Psoriasis Questionnaire Might Identify Risk of Axial Disease


NEW YORK. According to a study called ATTRACT, which was presented at the Study Group’s annual meeting, a questionnaire-based screening tool appears to speed up the diagnosis of axial disease in patients with psoriasis but no clinical signs of joint pain. and assessment of psoriasis and psoriatic arthritis.

Dr. Davis Benfaremo

According to Davis Benfaremo, MD, from the Department of Clinical and Molecular Research at the Marche Polytechnic Institute, the risk of late diagnosis of the axial component in patients with psoriasis, which means delaying the main diagnosis of psoriatic arthritis (PsA), is significant. University, Ancona, Italy.


There is no “consensus on the best strategy for early detection of joint disease” in patients with psoriasis, but Benfaremo pointed out that the absence of an axial lesion is a particular problem because it is much more likely than swollen joints on clinical examination. .

While about one in three psoriasis patients have or will develop psoriatic arthritis, according to the National Psoriasis Foundation, delays in diagnosis are common, according to Benfaremo. Patients with undiagnosed PsA characterized by only axial involvement may not notice subtle symptoms or may be attributed to other causes.

There are several screening questionnaires for identifying joint symptoms in patients with psoriasis, such as the five-question psoriasis epidemiology screening tool, but the questionnaire tested in the ATTRACT study specifically targets axial lesions. He has been characterized as the first to do so.


The ongoing ATTRACT study has included 253 patients with psoriasis but no history of psoriatic arthritis or axial disease to date. In the study, patients are screened for PsA based on a patient-filled yes or no questionnaire that takes only a few minutes to complete.

“This is a validated questionnaire for axial [spondyloarthritis]but we adopted it to identify patients with psoriasis and psoriatic arthritis,” Benfaremo explained.


Dr. Fabian Proft

The Axial Spondyloarthritis Questionnaire (axSpA) was originally evaluated and validated by Fabian Proft, MD, Head of Clinical Research at the Charite Hospital in Berlin. In addition to the self-administered questionnaire, Proft and colleagues have also created a self-administered questionnaire that clinicians will use.

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In the ATTRACT study, patients filled out a questionnaire on an electronic device in the waiting room. Positive responses to specific symptom questions regarding back pain and joint function, as well as joint symptoms, divided patients into three groups:

  • Patients in group A did not respond positively to any of the questions about symptoms that might raise suspicion of axial disease. They made up about one-third of those that have been tested so far.

  • Group B patients were those who responded positively to at least two questions related to high suspicion of axial involvement. They made up 45% of patients.

  • The remaining patients were placed in Group C, an intermediate risk category, based on positive responses to some but not all of the questions regarding axial symptoms.

Group B people are referred to a rheumatologist. Patients in group C are given “conditional” eligibility based on the presence of additional risk factors.

AxSpA screening tool ‘makes sense’ for potential use in PA

The main outcome of the ATTRACT study is the early detection of axial PsA. Proper identification of patients with or without peripheral joint involvement is one of several secondary outcomes. The identification of patients who meet the International Spondyloarthritis Assessment Society (ASAS) criteria for axSpA is another secondary outcome.


Of the 114 patients placed in group B and analyzed so far, 87 underwent examination by a rheumatologist with laboratory tests and imaging, as well as a clinical examination.

Of the 87 examined by a rheumatologist, 17 had neither axial nor peripheral inflammation. A further 19 were diagnosed with axial disease, including 14 who met ASAS criteria. A total of 10 patients were classified as having psoriatic arthritis with peripheral inflammation according to the classification criteria for psoriatic arthritis, and 41 are still considered to have axial or peripheral psoriasis based on further evaluation.

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“Among patients with axial psoriasis, only 10% had elevated C-reactive protein levels,” says Benfaremo, echoing previous findings that inflammatory biomarkers alone are of limited value in identifying psoriasis patients at high risk for joint disease.

The findings are preliminary, but Benfaremo said the questionnaire offers hope for a routine stratification of patients who should be considered for consultation with a rheumatologist.

If further analysis confirms the clinical usefulness of these strata, there is potential to significantly accelerate the diagnosis of PA.

When contacted to comment on this work, Proft said there is an important need for new strategies to reduce the delay in diagnosing psoriasis in patients with psoriasis. He believes the screening tool he developed for axSpA “makes sense” as a potential tool for PsA.

“If this is confirmed, it could be very useful for earlier identification of the PA,” Proft said. He reiterated the importance of focusing on the axial lesion.

“Previous screening tools have focused on PsA symptoms more generally, but inflammation in peripheral joints is something you can easily see in most patients,” he said.

In addition to the patient-filled questionnaire and the physician-administered questionnaire, Proft also evaluated the online self-referral tool.

“If we can diagnose PsA earlier in the disease, we can start treatment earlier, prevent or delay joint damage, and potentially improve patient outcomes,” Proft said. He considers this an important line of research.

Benfaremo and Proft have reported no potential conflicts of interest.

This article originally appeared on, part of the Medscape professional network.


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