.kkm-mainz.de/rheumatologie). In order to keep the questionnaire simple, only dichotomous answers (yes/no) were used. The twelve questions were derived from discussions about appropriate questions among the authors and additional advice provided by other experienced rheumatologists. Questions number 1 to 4 relate to clinical signs of arthritis but do not necessarily impose a momentary active state of arthritis by asking if the patient ever had these signs. It was considered that these questions take into account the remitting and relapsing nature of PsA. We considered the detection of these patients being especially important in the context of a longitudinal follow-up of fluctuating arthritis, which might eventually lead to establishing prognostic parameters for PsA. Questions number 5 to 8 pertain to arthritis in a more indirect way by relating to the discomfort caused by joint pain or dysfunction. Questions number 9 to 13 relate to the clinical signs of inflammatory back pain which can be associated with PsA. An additional


Table 2. The GEPARD questionnaire targets arthritic complaints of peripheral joints and spinal manifestations in addition of duration of arthritic symptoms thus enableing early detection of PsA. The patient alone answers the questionnaire. The physician or assistant counts the positive answers. The cut-off value of equal or more than 4 positive answers showed a sensitivity of 89% and a specificity of 73% to detect PsA in Ps patients

consult rheumatologists or orthopedics. However, the vast majority of Ps patients gather within the dermatology setting. Therefore, it seems rational to screen patients for arthritic

From July 2005 until October 2008, we validated and established the self-administered patient-screening questionnaire GEPARD (GErman Psoriasis ARthritis Diagnostic questionnaire) to detect PsA in psoriatic patients seeking primarily dermatologic care (Härle, 2010) (Tab. 2 and www.kkm-mainz.de/rheumatologie). In order to keep the questionnaire simple, only dichotomous answers (yes/no) were used. The twelve questions were derived from discussions about appropriate questions among the authors and additional advice provided by other experienced rheumatologists. Questions number 1 to 4 relate to clinical signs of arthritis but do not necessarily impose a momentary active state of arthritis by asking if the patient ever had these signs. It was considered that these questions take into account the remitting and relapsing nature of PsA. We considered the detection of these patients being especially important in the context of a longitudinal follow-up of fluctuating arthritis, which might eventually lead to establishing prognostic parameters for PsA. Questions number 5 to 8 pertain to arthritis in a more indirect way by relating to the discomfort caused by joint pain or dysfunction. Questions number 9 to 13 relate to the clinical signs of inflammatory back pain which can be associated with PsA. An additional
