Psoriatic Arthritis: Symptoms, Causes & Treatments
What Is Psoriatic Arthritis?
Psoriatic arthritis is an inflammatory joint condition that usually occurs in association with psoriasis of the skin.
It is called an autoimmune condition because it occurs when the body's immune system starts to attack healthy cells and tissues. This leads to joint inflammation and an overproduction of skin cells.
Nearly 5 million people in the U.S. have psoriasis, and an estimated 7% to 26% have psoriatic arthritis (350 thousand to 1.5 million). There is no cure for psoriatic arthritis and treatment focuses on controlling symptoms and preventing joint damage.
What Causes Psoriatic Arthritis?
Experts are not sure exactly what causes the immune system to target healthy cells and tissue, but suspect both genetic and environmental factors play a role. Studies have reported that first-degree relatives of psoriatic arthritis patients have a nearly 50 times greater risk of developing the disease than the general population.
Other studies have identified physical trauma or environmental factors, such as a bacterial or viral infection, as a trigger of psoriatic arthritis in people at risk genetically. Men are more likely to develop psoriatic arthritis than women.
Psoriatic Arthritis Symptoms
In 60-80% of people, symptoms of psoriasis precede symptoms of psoriatic arthritis by up to 10 years (although in some people it may take 20 years before arthritic symptoms develop). In 15-20% of people, psoriatic arthritis appears before psoriasis, and occasionally, both conditions appear simultaneously.
Joint pain, stiffness, and swelling are the main symptoms of psoriatic arthritis reported, and joints may feel warm to the touch. 35% of people with psoriatic arthritis develop exceptionally swollen fingers and toes, which resemble sausages. Deformities and swelling in the hands and feet can sometimes precede significant joint symptoms. Symptoms often resemble those of rheumatoid arthritis.
Any joint in the body can be affected, including the spine and sacroiliac joint, although an asymmetrical presentation (affecting only one side of the body) is common. Psoriatic arthritis can also cause pain where tendons and ligaments attach to the bone, especially in the foot, resulting in plantar fasciitis (pain in the sole of the foot) or Achilles tendinitis (pain at the back of the heel).
Fingernail Psoriasis Found in 80% of People With Psoriatic Arthritis
Fingernail psoriasis can be an early sign of psoriatic arthritis, and many different nail changes have been reported including splinter hemorrhages (blood spots under the nail), vertical ridges on the nail, nail crumbling and cracking of the free edge, and Beau's lines (deep, grooved ridges that run across the fingernail).
Other common symptoms of psoriatic arthritis include general fatigue, inflammation of the colored part of the eye (iritis), and mouth ulcers.
Symptoms of psoriatic arthritis come on slowly, and the condition can range in severity. At times, symptoms can be severe (called flares), but these usually alternate with periods of remission. Unfortunately, the condition tends to worsen with time, affecting mobility and day-to-day activities.
How Is Psoriatic Arthritis Diagnosed?
The diagnosis of psoriatic arthritis is based on your symptoms, a physical examination of your skin and joints by a doctor, and X-ray findings. Other conditions, such as ankylosing spondylitis, gout, osteoarthritis, reactive arthritis (Reiter's syndrome), and rheumatoid arthritis also need to be ruled out before the diagnosis can be made.
Although there are no diagnostic blood tests for psoriatic arthritis, tests may be conducted to rule out other conditions with a similar presentation (such as rheumatoid arthritis), or to assess the severity of joint inflammation.
Psoriatic Arthritis Treatment
Treatments for psoriatic arthritis aim to relieve pain, reduce swelling, and some may even prevent further joint damage. Traditionally, a step-wise approach has been used with treatment, starting with the safest medication first before progressing to more aggressive treatments. However, experts now suggest that treating the condition more agggresively from the outset can reduce eventual joint damage and disability.
The five main types of treatment include:
- Nonsteroidal anti-inflammatories (NSAIDs)
- Disease-modifying antirheumatic drugs (DMARDs)
- New oral treatments for inflammation
- Complementary treatments.
Nonsteroidal anti-inflammatories (NSAIDs)
NSAIDs help to decrease inflammation and relieve joint pain and stiffness associated with psoriatic arthritis. Examples of NSAIDs that may be used to treat psoriatic arthritis include:
- celecoxib (Celebrex)
- diclofenac (Arthrotec, Voltaren)
- etodolac (Lodine)
- ibuprofen (Advil, Motrin)
- indomethacin (Indocin)
- ketoprofen (Orudis)
- nabumetone (Relafen)
- naproxen (Aleve, Naprosyn)
- oxaprozin (Daypro)
- piroxicam (Feldene)
- sulindac (Clinoril)
- tolmetin (Tolectin DS).
Although NSAIDs help the symptoms of psoriatic arthritis, they do not slow progression of the disease. Side effects include gastrointestinal upset, an increased risk of bleeding, and a potentially increased risk of having a heart attack. Your doctor will decide if NSAIDs are right for you and which one would suit you best.
Disease Modifying Antirheumatic Drugs (DMARDs)
Disease-modifying antirheumatic drugs (DMARDs) are a diverse class of medicines that may be given in an attempt to slow or stop joint and tissue damage and the progression of psoriatic arthritis. They are also effective at relieving severe symptoms of the disease.
Examples of DMARDs used to treat psoriatic arthritis include:
Biologics are medications derived from living organisms that target specific parts of the immune system that fuel inflammation. They have revolutionized the treatment of a number of chronic conditions including Crohn's disease, multiple sclerosis, psoriasis, rheumatoid arthritis, and psoriatic arthritis.
They are notoriously expensive because they are complex to make and used for only a limited range of conditions. Examples of biologics that are FDA-approved for use in psoriatic arthritis include:
Other Psoriatic Arthritis Treatments
Several other medications may also be used for the treatment of psoriatic arthritis. Examples include:
- glucocorticoids: Both oral and injectable glucocorticoids may be considered for the short-term relief of acute, severe, joint inflammation and swelling. However, in some people they may provoke severe forms of psoriasis and psoriatic skin lesions may worsen when the drug is discontinued
- HP Acthar gel: This is a man-made form of corticotrophin, a hormone that is found naturally in the body. It may be given to relieve swelling and inflammation associated with flares of psoriatic arthritis
- apremilast (Otezla): This is an oral phosphodiesterase 4 (PDE4) inhibitor that can improve overall inflammation and difficult-to-treat nail psoriasis, as well as tendon and ligament inflammation, finger and toe swelling, and fatigue
- tofacitinib (Xeljanz): Tofacitinib inhibits an enzyme, Janus kinase (JAK), responsible for controlling much of the inflammatory action within cells.
Your doctor will decide which medication is best suited to you. In most people, a combination of medications from different classes are given.
Complementary and Alternative Treatments For Psoriatic Arthritis
Making certain lifestyle changes or incorporating non-pharmacological treatments into your management plan may provide additional relief from symptoms associated with psoriatic arthritis. Always talk with a licensed health care professional before making these changes, because some may not be suitable for you.
- Diet and Nutrition: Weight-reducing, heart-protecting, or anti-inflammatory diets may help indirectly. Up to 25% of people with psoriasis are sensitive to gluten and these people may benefit from a gluten-free diet.
- Vitamins and supplements (such as methylsulfonylmethane, omega-3 fatty acids, vitamin D): Some individuals have reported symptom improvement; however, few high-quality trials exist.
- Herbal Remedies: Remedies like aloe vera, apple cider vinegar, capsaicin, or turmeric have been used for psoriasis or psoriatic arthritis, but support for their effects is mainly anecdotal. Some may interact with your current medications or cause unwanted side effects such as bleeding.
- Stress-reducing techniques: Stress has been identified as a trigger of psoriasis in some people and practices such as meditation and mindfulness as well as the use of essential oils such as chamomile, lavender, rose, and tea tree can help calm the mind.
Physical activity is also important for your overall health and regular exercise helps maintain a good body weight and lower your risk of heart disease and type 2 diabetes. Acupressure, acupuncture, massage, Tai Chi, and yoga may also help.
Finished: Psoriatic Arthritis: Symptoms, Causes and Treatments
Al Hammadi, A. Psoriatic Arthritis. eMedicine https://emedicine.medscape.com/article/2196539-overview
Busse K, Liao W. Which Psoriasis Patients Develop Psoriatic Arthritis? Psoriasis forum / National Psoriasis Foundation. 2010;16(4):17-25
Treating psoriatic arthritis. National Psoriasis Foundation. https://www.psoriasis.org/psoriatic-arthritis/treatments
Keating GM. Apremilast: A Review in Psoriasis and Psoriatic Arthritis. Drugs 2017:77(4);459
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