Do different genders experience PsA differently? Save

There has been a lot of talk lately about the difference in the way male and female PsA patients experience their disease.  Are the differences only cultural or are there important clinical differences in the disease presentation, organ involvement and complications that physicians should be aware of? 

This is particularly important since in PsA, unlike RA, there is not a female preponderance.   

Results from an observational, cross-sectional study (Abstract #0400) were presented in the 2022 American College of Rheumatology (ACR) Convergence and attempted to shed light in this important clinical issue.  170 adult PsA patients, 50% female and 50% male, were included in this study.  The mean participant age was 54.5±13.5 years and mean disease duration was 11.4±9.7 years.  The majority of patients had peripheral only arthritis, 88.2% in men and 83.5% in women.  X-rays were read by 3 experienced rheumatologists according to Sharp/ van der Heijde index but there were not statistically significant differences (men X 43.1±75.4 vs women X 37.1±55.8, p=NS).

When they analyzed differences in disease activity, females presented with a higher frequency of enthesitis (31.2% vs 16.5%, p=< 0.0001), as measured by the MASES score, and higher DAPSA-ERS (X 17.9±11.9 vs X 14.5±10.5, p=0.048), while males had higher skin involvement (BSA X 6.5±14.3 vs X 3±15.3, p=0.032).

However, no significant differences were found in functional capacity (HAQ-A men X 0.92±0.7 vs women 0.72±10.5) and quality of life (PsAQoL men X 6.4±6.5 vs women X 7.2±6.4).

The observed difference held true even after adjusting for multiple sociodemographic and clinical variables.  In multivariate analysis, adjusting for age and disease duration, males still showed higher skin involvement by BSA (OR 1.05, 95%CI 1.01-1.1), while the enthesitis score MASES was lower in this group (OR 0.8, 95%CI 0.73-0.98, p= 0.03).

This finding may explain, in part, some of the obstacles that women often face before the diagnosis of psoriatic arthritis is established and targeted treatment can be initiated.  In the absence of serologic diagnostic tests and biomarkers, the diagnosis depends primarily with the clinical acumen and the experience of the physician.  Since the sentinel finding of skin psoriasis may be less frequent or pronounced in women and the lack of serologies (immunologic tests, inflammatory markers) that can be used to screen for or confirm the diagnosis, women may be erroneously diagnosed as suffering from primary “fibromyalgia”, especially since the diffuse entheseal involvement of PsA can often closely mimic clinically this condition.  

Clinicians should be aware of the inter-gender differences in clinical presentation of PsA.  This knowledge may enhance their ability to diagnose this disease earlier, especially in women with limited psoriatic skin disease and diffuse musculoskeletal pain that may be confused with non-inflammatory pain conditions such as fibromyalgia.