EULAR Points to Consider for the Definition of Clinical and Imaging Features Suspicious for Progression from Psoriasis to Psoriatic Arthritis: Paving the Way for Interception in Psoriatic Arthritis

The authors established five overarching principles, some of which are already internalized and known without the need for expert committees, including that people with PsO may develop PsA at different time points or the importance of close collaboration between dermatologists and rheumatologists to understand and optimize PsA prevention, interception, and early diagnosis. Some others are reasonable in clinical practice, such as considering the risk factors for PsA in a patient or the suspicion of early forms of PsA can condition their therapeutic course. The most controversial and important—and may give rise to the greatest conflicts of interest—is that certain systemic treatments of PsO may reduce the risk of transition to PsA.

In a more practical approach, the authors advocated that, in the absence of characteristic serological markers of PsA—which is a clear objective drawback but an opportunity for the meticulous work of the clinician—joint symptoms, particularly arthralgia, should be interpreted as a risk factor in patients with PsO. Imaging tests may be more sensitive than the clinical examination for the detection of musculoskeletal inflammation, considering that up to 40% of people with PsO, even if not affected by joint pain, show subclinical synovio-entheseal alterations detected by ultrasonography and structural entheseal lesions detected by high-resolution peripheral quantitative computed tomography (CT) scan. Considering that joint symptoms are very frequent in the general population, and to avoid overdiagnosis, it is proposed that signs and symptoms continue to be the guide, with imaging as support.

The positioning of the EULAR can be considered as one of extraordinary strategic acumen. The authors do not debate whether there is sufficient data to prove the efficiency of early interception but rather define which patients could be suitable for inclusion in clinical trials and prospective studies to demonstrate this concept. This positioning will be useful in standardizing research and clinical practice in the coming years and will reinforce the work, prestige, and significance of the EULAR itself. In this sense, they lay the foundations for further knowledge. The authors also recall that prevention involves not only the choice of treatment or its early initiation but also the lines that will be most influenced by research. It also involves the commitment of the patient to control risk factors (e.g., weight management) and acquire training on the signs and symptoms of the PsA, which are sometimes more difficult to implement than therapeutic choices.

The article illustrates the positive interdisciplinary collaboration between dermatologists and rheumatologists, which extends beyond the boundaries of international organizations and has been in place for several years through joint clinical initiatives. Meanwhile, the figure (see below) that illustrates the classification and evolution of patients from their predisposition to PsA to its full development is one of the most iconic in recent years in this field and has been continuously reproduced. It may be posited that this is a reference point for a paradigm shift in which we can trust the signals before the evidence occurs. Thus, interception of PsA can be a palpable reality, and the EULAR establishes the rules of the game to measure it.