¹Assistant Professor, ²Professor, Department of Skin and VD, VMGMC, Solapur, Maharashtra, INDIA.

²Professor, Department of Skin and VD, Government Medical College, Latur, Maharashtra, INDIA.

Email: gnagesh0418@gmail.com,  chakote_smita@rediffmail.com   drajayovhal@gmail.com

RESULTS

Out of these 88 had joint complaints. 36 amongst the 88 had to be excluded from the study due to the following reasons; 22 had arthralgia but no evidence of arthritis, 9 had frank osteoarthritis on radiology and 5 denied informed consent. Thus, 52 patients who fulfilled the inclusion criteria were enrolled in the study.

Table 1: Case wise distribution of study population

Cases of Psoriatic arthropathy constituted the major group (46.15%) in our study population. Male preponderance (53.84%) was noted in our study population. Maximum number of cases in our study population were clustered in the 5^th decade (26.92%).

Psoriatic arthropathy

The total number of DIP joints clinically involved was 31. Limitation of movement was present in 77.41% among these i.e. in 24 joints. Radiological involvement was seen in 83.33% among these i.e. 20 joints. Clinically 20 PIP joints were involved, out of which 80% showed radiological changes. The most common among the large peripheral joints, involved were the ankle followed by knee in 25% and 20.8% of patients respectively. The MCP joints were involved in 33.33% of patients. The DIP and PIP joint involvement was seen in 45.83% and 33.33% respectively. Most common type of arthritis in our study population was RA like (33.33%) followed by oligo-articular type (29.16%).The average time by which skin preceded joint involvement was 6.375 years. Arthropathy occurred after skin lesions of psoriasis in 12.5 % of patients at an average of 3.33 years. The occurrence of skin disease before Arthropathy was found to be significantly more i.e. in 21 out of 24 patients(83.3%).(Chi square=9.3, df=1, P=0.002 Significant).The maximum number of patients in each of the subtypes of arthritis, had only few skin lesions i.e. <30%. The average number of joints affected per patient varied between 4 and 10.75%. A significantly higher number of Psoriatic arthropathy patients had skin involvement less than 30% (Mann Whitney Z =20193, P=0.027 Significant).

Table 2: Type of Skin Involvement and Subtype of Arthritis

Significantly higher number of patients i.e. 21 out of 24 (87.5%) had chronic plaque type of psoriasis (chi square=12.04, df=1, P<0.001 HS). The average number of joints affected in chronic plaque type of psoriasis was 5.71.

SLE arthropathy

Table 3: Subtypes of SLE Arthritis

Out of 6 patients of SLE arthropathy 3 had non-deforming arthropathy whereas 2 had erosive arthropathy. Average number of joints involved were more in erosive and non-deforming type (5.5), as compared to mild deforming type (1).

Table 4: Comparison of ACR Criteria in SLE Arthropathy

Amongst the ACR criteria, photosensitivity, oral ulcers, hematological abnormalities and ANA positivity were seen in all of the patients whereas 5 of 6 patients had malar rash. Their exact correlation with individual arthritis type could not be commented upon due to small group of patients observed. Most common radiological abnormality observed in SLE arthropathy was soft tissue swelling i.e. in 20 of 23 joints involved (86.95%) followed by joint subluxation and erosion (13% each).

Leprosy arthritis

Table 5: Subtypes of Arthritis in Leprosy

The joint changes in leprosy patients of our study group appeared in 4^th decade presenting as Acute polyarthritic type in 3 out of 8 patients(37.5%), Swollen hands and feet syndrome and Charcot’s arthropathy type in 2(25%) each. The average number of joints involved was maximum (10.66) in acute polyarthritic type.

Table 6: Comparison of Arthropathy with Respect to Type of Leprosy

Arthritic manifestations were most commonly seen in both Borderline Tuberculous and Borderline Lepromatous Leprosy (37.5% each). Acute polyarthritic type (2 of 3) and Swollen hands and feet syndrome (1 of 2) occurred more frequently in Tuberculous pole (60%) as compared to lepromatous pole( 1 of 3 and 0 of 2 respectively) i.e. 20%. However, Charcot’s arthropathy presented more in lepromatous pole (2 of 2).

Scleroderma and arthritis

Out of 8 leprosy patients 2 had features of type 1 reaction and presented with acute polyarthritis whereas 3 had features of type 2 reaction with hands and feet syndrome.

Table 7: Distribution of cases according to type of arthritis

Most common type of arthritis observed in our study group was polyarticular, seen in 5 of 7 (71.42%) patients. Most of the joints involved were DIP joints (94.8%).

Table 8: Comparison of skin findings with type of arthritis

Most common presenting features in scleroderma with arthritis were cutaneous sclerosis, RP, finger tip ulceration and ulcerations at bony prominences. Among systemic manifestations gastrointestinal abnormalities were more frequently seen.

Dermatomyositis and arthritis

We encountered 2 cases of dermatomyositis having arthritis. Both were males with age at presentation 45 years and 52 years. The onset of arthritis is preceeded by clinical diagnosis of disease by 1 year and 6 months respectively. The total number of joints involved were 3 and 4 respectively (average 3.5). Both heliotrope rash and Gottron’s sign were seen in both patients whereas Shawl sign and V sign were present only in first patient. Morning stiffness was seen in both. Both patients presented with pauci-articular type of arthritis mainly involving large joints like wrists and ankles. No patient had any systemic manifestations. Radiologically both patients had only soft tissue swelling without any erosive changes.

Behcet’s disease and arthritis:

Two of the arthritic cases belonged to Behcet’s disease, one male and female with age 28 years and 25 years respectively (average age at presentation being 24.5 years). Both presented with joint disease a year later after diagnosis of the disease. Total number of joints involved were 4 in each patient.

Both patients had recurrent oral and genital ulcers. First patient had EM like skin lesions and positive pathergy test in addition whereas 2^nd patient had bilateral conjunctivitis. Both presented with oligoarticular type of arthritis affecting large joints like wrists and knees. Radiography showed soft tissue swelling though one of the joint in 1^st patient had frank erosive changes.

Gout and arthritis

We also presented with a 43 year-old female case of tophaceous gout with onset of skin disease in the form of tophi over both ankles and feet at the age of 35 years with onset of joint disease since 1 year. She had a history of morning stiffness. Both ankles and tarsal joints were involved with joint effusion in both and erosive changes in rt ankle joint. Systemically she was unremarkable.

Multicentric reticulohistiocytosis

A 50 year old male presented with severe debilitating joint pains involving with restricted mobility of metacarpophalangeal, proximal and distal interphalangeal, knee, elbow and shoulder joints with flexion deformity of bilateral distal interphalangeal joints of 8 months duration and grouped, firm, reddish brown, non-tender papules and nodules over arms, lower abdomen, back, buttocks and bilateral knees and feet 4 months later. X-ray hands showed mild osteopenia with flexion deformity of distal interphalangeal joints. Histopathologically, diffuse histiocytic infiltration confirmed the diagnosis to be Multicentric Reticulohistiocytosis.

Crohn’s disease and arthritis

A 30 year male known case of Crohn’s disease since 3 years presented with recurrent oral aphthe and arthritis of both knees. Arthritic manifestation started 3 months later the onset of oral lesions, 1 year after the disease diagnosis. She complained of morning stiffness and fleeting type of joint pain affecting major joints. Radiography revealed only soft tissue swelling of bilateral knees without joint effusion or erosive changes.

DISCUSSION

Out of 52 patients, 24(46.15%) belonged to psoriatic group, 8 (15.38%) leprosy group, 7(13.46%) scleroderma group, 6 (11.53%) SLE group, 2 (3.84%) each in Dermatomyositis and Behcet’s disease group. We encountered only one case each of Gout, Crohn’s disease and Multicentric reticulohistiocytosis. Other skin diseases presenting with joint manifestations like Acne, Rheumatoid arthritis, reactive arthritis , Vasculitic syndromes etc were not seen in our study group. We could not encounter any study broadly considering all skin diseases with arthropathy to compare with our study results. A statistically significant number of patients (i.e. 18 out of 24,75%) had only limited skin involvement (<30%) and majority were of chronic plaque type of psoriasis. Extensive involvement is found only in a small percentage of patients(> 60% involvement only in 2 out of 24 patients (8.33%). While controversy exists regarding the increase in frequency of PSA as skin lesions become more extensive,^3-7 the numbers of studies disproving the same are on the rise which include studies from India.^8,9The average number of joints involved per patients was highest for the group with skin involvement 30-60% (10.75 joints). The total number of joints involved was quite high in patients with skin involvement of less than 30% body surface area. This could have been because the maximum number of patients (75%) had less than 30% of BSA involved. We could not find any study commenting on number of joints correlating with percentage of skin involvement. Out of the 21 patients with chronic plaque type of psoriasis, maximum number of patients had oligoarticular type of PSA (33.33%). The next most frequent type of arthropathy among patients with chronic plaque psoriasis was the RA like and Axial type (28.57% each). Both palmoplantar and generalised pustular psoriasis type patient had RA like arthropathy whereas erythrodermic psoriasis patient had DIP predominant arthropathy. Correlation of type of joint involvement with type of psoriasis has not been described previously. Hence, there are no studies available for comparison. Out of 6 patients of SLE arthropathy 3(50%) had non-deforming arthropathy whereas 2(33%) had erosive arthropathy. Average number of joints involved were more in erosive and nondeforming type (5.5) as compared to mild deforming type (1). R M van Vugt et al,¹⁰ in their SLE cohort reported Jaccoud’s arthropathy to be commonest (8 of 17, 47%), followed by mild deforming arthritis (6 of 17, 35.29%). We did not encounter any case of Jaccoud’s arthropathy. No study mentions about average number of joints involved.Amongst the ACR criteria photosensitivity, oral ulcers, hematological abnormalities and ANA positivity were seen in all of the patients whereas 5 of 6 patients had malar rash. Among the ACR criteria Discoid rash (0 of 6) and serositis (2 of 6) were found to be least associated with SLE arthropathy. Their exact correlation with individual arthritis type could not be commented on due to small group of patients observed. R M van Vugt et al,¹⁰ in their SLE cohort found Renal disorder as the only ACR criterion significantly lower and fetal loss significantly higher in patients with SLE arthropathy. Similarly, Thelma L. Skare et al,¹¹ in their Jaccoud’s arthropathy group demonstrated that kidney involvement was significantly low compared to other SLE patients. However in our study, 4 out of 6 patients demonstrated renal abnormality.6 out of 8 (75%) leprosy patients presenting with arthritis in our study group had borderline disease (BT and BL) followed by lepromatous leprosy (2 of 8, 25%). Thus, arthritic manifestations were most commonly seen in both Borderline Tuberculous and Borderline Lepromatous Leprosy (37.5% each). Acute polyarthritic type (2 of 3) and Swollen hands and feet syndrome(1 of 2) occurred more frequently in Tuberculoid pole (60%) as compared to lepromatous pole (1 of 3 and 0 of 2 respectively) i.e. 20%. However, Charcot’s arthropathy was found to present only in lepromatous pole (2 of 2).Out of 8 leprosy patients, 2 (25%) had features of Type 1 reaction and presented with acute polyarthritis whereas 3 (37.5%) had features of Type 2 reaction with hands and feet syndrome. In Sarkar et al¹² study group the most common type of leprosy was the tuberculoid (TT, i.e. polar tuberculoid and BT, i.e. borderline tuberculoid) variety comprising 47 patients (46.07%). Other varieties in decreasing order were borderline (BB, i.e. mid-borderline and BL, i.e. borderline lepromatous) with 38 (37.25%) patients, lepromatous (LL, i.e. polar lepromatous) with 10 (9.8%) patients, indeterrminate with six (5.88%) cases, and pure neuritic type with only single case (0.98%). However, the above mentioned study did not correlate type of arthritis with type of leprosy. Vengadakrishnan et al¹³ in their study found arthritic manifestations to be common in patients with borderline lepromatous leprosy (27%), followed by those with tuberculoid leprosy (13%). The incidence of arthritis in lepra reactions was 57%. Thus, both study results are consistent with our study regarding type of leprosy presenting with arthropathy. However, no study mentions about incidence of lepra reactions associated with arthritis and correlation of type of arthropathy with type of leprosy. In our study group most common features manifesting in scleroderma with arthritis were cutaneous sclerosis, Raynod’s phenomenon (RP), finger tip ulceration. Among systemic manifestations, gastrointestinal abnormalities were more frequently seen. We were unable to find any study documenting exact correlation between arthritic pattern and other cutaneous and systemic features of scleroderma.

CONCLUSION

The commonest joint change associated with cutaneous disorder was Psoriatic arthropathy in 46.15% patients followed by belonged to the leprosy arthritic (15.38%), Sclerodema arthritis (13.45%) and SLE arthropathy (11.53%).

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