Juvenile psoriatic arthritis patients at Tripoli Children's Hospital

Mediterranean Journal of ISSN: 2789-1895 https://mrj.org.ly Medical Research Mediterr J Med Res Hashad SS, Alghareeri S. Mediterr J Med Res. 2025; 2(4): 230-238. Page 230 ORIGINAL RESEARCH article Juvenile psoriatic arthritis patients at Tripoli Children's Hospital 1 Suhaylah Alghareeri and * 2 1, Soad S. Hashad Tripoli Children’s Teaching Hospital, Ministry of Health, Tripoli, Libya 1 Department of Pediatrics, Faculty of Medicine, University of Tripoli, Tripoli, Libya 2 Author to whom correspondence should be addressed * Received: October 01, 2025, Accepted: November 06, 2025, Published online: November 13, 2025 HOW TO CITE THIS Hashad SS, Alghareeri S. Juvenile psoriatic arthritis patients at Tripoli Children's Hospital. Mediterr J Med Res. 2025; 2(4): 230-238. [Article number: 28]. https://doi.org/10.5281/zenodo.17610647 Keywords: Children, Juvenile psoriatic arthritis, psoriatic, rheumatic disease Abstract: Juvenile psoriatic arthritis (JPsA) is a relatively rare condition in childhood, as it represents about 5.0% of the whole Juvenile Idiopathic Arthritis (JIA). There are fewer reports describing the characteristics and outcome of patients with JPsA. The purpose of this study is to determine characteristic features, treatment, and patients' outcomes of JPsA among Libyan children and to compare the findings with other populations worldwide. Medical records of all the patients who met the Vancouver criteria (definite or probable) or ILAR criteria for JPsA, and who were followed up at the Pediatric Rheumatology Clinic in Tripoli Children's Hospital between 2001 and 2020, were retrospectively reviewed, and data were analyzed. The study included a total of 12 cases of JPsA over the study period; all were met Vancouver criteria for juvenile PsA: 42.0% not fulfill ILAR criteria. JPsA represents 4.8% of total JIA cases with a male-to-female ratio of 1: 1, and a mean age of 10.2±6.5 years. The mean age of disease onset was 5.8±5.3 years. Polyarticular pattern was the predominant (58.3%), ANA and HLAB27 were positive among 33.3% and 12.5% of the studied cases, psoriasis in 33.3% of cases, Uveitis in 30.0%, uveitis complications were occurred in one patient. Biologic drugs were used in 25.0% of the patients. The study concludes that the characteristics of JPsA in Libyan children are different from those of other countries regarding a higher frequency of uveitis, equal sex-related distribution, and absence of nail changes. This difference may be attributed to different classification criteria used. Introduction The most common rheumatic disease among children is Juvenile idiopathic arthritis (JIA), which includes all arthritis forms that last for six weeks and onset before the age of 16 years [1]. Depending upon the geographical area, the incidence and prevalence vary between 1.6 to 23 for 100,000 children [2-9]. The categorization suggested by ILAR encompasses seven different, mutually exclusive classes, determined by clinical and laboratory measures [10]. Undifferentiated arthritis, not fit for criteria in any subtype, or fit for two or more subtypes [11]. Polyarticular JIA involves five or more joints during the first six months, occurs at any time before the age of 16 years [12, 13]. Systemic JIA (SJIA) is associated with a daily quotidian fever of 39°C persisting for more than two weeks. SJIA onset in adolescents is rare and adult onset is reported in a few cases [14]. Enthesitis-related arthritis (ERA) is arthritis and enthesitis of at least six weeks’ duration [15]. The sacroiliacs, knees, ankles, and hips are the commonly affected joints at diagnosis, small joints of the feet and toes are involved [16]. Evidence for the heritability has shown that JIA has a sibling relative risk ranging from , which Creative Commons Attribution License access article is distributed under the-2025. This open © Copyright permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Mediterranean Journal of ISSN: 2789-1895 https://mrj.org.ly Medical Research Mediterr J Med Res Hashad SS, Alghareeri S. Mediterr J Med Res. 2025; 2(4): 230-238. Page 231 15 to 30, similar to that of type 1 diabetes [17]. Although autoreactive B cells have other important pathogenic functions in JIA as antigen presenting cells within the synovium [18]. The pathetiologic role of infections in causing JIA, and the mediating role of genetic factors, remain unclear [19]. There are no laboratory test or combination of studies to confirm the diagnosis but they can be used to offer evidence of inflammation, support the clinical diagnosis [20]. Rheumatoid factor serology is shown to likely be positive in children with JIA and diseases other than JIA [21]. In individuals with oligoarticular onset disease, ANA deliberates risk for the development of asymptomatic uveitis [22]. Anti-cyclic citrullinated peptide antibodies can indicate severe patterns of disease, and not a diagnostic marker for JIA [23]. Magnetic Resonance Imaging is able to evaluate the manifestations of JIA [24]. Bone scans using technetium-99m are beneficial for detecting the early stage of inflammatory arthritis [25]. A multidisciplinary team approach to the management is important to improve the care of children with arthritis [26]. Intraarticular corticosteroid is effective treatment for synovitis with JIA [27, 28]. Methotrexate (MTX) is the usual first-line systemic immunosuppressive agent in children with JIA-associated uveitis, and in those who are refractory to, or dependent on topical glucocorticoids [29, 30]. Etanercept is used in JIA [31], which has been demonstrated to improve ability and quality of life [32, 33], and is potentially capable of reducing the progression of radiographic joint damage [34]. Infliximab with MTX has been shown to produce an important, rapid, and durable clinical effect with JIA [35]. Tocilizumab has proven useful even in patients whose JIA has been refractory and appears quite effective as monotherapy [36]. Systemic glucocorticoids are used for severe JIA-associated complications [37, 38]. Rapid and accurate diagnosis and therapy are essential to prevent permanent damage of the joint and preserve joint functionality [39]. The prevalence of psoriasis of varies according to regions, but worldwide it is 2.0-11.0% [40]. The psoriasis location can increase the risk of psoriatic arthritis (PsA) with intergluteal and perianal lesions [41]. PsA is a differing inflammatory disorder marked by various clinical manifestations [42]. The American Rheumatism Association recognizes PsA as a separate disease [43]. Spondylitis presented in 40.0% [44]. The prevalence in Europe and other countries varies from 0.02 to 0.42% [45, 46]. There was a difference between PsA and psoriasis alone at three loci (HLA-C, IL-12B and IL-23R) [47]. Presence of two minor criteria is considered probable JPsA [48]. Two JPsA clinical subtypes are identified and is associated with HLA-B27; antinuclear antibodies are usually absent [49]. In PsA, especially the axial pattern, uveitis may initiate as unilateral and become bilateral in the course of the disease [50]. In peripheral arthritis, NSAID monotherapy without DMARDs should not exceed one, and other treatment possibilities should be considered. While when axial or entheseal involvement dominates the clinical picture, the duration of NSAID therapy might be prolonged up to 12 weeks, provided they have already induced relief for weeks [51]. Systemic glucocorticoids may be used with caution at the lowest effective dose, and MTX has proven efficacy in skin psoriasis and has become the standard DMARD for skin psoriasis [51]. Several other TNFi are approved in adult PsA for juvenile psoriasis; however, specific data on their effectiveness in JPsA remain scarce [52]. Despite this, identification and treatment are still not optimal, and the diagnosis was significantly delayed in the majority of patients. Delays in diagnoses of six and 12 months have been shown to impact long-term joint damage and functional disability [43]. Thus, the aim of this study was to determine all cases of psoriatic arthritis in terms of demographic data, diagnosis, treatment, and prognosis. Materials and methods Study design and period: This study was carried as cross-sectional study of the medical records of all the patients diagnosed with psoriatic arthritis who are referred to the Rheumatology Clinic. Study setting: This study carried out in Tripoli Children's Hospital which is one of teaching hospital providing tertiary health care services, with a number of pediatric subspecialty clinic including: cardiology, endocrine, respiratory, neurology, gastroenterology, metabolic, neonatology, nephrology, and rheumatology clinic, the Mediterranean Journal of ISSN: 2789-1895 https://mrj.org.ly Medical Research Mediterr J Med Res Hashad SS, Alghareeri S. Mediterr J Med Res. 2025; 2(4): 230-238. Page 232 rheumatology clinic is the only government clinic offer pediatric rheumatology services covering all western and south area of Libya. Study population: The study was carried out by reviewing the medical records of children with a diagnosis of psoriatic arthritis according to the international League of Associations for Rheumatology Classification (ILAR) or Vancouver criteria (definite or probable). Patients with active disease as well as those in clinical remission were included in the period of 2001-2020. Inclusion criteria: Any child diagnosed with psoriatic arthritis. Exclusion criteria: Other types of juvenile idiopathic arthritis patients. Study tool: A performed case sheet was used to obtain the relevant data from the medical records including the following: Age, sex, diagnosis, treatment and prognosis in the patients. Study measurements: The following measurements were used in this study in the purpose of comparison: treatment regimens, disease activity which is represented by JADAS score in the form of inactive disease on treatment, active disease on treatment, inactive disease off treatment, active disease off treatment and disease outcome which was evaluated by JADI score. Ethical consideration and consent process: Ethical approval was obtained from the scientific committee and the head of Tripoli Children's Hospital before starting the study. Statistical analysis: The collected data was coded and SPSS software was used for analysis. Frequency, percentage, mean, and SD were used for descriptive statistics. Results In this study, out of 12 children meeting the Vancouver criteria for juvenile PsA, five cases (42.0%) did not fulfill ILAR criteria. Grounds for exclusion were family history of psoriasis limited to second-degree relatives (25.0%), presence of systemic JIA (8.3%), RF not done (8.3%) and HLA-B27 in a male with arthritis onset after age six (8.3%). In addition, JPsA represents 4.8% of total JIA cases. Demographic data: Among the 12 patients, 50.0% were females, male: female ratio was 1: 1. The mean age of patients was 10.2±6.5 years, disease onset above four years of age was observed in 50.0%, mean age of JPsA onset was 5.8±5.3 years. 33.3% of the patients were diagnosed with psoriasis: Two had psoriasis before the onset of arthritis (median 10.0 months). Family history of psoriasis was found in 83.3% patients: 60.0% had a first-degree relative and 40.0% had a second-degree relative. One patient did not attend follow-up. The duration of follow up in the rest of the patients was 45.4%, less than two years, and 54.6% more than two years. Clinical feature: Arthritis was presented in all cases; arthritis onset pattern is shown in Table 1. Polyarticular pattern was the predominant (58.3%). Hips were affected in one patient (8.3%), while no axial involvement, no nail changes were observed; dactylitis was observed in 66.7% of the cases. Enthesitis was seen in 8.3%. Systemic manifestations were observed in 8.3%. Uveitis was observed in 30.0% of cases, of which all were females, as shown in Table 2. Uveitis complications occurred in one, four-year-old-girl, who had psoriasis, early disease onset, ANA titer >1: 320 and negative HLAB27. With regard to the serology result, rheumatoid factor, it was negative in all the patients. HLAB27 (missing values in four patients), it was positive in one patient (12.5%). The ANA was present in four patients accounting for 33.3%. ANA titer and pattern are shown in Table 3. ANA was more frequently seen in oligoarticular pattern (P=0.098), and the youngest age group at disease onset (P=0.221) Anti-CCP test (missing values in eight patients), negative in four patients. Mediterranean Journal of ISSN: 2789-1895 https://mrj.org.ly Medical Research Mediterr J Med Res Hashad SS, Alghareeri S. Mediterr J Med Res. 2025; 2(4): 230-238. Page 233 Table 1: Comparison between arthritis patterns concerning JPsA general and clinical features Table 2: General characteristics and treatment of JPsA-associated uveitis Table 3: ANA titer and pattern in JPsA children With respect to the treatment, all JPsA were treated with NSAIDs at presentation and/or during follow-up. Methotrexate was used in 66.7% of the patients, as shown in Table 4; it was more frequently used in polyarticular than oligoarticular pattern disease (P=0.679). Biologics were used in 25.0% of the patients, were more used in females and in younger age patients at disease onset (P=0.083). Intra-articular injection was used in 16.7% of the patients. Table 5 shows the disease outcome concerning clinical, laboratory data and treatment used. Variables Polyarticular pattern N, (%) Oligoarticular pattern N, (%) P value Gender Female Male 3 (42.9) 4 (57.1) 3 (60.0) 2 (40.0) 0.558 Age at disease onset ≤ 4 yrs. > 4yrs. 4 (57.1) 3 (42.9) 2 (40.0) 3 (60.0) 0.558 Patients with psoriasis 3 (42.9) 1 (20.0) 0.408 Family history of psoriasis 5 (71.4) 5 (100) 0.190 Peripheral joints 7 (100) 5 (100) Axial joints 0.0 (0.0) 0.0 (0) Hip joints 1 (14.3) 0.0 (0) 0.377 Dactylitis 4 (57.1) 4 (80) 0.408 Enthesitis 1 (14.3) 0.0 (0) 0.377 Variables JPsA uveitis N, (%) P value Gender Female Male 3 (100) 0 (0.0) 0.038 Age at disease onset ≤ 4 years > 4 years 2 (66.7) 1 (33.3) 0.490 Patients with psoriasis 2 (66.7) 0.098 Family history of psoriasis 2 (66.7) 0.571 Arthritis onset pattern Oligoarticular onset Polyarticular onset 2 (66.7) 1 (33.3) 0.260 Positive ANA 2 (66.7) 0.260 Positive HLAB27 0 (0.0) 0.408 Treatment NSAIDs Methotrexate Intra-articular injection Biologics 3 (100) 3 (100) 1 (33.3) 2 (66.7) -- 0.301 0.490 0.098 Follow up duration ≤ 2 years > 2 years 0 (0.0) 3 (100) 0.161 JPsA patients N, (%) [ANA pattern] ANA titer 2 (16.7) [Mixed, homogenous] > 1: 320 2 (16.7) [Nucleolar, homogenous] 1:160-320 8 (66.6) < 1: 80 Mediterranean Journal of ISSN: 2789-1895 https://mrj.org.ly Medical Research Mediterr J Med Res Hashad SS, Alghareeri S. Mediterr J Med Res. 2025; 2(4): 230-238. Page 234 Table 4: Medications used during the course of the disease Table 5: Disease outcome concerning clinical, laboratory data, and treatment used *One case is missing Discussion In the current study, medical records of 12 children at the Pediatric Rheumatology Clinic were retrospectively analyzed. This does not represent all cases seen in Libya during this period, but represents the referral pattern at Tripoli Children's Hospital. JPA was represents 4.8% of total JIA cases; it was 1.5% of JIA in Egyptian [53], 4.87% in the Saudi Arabia study [54], while in the Jordanian study, it was 8.5% [55]. There was no sexrelated difference, on contrary to female predominance reported by Al-Hemair and others [54] and Stoll et al. [56]. Meanwhile, male predominance was reported by Alzyoud et al. [55] and Zisman et al. [57]. The mean age of disease onset was 5.8±5.3 year, which was lower than that reported in Canada (8.0±4.4 year) by Butbul et al [58] and by Al-Hemairi et al. [54] (8.47±3.09 years). The present results regarding psoriasis were higher than that reported by Stoll et al. [56], was 25.0%, but lower than that reported by Zisman et al. [57], who found psoriasis in 66.8% of the cases. Family history of psoriasis showed high frequency among patients as reported by Hamilton et al. [59] and Butbul et al. [58]. Similar to a previous study in Turkey by Kalyoncu et al. [60], polyarticular-onset was found to be the most common clinical pattern. In contrast to the results of Butbul et al. [58], who reported oligoarticular-onset predominance. Concerning dactylitis, the current results were much higher than that reported by Butbul et al. [61] was 30.0%, while no nail changes were reported in the patients of this study, in contrast to 53.0% in the same study [61]. Being higher than the Saudi study [54], the frequency of ANA positivity in the children of the present study P value Oligoarticular pattern N, (%) Polyarticular pattern N, (%) Treatment 5 (100) 7 (100) NSAIDs 0.679 3 (60) 5 (71.4) Methotrexate 0.793 1 (20) 1 (14.3) Intra-articular injection 0.735 1 (20) 2 (28.6) Biologics Variable Articular damage only N, (%) Both articular and extraarticular damage N, (%) P value Gender Female Male 1 (33.3) 2 (66.7) 1 (100) 0 (0.0) 0.248 Age at disease onset ≤ 4 years > 4 years 1 (33.3) 2 (66.7) 1 (100) 0 (0.0) 0.248 Psoriasis in patient 0 (0.0) 1 (100) 0.046 Arthritis onset pattern Oligoarticular Polyarticular 1 (33.3) 2 (66.7) 0 (0.0) 1 (100) 0.505 Positive ANA 1 (33.3) 1 (100) 0.248 Positive HLAB27 1 (50) * 0 (0.0) 0.386 treatment regimens: NSAIDs & Methotrexate NSAIDs, Methotrexate & biologics 2 (66.7) 0 (0.0) 1 (100) 1 (100) 0.505 0.083 Drug compliance Good Poor 1 (33.3) 2 (66.7) 0 (0.0) 1 (100) 0.505 Follow up duration ≤ 2 years > 2 years 2 (66.7) 1 (33.3) 0 (0) 1 (100) 0.248 Mediterranean Journal of ISSN: 2789-1895 https://mrj.org.ly Medical Research Mediterr J Med Res Hashad SS, Alghareeri S. Mediterr J Med Res. 2025; 2(4): 230-238. Page 235 was 33.3%, although a higher frequency was reported in Taiwan by Shen et al. [62] was 66.7%. Absence of ANA positivity was reported in other studies [9, 53, 55]. As found by Butbul et al. [60], it's more frequently seen in oligoarticular onset disease. HLAB27 was found in 12.5%, while higher results were reported by Flatøb et al. [63] by 19.0%. Previous studies in Taiwan [62] and America [56] reported by 33.3% and 46.0%, respectively. Uveitis was manifested among 33.3% of the cases, which was higher than that reported in Germany by 6.6% [64]. In contrast to the results of Abdwani et al. [9], Al-Hemairi et al. [54] and Hamilton et al. [59], who reported absent cases of uveitis. The present results were similar to the German study by BaquetWalscheid [65] who found that JPsA-uveitis patients more frequently female, antinuclear antibody positive and younger at PsJA onset as well as in Libya [66]. As found by Butbul et al. 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Conflict of interest: The authors declare the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethical issues: The authors completely observed ethical issues, including plagiarism, informed consent, data fabrication or falsification, and double publication or submission. Data availability statement: The raw data that support the findings of this article are available from the corresponding author upon reasonable request. Author declarations: The authors confirm that they have followed all relevant ethical guidelines and obtained any necessary IRB and/or ethics committee approvals. Generative AI disclosure: No generative AI was used in the preparation of this manuscript.