Assessment of Osteoporosis in

Psoriasis with and without Arthritis:

Correlation with Disease Severity

Dr. Sahar Fathi

Assisstant Professor of Rheumatology, Physical
Medicine and rehabilitation Ain Shams University
Psoriatic patients are susceptible to
osteoporosis
The cause of osteoporosis in PsA
patients is not well defined.

 Chronic inflammation and inflammatory

cytokines (TNF-α).
 Medications such as glucocorticoids.
 Prolonged immobilization due to joint
dysfunction and severe pain.
 TNF-α

 Increases number of circulating osteoclast

precursors (OCPs) .

 Induces RANKL expression.

 Osteoprotegerin (OPG)

 OPG = Osteoclast differentiation inhibiting

protein.
 OPG functions as a decoy receptor to prevent
RANKL signaling.
 Shown to affect bone density.

Lack of OPG Normal OPG Extra OPG

 OPG / RANKL / RANK Receptor

Hormones
 RANKL and OPG are secreted Cytokines RANK Ligand
by osteoblasts and bone RANK

Osteoclast
marrow stromal cells. OPG
Precursor

 RANKL functions to promote Osteoblasts

RANK

osteoclast formation and Osteoclast

activation and inhibit apoptosis.
Bone

 RANK is expressed by osteoclasts.

 RANK Ligand (RANKL) is a Key Mediator of
Osteoclast Activity

(receptor activator of NFB ligand)

OPG
RANKL
RANK
CTSK

Osteoclast
Stromal cells Osteoclast (mature)
Osteoblasts precursor
 The RANKL / OPG Balance
growth factors gravity

hormones vitamins
PTH drugs
cytokines aging

RANKL OPG
 Aim of the Study

We aimed to assess osteoporosis in patients

with psoriasis and PsA by DEXA, and measuring
serum OPG level. Correlate these findings with
the extent of both skin and joint manifestations.
 Patients & Methods
- This study included 50 patients with psoriasis, 16
patients of them with PsA and 20 healthy, age-
and sex-matched controls.

- The diagnosis of psoriasis was made clinically,

based on characteristic skin lesions.

- PsA patients fulfilled diagnostic

criteria defined by the classification
of psoriatic arthritis (CASPAR) study.
 CASPAR Criteria
ClASsification criteria for Psoriatic ARthritis
Patient must have inflammatory articular disease with 3
or more of the following 5 criteria:

1- Personal OR family history of psoriasis (1st or 2nd degree relative).

2- Psoriatic nail disease including: onycholysis, pitting, hyperkeratosis on current

physical exam.

3- Negative RF.

4- History of or current dactylitis .

5- Radiographic evidence of juxta-articular new bone formation, appearing as ill

defined ossification near joint margins on plain radiographs of the hand or foot.
 Exclusion criteria
 post-menopausal females.
 patients with history of cigarette smoking
or alcohol abuse.
 Those who received systemic steroids,
retinoids, calcium and/or vitamin D
supplementation within the last 12 months.
 All patients had been physically active
during the preceding 12 months.
 Clinical Assessment
 The severity and extent of psoriasis was assessed by
the psoriasis area severity index (PASI) for each patient.

 The severity of joint manifestations in PsA patients was

assessed by the peripheral joint score with one point for
each involved joint (range 0–70).

 Joint involvement was defined as synovial swelling

and/or joint deformity and/or radiological abnormality.
 Pattern of peripheral joint
involvement
 Distal interphalangeal (DIP)
 Interphalangeal (IP) of the thumbs,
 Proximal interphalangeal (PIP),
 Metacarpophalangeal (MCP),
 Wrist, elbow, shoulder,
 Temperomandibular,
 Sternoclavicular, acromioclavicular,
 Hip, knee,
 Tibiotalar, talocalcaneal, midtarsal,
 Metatarsophalangeal (MTP),
 IP joints of the first toe ,
 The remaining toes (each toe counting as one) .
 PASI score
 The body is divided into four sections (head (H) (10% of
a person's skin); arms (A) (20%); trunk (T) (30%); legs
(L) (40%).

 The sum of all three severity parameters is then

calculated for each section of skin, multiplied by the area
score for that area and multiplied by weight of respective
section (0.1 for head, 0.2 for arms, 0.3 for body and 0.4
for legs).

 PASI = 0.1 (Eh+Ih+Dh) Ah +0.2 (Eu+Iu+Du)Au +0.3

(Et+It+Dt) At+ 0.4 (El+Il+Dl) Al
 PASI score
 Area <10% =1 10-29% =2
30-49%=3 50-69%=4

70-89%=5 90-100%=6

 Erythema (redness) 01 2 3 4
 Induration (thickness) 01 2 3 4
 Desquamation (scaling) 0 1 2 3 4
- Plain x-ray of the hands, feet, and
affected joints were obtained for PsA
patients.

- BMD was measured at the femoral neck,

lumbar spine and wrist using DEXA.

- serum OPG was measured by ELISA.

RESULTS
 The patient's age range was 20-50 years
in both groups, with a mean of 37 ± 10
years in group I and 35 ± 10 years in
group II.

 Total
joint score in PsA patients (group II)
ranged from 1 to 8 (mean of 3.25 + 1.78).
 Nail involvement was detected in 12 patients in
group I (35.3%) and 12 patients in group II (75%).
Nail lesions
Onycholysis
 Comparison between group I and group II as
regards disease duration, psoriasis area and PASI
scores.
P Group II (n =16 ) Group I (n = 34)
Mean+ Range Mean+ Range
SD SD

0.55 8.2+ 5.1 1.5 - 8.13+7 0.5 - 25 Disease

20 duration
0.01 3.11+ 1.2 1.92+ 0.7 - Psoriasi
* 1.6 -5.7 1. 23 5.6 s area
0.09 20.8+18 5.2- 12.57 2.8 PASI
61.2 +10.87 -39.6
 OPG Levels
Controls (n= Group II Group I
20) (n = 16) (n = 34)
Mean+ Range Mean+ Rang Mean Rang
SD SD e + SD e
7.65+ 3-15 22.68+ 14-35 21.14 8-35 OPG
3.32 7.04 + (pg/ml)
8.62
Osteoprotegrin in psoriasis,PsA
and controls
Psoriatic
patients
PsA patients

Controls

30

20

10

0
 Comparison between the study groups regarding
the radiological assessment of osteoporosis by
DEXA revealed statistically significant
differences between either psoriatic or PsA
patients and controls as regard T and Z score of
lumbar spine, neck of femur, and wrist (p< 0.05).

 Group II (PsA) showed significantly lower T

score in the femoral neck and wrist, compared to
group I (p< 0.05).
In PsA patients (group II), total joint score correlated
positively with disease duration (r = 0.53, p = 0.03).

Positive correlation between total joint score and

psoriasis area (AS) in group II.
9
8
7
Total Joint Score

6
5
4
3
2
1
0
1 2 3 4 5 6
PASI_AS
Negative correlation between total joint score and Z-
score femur neck in group II.

9
8
7
6
Tot-Joint Scr

5
4
3
2
1
0
-2.5 -1.5 -0.5 0.5 1.5
Z-Scr-Fem eur
 CONCLUSION
 Psoriatic patients with or without arthritis could suffer
from osteoporosis as evidenced by significantly
increased serum OPG level as a compensatory
mechanism to enhanced osteoclastic activity. However,
PsA patients had more significant osteoporosis in neck
of femur and wrist as detected by DEXA.

 Prolonged and extensive cutaneous disease is an

important risk factor for the development and severity of
PsA.

 The more the number of affected joints is, the higher the
risk of osteoporosis would be.