What is psoriatic arthritis?
Psoriatic arthritis is a form of inflammatory arthritis that is associated with psoriasis of the skin. Psoriasis is a lifelong skin condition that has been diagnosed in over 4 million Americans. Up to 30 percent of people with psoriasis can develop psoriatic arthritis. Psoriasis is most commonly seen as raised red patches or lesions covered with a silvery white buildup of dead skin cells, called a scale.
Psoriatic arthritis causes pain, stiffness, swelling, and tenderness of the joints, making movement of the joint(s) difficult. You can also get inflammation outside the joints such as at the tendon insertions called enthesitis, i.e., Achilles’ tendonitis. There is also a sausage-like swelling of the fingers and toes known as dactylitis.
There are five different types of psoriatic arthritis. The types of psoriatic arthritis differ by which types of joints are involved, ranging from solely affecting the hands or spine areas to a severe deforming type called arthritis mutilans.
How is psoriatic arthritis diagnosed?
There is no one definitive test for psoriatic arthritis. The diagnosis is made mainly on a clinical basis; doctors will often take a medical history, perform a physical examination, order blood tests, MRIs and X-rays of the joints that are affected to diagnose psoriatic arthritis. It is important to rule out other types of arthritis that may cause similar signs and symptoms, such as gout and rheumatoid arthritis.
The onset of psoriatic arthritis symptoms may vary. For some, the onset of symptoms may be gradual and subtle, and for others it may be sudden and dramatic. You may not have all of these symptoms but the following are the most common:
Joint symptoms
- Discomfort, stiffness, pain, throbbing, swelling, or tenderness in one or more joints
- Reduced range of motion in joints
- Joint stiffness and fatigue in the morning
- Tenderness, pain, or swelling where tendons and ligaments attach to the bone (enthesitis)
- Inflammation of the eye (such as conjunctivitis)
Skin symptoms
- Silver or gray scaly spots on the scalp, elbows, knees, and/or the lower spine
- Inflammation or stiffness in the lower back, wrists, knees or ankles, or swelling in the distal joints (small joints in the fingers and toes closest to the nail), giving these joints a sausage-like appearance
- Pitting of the nails (small depressions)
- Detachment of fingernails or toenails
Other symptoms (may help a doctor confirm the diagnosis of psoriatic arthritis)
- Positive testing for elevated sedimentation rate (indicates the presence of inflammation)
- Positive testing for elevated C reactive protein (indicates the presence of acute inflammation)
- A negative test for rheumatoid factor
- Anemia - a state in which there is a decrease in hemoglobin (protein in the blood that transports oxygen) and red blood cells, which usually causes fatigue, shortness of breath, and a pale appearance
Diagnosis may be easier to confirm for your physician if psoriasis co-exists with symptoms of arthritis. However, in as many as 15 percent of cases, symptoms of psoriatic arthritis appear before symptoms of psoriasis. Symptoms of psoriasis may include frequent episodes of redness and itching, thick, dry, silvery scales on the scalp, elbows, knees, or the trunk, and nail abnormalities.
X-rays of your joints
In the very early stages of the disease, X-rays usually do not reveal signs of arthritis and may not help in making a diagnosis. In the later stages, X-rays may show changes that are characteristic of psoriatic arthritis but not found with other types of arthritis, such as the "pencil in cup" phenomenon where the end of the bone gets whittled down to a sharp point. It is important to see if there are erosions on your X-rays, which would indicate more severe inflammatory changes to your joints.
Who is at risk for psoriatic arthritis?
Psoriatic arthritis can develop at any time in your life; however, for most people it appears between the ages of 30 and 50. Psoriatic arthritis seems to affect men and women equally. While the cause is not known, genetic factors, along with the immune system, infection, and physical trauma play a role in determining who will develop the disorder.
As many as 40 percent of people with psoriatic arthritis have a family history of skin or joint disease. Children of parents with psoriasis are three times more likely to have psoriasis and are at greater risk for developing psoriatic arthritis than children born of parents without psoriasis.
If you do have psoriasis, it is important to let your doctor know that you are having joint pain. In as many as 85 percent of cases the skin disease occurs before the joint disease.
What causes psoriatic arthritis?
The cause of psoriatic arthritis is unknown. Researchers suspect that it develops from a combination of genetic (heredity) and environmental factors. Psoriasis itself is not an infectious condition.
Recent research has shown that tumor necrosis factor (TNF) is involved in causing the signs and symptoms of psoriatic arthritis. People with psoriatic arthritis have increased levels of TNF both in their joints and affected skin areas. These increased levels of TNF can overwhelm the immune system, making it unable to control the inflammation associated with psoriatic arthritis.
The approach to treatment
It is important to be diagnosed early so that treatment of psoriatic arthritis can relieve pain and inflammation and help prevent progressive joint involvement and damage. Without treatment, psoriatic arthritis can potentially be disabling and crippling.
The type of treatment will depend on how severe your symptoms are at the time of diagnosis. Some early indicators of more severe disease include onset at a young age, having many joints involved, and spinal involvement. Good control of the skin may be valuable in the management of psoriatic arthritis of the limbs.
Status of new biologic agents approved or in the process of investigation for psoriatic arthritis and psoriasis
Enbrel (etanercept)
Psoriatic Arthritis: Approved
Psoriasis: Approved
Humira (adalimumab)
Psoriatic Arthritis: Approved
Psoriasis: Clinical trials only
Remicade (inflixamab)
Psoriatic Arthritis: Approved
Psoriasis: Clinical trials only
Amiveve (alefacept)
Psoriatic Arthritis: Clinical trials only
Psoriasis: Approved
Raptiva (efalizumab)
Psoriatic Arthritis: Clinical trials only
Psoriasis: Approved
Treating psoriatic arthritis
Psoriatic arthritis treatment is intended to relieve the symptoms of the disorder, and may include any combination of the following:
- Medication options
- Non steroidal anti-inflammatory medications (NSAIDs)
- Disease modifying anti-rheumatic agents (DMARDs)
- Exercise
- Heat and cold therapy
- Joint protection and energy conservation
- Splinting
- Surgery
There are many different medication options for treating psoriatic arthritis. Options depend on the severity, number of joints involved, and associated skin symptoms. During the early stages of the disease, mild inflammation may respond to non-steroidal anti-inflammatory drugs (NSAIDs). Cortisone injections may be given judiciously to treat persistent single joint involvement. For patients who are unresponsive to NSAID therapy, or those with erosive disease, DMARD treatment is indicated. DMARDs that are effective in treating psoriatic arthritis include: methotrexate, sulfasalazine, cyclosporine, leflunamide, and biologic agents. The biologic agents are among the most exciting breakthroughs in recent years, and ongoing research will continue to improve treatment options. Through specialized biological engineering techniques, we now have medicines that can not only reduce the signs and symptoms of psoriatic arthritis but also slow the progression of joint damage.
There are also many non-medicine therapies that can be used in addition to medicine to help with your joint symptoms.
Exercise
Moderate, regular exercise may relieve joint stiffness and pain caused by the swelling associated with psoriatic arthritis. A tailored program of range-of-motion and strengthening exercises, combined with low-impact aerobics, may be helpful.
Regardless of the exercise program you select, it's important to choose one you enjoy so that you maintain it. Improper exercise programs may make psoriatic arthritis worse. Before beginning any new exercise program, discuss exercise options with a physician. Also, begin new exercise programs under the supervision of a physical therapist or qualified professional, preferably one with experience working with arthritis patients.
Heat and cold therapy
Heat and cold therapy involves alternating applications of moist heat and cold to affected joints to provide temporary relief of pain and swelling. Moist heat -- supplied by a warm towel, hot pack, or warm bath or shower -- can help relax aching muscles and relieve joint pain and soreness.
Cold therapy -- supplied by a bag of ice or even frozen vegetables wrapped in a towel -- can reduce swelling and relieve pain by numbing the affected joints.
Joint protection and energy conservation
Daily activities should be performed in ways that reduce excess stress and fatigue on joints. Proper body mechanics (the way you position your body during a physical task) may not only protect joints, but also conserve energy. People with psoriatic arthritis are encouraged to frequently change body position at work, at home, and during leisure activities. Maintaining good posture - sitting/standing up straight and not arching your back -- also is valuable for preserving function.
Splinting
Your physician may recommend splinting to help with inflammation or problems with joint alignment or stability by resting your joints. However, joints should not be totally immobilized. Splints should be removed periodically to perform gentle range-of-motion exercises to maintain mobility in those joints.
Surgery
Most people with psoriatic arthritis will never need surgery. Severely damaged joints may require arthroplasty or joint replacement surgery, in which natural joints are replaced with man-made ones to restore function in the affected area. Surgery also may relieve pain, improve movement, or improve the physical appearance of the affected area.
Living with psoriatic arthritis
There is no cure for psoriatic arthritis. However, by understanding the disorder and knowing what to expect, you can learn new and different ways to complete daily tasks or plan activities during the times and days you are least bothered by the effects of the disease. Once you understand and learn to predict the ways in which your body responds to the disease, you can use exercise and therapy to alleviate discomfort and reduce stress and fatigue.
Mental exercises, as well as sharing your experiences with family, a counselor or a support group, may help you cope with the emotional stress related to changes in physical appearance and disability associated with the disorder.
Support groups and resources
The National Psoriasis Foundation
6600 SW 92nd Avenue, Suite 300
Portland, OR 97223
503.244.7404
www.psoriasis.org
The Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
800.283.7800
www.arthritis.org
The American Juvenile Arthritis Organization
1330 West Peachtree Street
Atlanta, GA 30309
800.283.7800
www.arthritis.org/ajao
Road Back Foundation
4985 N. Lake Hill Drive
Delaware, OH 43015-9249
740.881.5601
http://roadback.org
© Copyright 1995-2008 The Cleveland Clinic Foundation. All rights reserved
Can't find the health information you’re looking for? Ask a Health Educator, Live!
Click here to go to the Department of Rheumatic and Immunologic Diseases Web site.
Know someone who could use this information?....send them this link.
This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 10/31/2006
