Peripheral Involvement in SpondyloArthritis - ASAS PerSpA


The various clinical forms of Spondyloarthritis include spinal (axial) features, peripheral arthritis, enthesopathy and extra-articular features such as uveitis, psoriasis and inflammatory bowel disease.

The peripheral rheumatological investigations (e.g. arthritis, dactylitis, peripheral enthesitis) can occur either concomitantly of the axial disease or independently alone or before the axial disease).

However, some questions remain, such as the prevalence of “isolated” peripheral spondyloarthritis, the clinical presentation of peripheral involvement in patients with skin psoriasis or the country variability of phenotypes.

Moreover, in order to evaluate the natural history of peripheral rheumatological involvement, some outcome parameters have been proposed such as the number of synovitis, the number of dactylitis, several enthesitis indices.

However, there is an ongoing discussion related to the validity of these outcome parameters and whether the rheumatological community should revisit it.


a) to evaluate the clinical peripheral rheumatological features of spondyloarthritis with regard to a concomitant axial disease, a concomitant skin psoriasis and across the regions of the world;

b) To evaluate the validity of existing outcome measures of peripheral rheumatological features and to explore the possibility to improve them.


Observational, cross-sectional, multicentric and international study with 24 participating countries representing the four continents. The inclusion criteria were adult patients, diagnosed as Spondyloarthritis (either axSpA, pSpA or PsA) by the treating rheumatologist and to be able to answer the questionnaires.


A total of 4465 patients were included (61% men, mean age 44.5 years) from four geographic areas: Latin America (n=538), Europe plus North America (n=1677), Asia (n=975) and the Middle East plus North Africa (n=1275). Of those, 78% had ever suffered from at least one peripheral musculoskeletal manifestation; 57% had peripheral joint disease, 44% had enthesitis and 15% had dactylitis. Latin American had far more often peripheral joint disease (80%) than patients from other areas. Patients with PsA had predominantly upper limb and small joint involvement (52%). Hip and shoulder involvement was found in 34% of patients. The prevalence of enthesitis ranged between 41% in patients with axSpA and 65% in patients with Juv-SpA. Dactylitis was most frequent among patients with PsA (37%).


These results suggest that all peripheral features can be found in all subtypes of SpA, and that differences are quantitative rather than qualitative. In a high proportion of patients, axial and peripheral manifestations coincided. These findings reconfirm SpA clinical subtypes are descendants of the same underlying disease, called SpA.


Timelines of the project: July 2018 – February 2020


Project Team

PI: Maxime Dougados (Paris, France)

Steering committee: Maxime Dougados (Paris, France), Joachim Sieper (Berlin, Germany), Desirée van der Heijde (Leiden, Netherlands), Robert Landewé (Leiden, Netherlands), Anna Moltó (Paris, France).

Working group: Clementina López-Medina (Paris, France), Tuncay Duruöz (Istanbul, Turkey), Uta Kiltz (Herne, Germany), Bassel Elzorkany (Cairo, Egypt), Najia Hajjaj-Hassouni (Rabat, Morocco), Rubén Burgos-Vargas (Mexico City, Mexico), José Maldonado-Cocco (Buenos Aires, Argentina), Nelly Ziade (Beirut, Lebanon), Meghna Gavali (Hyderabad, India), Victoria Navarro-Compán (Madrid, Spain), Shue-Fen Luo (Taoyuan, Taiwan), Sara Monti (Pavia, Italy), Tae-Jong Kim (Gwangju, South Korea), Mitsumasa Kishimoto (Tokyo, Japan), Fernando M. Pimentel-Santos (Lisboa, Portugal), Jieruo Gu (Guangzhou, China), Ruxandra Schiotis (Cluj-Napoca, Romania), Floris van Gaalen (Leiden, Netherlands), Pál Géher (Budapest, Hungary), Marina Magrey (Cleveland, Ohio), Sebastián Ibáñez (Santiago, Chile), Wilson Bautista-Molano (Bogotá, Colombia), Walter P. Maksymowych (Edmonton, Canada) and Pedro M. Machado (London, UK).



  1. López-Medina C, Molto A, Sieper J, Duruöz T, Kiltz U, Elzorkany B, Hajjaj-Hassouni N, Burgos-Vargas R, Maldonado-Cocco J, Ziade N, Gavali M, Navarro-Compan V, Luo SF, Monti S, Tae-Jong K, Kishimoto M, Pimentel-Santos FM, Gu J, Schiotis R, van Gaalen FA, Geher P, Magrey M, Ibañez-Vodnizza SE, Bautista-Molano W, Maksymowych W, Machado PM, Landewé R, van der Heijde D, Dougados M. Prevalence and distribution of peripheral musculoskeletal manifestations in spondyloarthritis including psoriatic arthritis: results of the worldwide, cross-sectional ASAS-PerSpA study. RMD Open 2021 Jan;7(1):e001450
  1. López-Medina C, Chevret S, Molto A, Sieper J, Duruöz T, Kiltz U, Elzorkany B, Hajjaj-Hassouni N, Burgos-Vargas R, Maldonado-Cocco J, Ziade N, Gavali M, Navarro-Compan V, Luo SF, Biglia A, Tae-Jong K, Kishimoto M, Pimentel-Santos FM, Gu J, Muntean L, van Gaalen FA, Geher P, Magrey M, Ibáñez-Vodnizza SE, Bautista-Molano W, Maksymowych W, Machado PM, Landewé R, van der Hejde D, Dougados M. RMD Open 2021 Nov;7(3):3001728
  1. Zhao SS, Nikiphorou E, Boonen A, López-Medina C, Dougados M, Ramiro S. Association between individual and country-level socioeconomic factors and work participation in spondyloarthritis including psoriatic arthritis: analysis of the ASAS-perSpA study. Semin Arthritis Rheum 2021 Aug;51(4):804-812
  1. Boel A, van Lunteren M, López-Medina C, Sieper J, van der Heijde D, van Gaalen FA. Geographical prevalence of family history in patients with axial spondyloarthritis and its association with HLA-B27 in the ASAS-PerSpA study. RMD Open 2022 Mar;8(1):e002174
  1. Ziadé N, El Hajj J, Rassi J, Hlais S, López-Medina C, Gamal SM, Elzorkany B, Dougados M, Baraliakos X. Root joint involvement in spondyloarthritis: a post hoc analysis from the international ASAS-PerSpA study. Rheumatology (Oxford) 2022 Feb 2;61(2):667-678
  1. Benavent D, Plasencia C, Poddubnyy D, Kishimoto M, Proft F, Sawada H, López-Medina C, Dougados M, Navarro-Compán V. Unveiling axial involvement in psoriatic arthritis: an ancillary analysis of the ASAS-perSpA study. Semin Arthritis Rheum 2021 Aug;51(4):766-744
  1. Boel A, López-Medina C, van der Heijde DMFM, van Gaalen FA. Age at onset in axial spondyloarthritis around the world: data from the Assessment in SpondyloArthritis international Society Peripheral Involvement in Spondyloarthritis study. Rheumatology (Oxford) 2022 Apr 11:61(4):1468-1475
  1. Izci Duran T, Torgutalp M, Rios Rodriguez V, Proft F, López-Medina C, Dougados M, Poddubnyy D. The impact of psoriasis on the clinical characteristics, disease burden and treatment patterns of peripheral spondyloarthritis. Rheumatology (Oxford) 2022 Apr 22:keac235
  1. Capelusnik D, Zhao SS, Boonen A, Ziade N, López-Medina C, Dougados M, Nikiphorou E, Ramiro S. Individual-level and country-level socio-economic factors and health outcomes in spondyloarthritis: analysis of the ASAS-perSpA study. Rheumatology (Oxford) 2022 May 5;61(5):2043-2053
  1. Fitzgerald GE, Maguire S, López-Medina C, Dougados M, O’Shea FD, Haroon N. Tender to touch-Prevalence and impact of concomitant fibromyalgia and enthesitis in spondyloarthritis: an ancillary analysis of the ASAS PerSpA study. Joint Bone Spine 2022 May 27;89(6):105420
  1. Ziade N, Rassi J, Elzorkany B, López-Medina C, Gamal SM, Hlais S, Dougados M, Baraliakos X. What is peripheral spondyloarthritis? Identifying proportion, phenotype and burden in post hoc analysis of the ASAS-PerSpA study. Semin Arthritis Rheum 2022 Aug;55:152012
  1. Kwan YH, Tan L, Tan CS, López-Medina C, Dougados M, Proft F, Rios-Rodriguez V, Phang JK, Chew EH, Ostbye T, Thumboo J, Fong W. Elucidanting the role of a positive family history in differentiating between axial and peripheral spondyloarthritis: an ancillary analysis of the ASAS-PerSpA study. Clin Exp Rheumatol 2022 Sep;40(9):1762-1768
  1. Llop M, Gratacós J, Moreno M, Arévalo M, Calvet J, Dougados M, López-Medina C. Uveitis in peripheral spondyloarthritis patients: an ancillary analysis of the ASAS-PerSpA study. Ther Adv Musculoskelet Dis 2022 Sep 5;14:1759720X221119246
  1. Benavent D, Capelusnik D, Ramiro S, Molto A, López-Medina C, Dougados M, Navarro-Compán V. Does gender influence outcome measures similarly in patients with spondyloarthritis? Results from the ASAS-perSpA study. RMD Open 2022 Sep;8(2):e002514
  2. Ono K, Kishimoto M, Deshpande GA, Fukui S, Kawaai S, Sawada H, Matsuura M, V Rios Rodriguez, Proft F, Tada K, Tamura N, Taniguchi Y, Hirata A, Kameda H, Tsuji S, Kaneko Y, Dobashi H, Okano T, Haji Y, Morita A, Okada M, Komagata Y, López-Medina C, Molto A, Dougados M, Hisamatsu T, Tomita T, Kaname S. Clinical characteristics of patients with spondyloarthritis and inflammatory bowel disease versus inflammatory bowel disease-related arthritis. Rheumatol Int 2022 Oct;42(10):1751-1766. 
  3. Ladehesa-Pineda ML, Ortega-Castro R, Puche-Larrubia MA, Granados REM, Dougados M, Collantes-Estévez E, López-Medina C. Smoking and alcohol consumption are associated with peripheral musculoskeletal involvement in patients with spondyloarthritis (including psoriatic arthritis). Results from the ASAS-PerSpA study. Semin Arthritis Rheum 2022 Nov 30;58:152146
  4. Arevalo-Salaet M, López-Medina C, Moreno M, Navarro-Compan V, Calvet-Fontova J, Llop M, Dougados M, Gratacós J. Association between HLA-B27 and peripheral spondyloarthritis phenotype: results from the ASAS perSpA study. RMD Open 2022 Dec;8(2):e002696
  5. Granados REM, Ladehesa-Pineda ML, Puche-Larrubia MA, Escudero-Contreras A, Dougados M, Collantes-Estévez E, López-Medina C. Enthesitis indices identify different patients with this characteristic in axial and peripheral spondyloarthritis and also in psoriatic arthritis: ASAS-PerSpA data. Arthritis Res Ther 2023 Jun 8;25(1):99
  6. Chaudhary H, López-Medina C, Khan MA, Dougados M, Magrey M. Clinical profile and treatment utilisation based on HLA-B*27 status in axial spondyloarthritis: results from ASAS-PerSpA study. RMD Open 2023 Jul;9(3):e003179. 
  7. Santos H, Henriques AR, Machado PM, López-Medina C, Dougados M, Canhao H, Rodrigues AM, Pimentel-Santos FM. Determinants of health-related quality of life and global functioning and health in axSpA, pSpA and PsA: results from the ASAS-PerSpA study. Rheumatology (Oxford). 2023 Sep 21:kead503