Psoriatic Arthritis

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What is psoriatic arthritis?

Psoriatic arthritis is a form of inflammatory arthritis. It is a lifelong skin condition that has been diagnosed in over 7 million Americans, according to the National Institutes of Health. Up to 30 percent of people with psoriasis can develop psoriatic arthritis. Both psoriasis and psoriatic arthritis are chronic autoimmune diseases – meaning, conditions in which certain cells of the body attack other cells and tissues of the body.

Psoriasis is most commonly seen as raised red patches or skin lesions covered with a silvery white buildup of dead skin cells, called a scale. Scales can occur on any part of the body. Psoriasis is not contagious – you cannot get psoriasis from being near someone with this condition or from touching psoriatic scales.

There are five different types of psoriatic arthritis. The types differ by the joints involved, ranging from only affecting the hands or spine areas to a severe deforming type called arthritis mutilans.

How is psoriatic arthritis diagnosed?

There is no single test to diagnose psoriatic arthritis. Doctors make the diagnosis based on a patient’s medical history, physical exam, blood tests, and MRIs and/or X-rays of the affected joints.

X-rays are not usually helpful in making a diagnosis in the early stages of the disease. In the later stages, X-rays may show changes that are more commonly seen only in psoriatic arthritis. One such finding is called the "pencil-in-cup," which describes the finding where the end of the bone gets whittled down to a sharp point. This finding indicates more severe inflammatory changes to joints, which may require more aggressive treatment.

The diagnosis of psoriatic arthritis is easier for your doctor to confirm if the psoriasis exists along with symptoms of arthritis. However, in as many as 15% of patients, symptoms of psoriatic arthritis appear before symptoms of psoriasis. Since the disease symptoms can vary from patient to patient, it is even more important to meet with your doctor when symptoms worsen or new symptoms appear.

What are the symptoms of psoriatic arthritis?

The symptoms of psoriatic arthritis may be gradual and subtle in some patients; in others, they may be sudden and dramatic.

The most common symptoms – and you may not have all of these -- of psoriatic arthritis are:

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); example: Achilles’ tendonitis
  • 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 (small depressions) of the nails
  • Detachment or lifting 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 and anti-CCP (types of blood tests to help diagnosis certain other forms of arthritis)
  • 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

Who is at risk for psoriatic arthritis?

Psoriatic arthritis occurs most commonly in adults between the ages of 30 and 50; however, it can develop at any age. Psoriatic arthritis affects men and women equally.

Up to 40% 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, let your doctor know if you are having joint pain. In as many as 85% 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. They also think that immune system problems, infection, and physical trauma play a role in determining who will develop the disorder. Psoriasis itself is not an infectious condition.

Recent research has shown that people with psoriatic arthritis have an increased level of tumor necrosis factor (TNF) in their joints and affected skin areas. These increased levels can overwhelm the immune system, making it unable to control the inflammation associated with psoriatic arthritis.

The approach to treatment

Early diagnosis and treatment 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, multiple joint involvement, and spinal involvement. Good control of the skin may be valuable in the management of psoriatic arthritis. In many cases, you may be seen by two different types of doctors – a rheumatologist and a dermatologist.

What are the treatment options for psoriatic arthritis?

The aim of treatment for psoriatic arthritis is to relieve symptoms. Treatment may include any combination of the following:

  • Medication options
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Disease modifying anti-rheumatic drugs (DMARDs)
  • Exercise
  • Heat and cold therapy
  • Joint protection and energy conservation
  • Splinting
  • Surgery

Choice of medications depends on disease severity, number of joints involved, and associated skin symptoms. During the early stages of the disease, mild inflammation may respond to nonsteroidal anti-inflammatory drugs (NSAIDs). Cortisone injections may be used to treat ongoing inflammation in a single joint.

DMARDs are used when NSAIDs fail to work and in patients with erosive disease. DMARDs that are effective in treating psoriatic arthritis include: methotrexate, sulfasalazine, cyclosporine, leflunamide, and biologic agents.

The biologic agents are among the most exciting drug treatments. Not only do these drugs reduce the signs and symptoms of psoriatic arthritis, but they also slow down joint damage. The status of these drugs for use in psoriatic arthritis and psoriasis is shown below.

Status of New Biologic Agents Approved or in the Process of Investigation for Psoriatric Arthritis and Psoriasis
  • Enbrel (etanercept)
    Psoriatic Arthritis: Approved for use
    Psoriasis: Approved for use
  • Humira (adalimumab)
    Psoriatic Arthritis: Approved for use
    Psoriasis: Approved for use
  • Remicade (inflixamab)
    Psoriatic Arthritis: Approved for use
    Psoriasis: Approved for use
  • Amiveve (alefacept)
    Psoriatic Arthritis: In clinical trials
    Psoriasis: Approved for use
  • Simponi (golimumab)
    Psoriatic Arthritis: Approved for use
    Psoriasis: In clinical trials
  • Stelara (ustekinumab)
    Psoriatic Arthritis: Not studied
    Psoriasis: Approved for use

There are also many non-medicine therapies that can be used in addition to medicine to help with your joint symptoms. Some of these therapies include:

Exercise

Moderate, regular exercise may relieve joint stiffness and pain caused by the swelling seen with psoriatic arthritis. Range-of-motion and strengthening exercises – designed specifically for you -- combined with low-impact aerobics, may be helpful.

Regardless of the exercise program you select, choose one you enjoy so that you continue to do it. Improper exercise programs may make psoriatic arthritis worse. Before beginning any new exercise program, discuss exercise options with a doctor. 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 switching the use of moist heat and cold therapy on affected joints. Moist heat -- supplied by a warm towel, hot pack, or warm bath or shower -- helps relax aching muscles and relieve joint pain, swelling, and soreness. Cold therapy -- supplied by a bag of ice or even a bag of 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 -- is helpful for preserving function.

Splinting

Your doctor may recommend splinting your joints to ease inflammation or problems with joint alignment or stability. However, to maintain movement in these joints, the splints should be removed from time to time and gentle range-of-motion exercises should be performed.

Surgery

Most people with psoriatic arthritis will never need surgery. However, severely damaged joints may require joint replacement surgery (arthroplasty; ie, natural joints are replaced with man-made ones). The goal of surgery is to restore function, 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
Phone: 503.244.7404
Website: www.psoriasis.org

The Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Toll-free: 800.283.7800
Website: www.arthritis.org

The American Juvenile Arthritis Organization
1330 West Peachtree Street
Atlanta, GA 30309
Toll-free: 800.283.7800
Website: www.arthritis.org/ja-alliance-main.php

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