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A 49 year old man gave a six month history of painful, tender metacarpophalangeal and proximal interphalangeal joints resulting in poor hand function caused by a weak grip. He had confirmed psoriatic arthritis and 10 years previously had been seen with similar symptoms and radiographs. He had never taken second line agents and until recently had been asymptomatic. On examination he had tender metacarpophalangeal joints but no clinical synovitis. His fingers showed shortening of several terminal phalanges. C reactive protein and erythrocyte sedimentation rate were not raised. His radiographs show acro-osteolysis of the terminal phalanges in hands and feet and an isotope bone scan showed increased activity in several terminal phalanges (figure, plain radiograph of the hands (A) and feet (B) showing acro-osteolysis of the terminal phalanges).
Acro-osteolysis is a destructive resorption of the terminal phalanges seen in a number of conditions including psoriatic arthritis.1 Its incidence and prevalence in psoriasis is unclear. Other associated conditions include: systemic sclerosis; vinyl chloride disease; Ehlers-Danlos syndrome; leprosy; and familial forms, which may be autosomal recessive or dominant. Its aetiopathogenesis is unclear. In some cases mast cell hyperplasia has been implicated, whereas in others (for excample, systemic sclerosis) ischaemia is thought more probable.2
Contributors:lama ammora, adrian jones. Rheumatology Unit, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB.