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Review
. 2020 Dec 8:12:1759720X20975915.
doi: 10.1177/1759720X20975915. eCollection 2020.

Skin manifestations in spondyloarthritis

Katharina Meier  1 , Alexandra Schloegl  2 , Denis Poddubnyy  3 , Kamran Ghoreschi  4
Affiliations
Review

Skin manifestations in spondyloarthritis

Katharina Meier et al. Ther Adv Musculoskelet Dis. .

Abstract

Spondyloarthritides (SpA) like psoriatic arthritis, axial spondyloarthritis/ankylosing spondylitis, reactive arthritis and inflammatory bowel disease (IBD)-associated SpA can present with characteristic skin manifestations. These SpA-associated skin disorders may precede joint involvement, reflect a loss of efficacy of a current systemic treatment or can even be treatment associated. Cutaneous manifestations in SpA not only add additional morbidity with physical impact but also impose a psychosocial burden on affected patients. Psoriasis (PsO) - the main skin disease in SpA - has a variety of clinical presentations, including plaque-type PsO, inverse PsO, guttate PsO, erythrodermic PsO, nail PsO and pustular types. SpA associated with IBD presents with neutrophilic and granulomatous skin disorders, including pyoderma gangrenosum, hidradenitis suppurativa and cutaneous Crohn's disease. Reactive arthritides has a favourable prognosis and may feature keratoderma blenorrhagicum or balanitis circinatum as typical skin manifestations. Immunologically, SpA-associated skin diseases share interleukin (IL)-17 and IL-23 dysregulation but show distinctive genetic and immunological profiles. Therefore, they vary in their treatment responses to targeted therapies with biologicals or small molecules. In this review, we highlight the clinical presentation of skin manifestations in SpA and discuss therapeutic approaches in this interdisciplinary field.

Keywords: erythema nodosum; hidradenitis suppurativa; psoriasis; psoriatic arthritis; pyoderma gangrenosum; skin; spondyloarthritis.

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Conflict of interest statement

Conflict of interest statement: KM has received honoraria or travel expenses for lecture and research activities from Abbvie, Biogen, Celgene, Janssen-Cilag and UCB Pharma. AS has received travel expenses from Janssen-Cilag and Celgene DP has received grant/research support from AbbVie, Lilly, MSD, Novartis, and Pfizer; has been a consultant for AbbVie, Biocad, Gilead, GSK, Lilly, MSD, Novartis, Pfizer, Samsung and UCB; and served on the speakers bureau for AbbVie, BMS, Lilly, MSD, Novartis, Pfizer and UCB. KG has received honoraria or travel expenses for lecture and research activities from Abbvie, Almirall, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Delenex, Eli Lilly, Galderma, Janssen-Cilag, Medac, MSD, Novartis, Pfizer and UCB Pharma.

Figures

Figure 1.
Figure 1.
Clinical presentation of PsO. (A) PV; (B) erythrodermic PsO; (C) guttate PsO; and (D) inverse PsO. PsO, psoriasis; PV plaque PsO.
Figure 2.
Figure 2.
Clinical presentation of PsO affecting the hands and feet. (A) Plantar PsO with hyperkeratotic plaques (left and middle) and pustular presentation (right). (B) Palmar PsO with hyperkeratotic plaques (left and middle) and pustular presentation (right). (C) Acrodermatitis continua of Hallopeau with severe onychodystrophy and oil drop dyschromia (*); (D) Nail PsO with onychodystrophy, pitting (*) and onycholysis (°). PsO, psoriasis.
Figure 3.
Figure 3.
Clinical presentation of pyoderma gangrenosum of the axilla (left) and the buttocks (right).
Figure 4.
Figure 4.
Clinical presentation of EN of the lower limbs. EN, erythema nodosum.
Figure 5.
Figure 5.
Clinical presentation of cutaneous Crohn’s disease of the lower left extremity. CD, Crohn’s disease.
Figure 6.
Figure 6.
Clinical presentation of HS of the axilla (left) and the groin (right). HS, hidradenitis suppurativa.
Figure 7.
Figure 7.
Skin manifestations in ReA. (A) BC of the glans and penis. (B) KB of the soles of the feet. CB, circinate balanitis; KB, keratoderma blenorrhagicum, ReA, reactive arthritis.
Figure 8.
Figure 8.
Efficacies targeting TNF-α in PsO, HS, PG, rSpA, nrSpA and PsA. The size of the circle presents the level of evidence, the colour represents the level of efficacy in the indicated disease.– As standards of therapeutic efficacies in PsO PASI90, in HS HiSCR, in SpA ASAS40 and in PsA ACR50 are used. The scheme is adapted from Eyerich et al. EMA, European Medicines Agency; FDA, United States Federal Drug Administration HS, hidradenitis suppurativa; nrSpA, non-radiographic axial SPA; PG, pyoderma gangrenosum; PsO, psoriasis; PsA, psoriatic arthritis; rSpA, radiographic axial SpA; SPA, spondyloarthritis; TNF-α, tumour necrosis factor alpha.
Figure 9.
Figure 9.
Efficacies targeting IL-17 in PsO, HS, PG, rSpA, nrSpA and PsA. The size of the circle presents the level of evidence, the colour represents the level of efficacy in the indicated disease.,– As standards of therapeutic efficacies in PsO PASI90, in HS HiSCR, in SpA ASAS40 and in PsA ACR50 are used. The scheme is adapted from Eyerich et al. EMA, European Medicines Agency; FDA, United States Federal Drug Administration HS, hidradenitis suppurativa; IL-17, interleukin 17; nrSpA, non-radiographic axial SPA; PG, pyoderma gangrenosum; PsO, psoriasis; PsA, psoriatic arthritis; rSpA, radiographic axial SpA; SPA, spondyloarthritis.
Figure 10.
Figure 10.
Efficacies targeting IL-12/23 and IL-23 in PsO, HS, PG, rSpA, nrSpA and PsA. The size of the circle presents the level of evidence, the colour represents the level of efficacy in the indicated disease.–,– As standards of therapeutic efficacies in PsO PASI90, in HS HiSCR, in SpA ASAS40 and in PsA ACR50 are used. The scheme is adapted from Eyerich et al. EMA, European Medicines Agency; FDA, United States Federal Drug Administration HS, hidradenitis suppurativa; IL-12, interleukin 12; IL-23, interleukin 23; nrSpA, non-radiographic axial SPA; PG, pyoderma gangrenosum; PsO, psoriasis; PsA, psoriatic arthritis; rSpA, radiographic axial SpA; SPA, spondyloarthritis.
Figure 11.
Figure 11.
Efficacies targeting IL-1 in PsO, HS, PG, rSpA, nrSpA and PsA. The size of the circle presents the level of evidence, the colour represents the level of efficacy in the indicated disease.,– As standards of therapeutic efficacies in PsO PASI90, in HS HiSCR, in SpA ASAS40 and in PsA ACR50 are used. The scheme is adapted from Eyerich et al. EMA, European Medicines Agency; FDA, United States Federal Drug Administration HS, hidradenitis suppurativa; IL-1, interleukin 1; nrSpA, non-radiographic axial SPA; PG, pyoderma gangrenosum; PsO, psoriasis; PsA, psoriatic arthritis; rSpA, radiographic axial SpA; SPA, spondyloarthritis.
Figure 12.
Figure 12.
Efficacies targeting IL-6 in PsO, HS, PG, rSpA, nrSpA and PsA. The size of the circle presents the level of evidence, the colour represents the level of efficacy in the indicated disease.– As standards of therapeutic efficacies in PsO PASI90, in HS HiSCR, in SpA ASAS40 and in PsA ACR50 are used. The scheme is adapted from Eyerich et al. EMA, European Medicines Agency; FDA, United States Federal Drug Administration HS, hidradenitis suppurativa; IL-6, interleukin 6; nrSpA, non-radiographic axial SPA; PG, pyoderma gangrenosum; PsO, psoriasis; PsA, psoriatic arthritis; rSpA, radiographic axial SpA; SPA, spondyloarthritis.
Figure 13.
Figure 13.
Efficacies targeting JAK in PsO, HS, PG, rSpA, nrSpA and PsA. The size of the circle presents the level of evidence, the colour represents the level of efficacy in the indicated disease.,– As standards of therapeutic efficacies in PsO PASI90, in HS HiSCR, in SpA ASAS40 and in PsA ACR50 are used. The scheme is adapted from Eyerich et al. EMA, European Medicines Agency; FDA, United States Federal Drug Administration HS, hidradenitis suppurativa; JAK, Janus kinase; nrSpA, non-radiographic axial SPA; PG, pyoderma gangrenosum; PsO, psoriasis; PsA, psoriatic arthritis; rSpA, radiographic axial SpA; SPA, spondyloarthritis.
Figure 14.
Figure 14.
Efficacies of abatacept and apremilast in PsO, HS, PG, rSpA, nrSpA and PsA. The size of the circle presents the level of evidence, the colour represents the level of efficacy in the indicated disease.,– As standards of therapeutic efficacies in PsO PASI90, in HS HiSCR, in SpA ASAS40 and in PsA ACR50 are used. The scheme is adapted from Eyerich et al. EMA, European Medicines Agency; FDA, United States Federal Drug Administration HS, hidradenitis suppurativa; nrSpA, non-radiographic axial SPA; PG, pyoderma gangrenosum; PsO, psoriasis; PsA, psoriatic arthritis; rSpA, radiographic axial SpA; SPA, spondyloarthritis.
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