CONDITIONS

What Is Psoriatic Arthritis

Psoriatic arthritis, or PsA, is a particular type of arthritis (joint inflammation) that develops in individuals with psoriasis, a skin condition that causes painful, itchy, and flaky skin rashes. Psoriatic arthritis can occur in any joint in the body. 30-50% of the 7.5 million Americans with psoriasis will develop psoriatic arthritis, and even fewer will develop severe forms of the condition.

Psoriatic arthritis is categorized by the location and severity of inflammation. There are five main types:

  1. Symmetric psoriatic arthritis. This is the most common type of psoriatic arthritis, accounting for about 50% of all cases. As its name “symmetric” suggests, this type of psoriatic arthritis affects both sides of the body equally, developing in opposing joints.
  2. Asymmetric psoriatic arthritis. This is the second most common type of psoriatic arthritis, accounting for about 30% of all cases. Asymmetric psoriatic arthritis does not affect each side of the body equally, and can occur in a random selection of joints.
  3. Distal psoriatic arthritis. In this type of psoriatic arthritis, inflammation occurs mainly in the nailbed region of the toes and fingers. Severe inflammation can cause the fingers and toes to swell, creating a “sausage-like” appearance. Nail discoloration, thickening, separation, or pitting often accompanies the swelling.
  4. This type of psoriatic arthritis refers to inflammation that is specific to the joints of the spine. Spondylitis can and often does occur along with other types of psoriatic arthritis
  5. Arthritis mutilans. This is a rare and especially damaging form of psoriatic arthritis that can lead to severe deformation of the hands and feet. Less than 5% of people with psoriatic arthritis will be diagnosed with arthritis mutilans.

 Cases of psoriatic arthritis can be mild or severe.

  • Oligoarticular psoriatic arthritis affects up to four joints.
  • Polyarticular psoriatic arthritis affects more than four joints.

What Causes Psoriatic Arthritis

Psoriatic arthritis occurs when the body’s immune system malfunctions and launches an immune response against healthy tissues in the joints. This is a continuation of the immune response launched against the skin in cases of psoriasis. Though there is currently no known cause for this immune system malfunction, leading research suggests that the cause is a mixture of environmental and genetic factors. Most recently, researchers at the University of Manchester found that the prevalence of psoriatic arthritis is closely associated to the KIR2DL1 or KIR2DL2/3 genes, opening up the door for further research on genetic causes of psoriatic arthritis.

Risk Factors For Psoriatic Arthritis

The following factors may affect your risk of psoriatic arthritis:

  • Psoriasis/other immune disorders. A diagnosis of psoriasis or other immune disorders increases the likelihood of developing psoriatic arthritis. However, having psoriasis or other immune conditions does not meant that you are guaranteed to develop psoriatic arthritis. Some sources estimate that 30 to 50% of psoriasis patients develop psoriatic arthritis. For others, the estimate is as low as 10 to 20%
  • Age. Cases of psoriatic arthritis may develop at any age, though most cases are diagnosed in between the ages of 30 and 50. Pediatric psoriatic arthritis (psoriatic arthritis in children) is rare but does occur.
  • Race. Psoriatic arthritis is much more common among white individuals than people of other races.
  • Family history. The prevalence of psoriatic arthritis in family members is one of the largest risk factors for developing the condition. According to the U.S. Library of Medicine’s Guide to Understanding Genetic Conditions, approximately 40% of people with psoriatic arthritis have a relative with the disease.

Diagnosing Psoriatic Arthritis

Because of its shared symptoms with other conditions such as osteoarthritis, rheumatoid arthritis, and gout, psoriatic arthritis is often difficult to diagnose. A diagnosis of psoriatic arthritis will most likely depend on a combination of the following:

  • Medical History, including family history, to identify symptoms and genetic susceptibility to the condition. Doctors will take the location and the duration of the pain and swelling into special consideration. Pre-existing psoriasis is a strong indicator for psoriatic arthritis.
  • Physical Exam, to assess the severity and location of joint inflammation.
  • Imaging Techniques such as x-rays, to assess internal damage to joints and identify locations of inflammation
  • Blood Tests, to rule out other forms of arthritis and similar conditions.

Symptoms of Psoriatic Arthritis

In the majority (85%) of psoriatic arthritis patients, symptoms of psoriasis (skin rashes, itching, flaking) develop before joint inflammation. According to the National Psoriasis Foundation, the following may be signs of psoriatic arthritis:

  • Generalized fatigue
  • Tenderness, pain and swelling over tendons
  • Swollen fingers and toes
  • Stiffness, pain, throbbing, swelling, and tenderness in one or more joints
  • A reduced range of motion
  • Morning stiffness and tiredness
  • Nail changes including separation from the nail bed, nail pitting, thickening, or discoloration
  • Redness and pain in the eyes

Prognosis

The prognosis for psoriatic arthritis varies depends on several factors:

  • Severity of the condition at onset. Cases of psoriatic arthritis that present severe symptoms at the onset are more likely to remain severe or progress than are cases that are mild at the onset.
  • Age of onset. Younger individuals who are diagnosed with psoriatic arthritis are more likely to experience disease progression than are older individuals.
  • Response to therapy. Psoriatic arthritis that does not respond to initial treatment are more likely to progress.
  • Family History. The disease course of family members with psoriatic arthritis can greatly influence an individual’s prognosis. 

Though there is always a risk of progression with psoriatic arthritis, there are many treatments available to help lessen the effects of the condition and discourage progression. Because these treatments are most effective when the condition is in its earliest phase, it is essential that you visit your doctor for regular check-ups and report any observed symptoms.

Living With Psoriatic Arthritis

A diagnosis of Psoriatic Arthritis can be challenging, but it doesn’t have to make you miss out on life. The following are tips to help you live well with psoriatic arthritis:

  • Find a doctor that you respect and are comfortable with. A trusting doctor/patient relationship is essential to successful treatment. Make sure he or she listens to your concerns and is considerate of your wants and needs as a patient.
  • Fight fatigue with activity. Psoriatic arthritis patients often report fatigue as being their most debilitating symptom. Engaging in 30-40 minutes of physical activity every day can help to combat fatigue, as well as keep the joints and tendons flexible.
  • Turn to your muscles for help stabilizing the joints. Concentrating on strengthening the muscles around the affected joint can help alleviate pain, swelling, and inflammation as well as boost overall energy levels. Try total-body conditioning activities such as yoga or swimming.
  • Don’t be ashamed of your symptoms. Many psoriatic arthritis patients feel that they are being a burden by talking about symptoms like pain and fatigue to loved ones and doctors. Don’t be ashamed of your symptoms – being attuned to your body and communicating your symptoms with others can actually lead to better treatment and support.
  • Make small adaptions where necessary so that you can stay comfortable through daily tasks. This might include workplace adaptions like changing the height of your desk, switching to an ergonomic keyboard design, or scheduling adaptations like working smaller breaks into the day.

Screening

While there is no universal screening recommendation specifically for psoriatic arthritis, it is recommended that patients with psoriasis be checked regularly for arthritis-like symptoms.

Be sure to schedule regular check-ups with your doctor. These should catch any early symptoms of either psoriasis or psoriatic arthritis.

If you are experiencing any symptoms of psoriasis or psoriatic arthritis, schedule an appointment with your doctor as soon as possible.

Prevention

There is no known way to prevent psoriatic arthritis. However, there are several things that you can do to help decrease the chance of disease progression or development of related conditions. These include:

  • Staying Active. Regular exercise has a host of benefits for psoriatic arthritis patients, including building muscle strength, decreasing inflammation in the body, fighting fatigue, and keeping joints and tendons flexible.
  • Maintain a balanced diet with plenty of fresh fruits and vegetables. Try to avoid highly processed foods and foods high in cholesterol, which can increase the chance of developing conditions that are often associated with psoriatic arthritis such as cardiovascular disease and Crohn’s disease.
  • Schedule regular check-ups with your doctor during which you talk about how you are responding to treatment and what new symptoms (if any) you are experiencing.

Common Treatment

There are a variety of different treatment options available for people with psoriatic arthritis that can help lessen symptoms and prevent disease progression. According to the National Psoriasis Foundation, the majority of psoriatic arthritis treatment methods fall into two categories:

Non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs are perhaps the most widely known form of psoriatic arthritis treatment, and include familiar painkillers such as aspirin. NSAIDs function by decreasing overall levels of inflammation in the body, thereby lessening pain and swelling in the joints. NSAIDS are available as over-the-counter medicine or in more powerful prescription doses. Popular NSAIDs used in the treatment of psoriatic arthritis include:

  • Sulindac (Clinoril)
  • Oxaprozin (Daypro)
  • Ibuprofen (Motrin, Advil)
  • Naproxen Sodium (Aleve, Anaprox, Naprelan, Naprosyn)
  • Ketoprofen (Orudis)
  • Nabumetone (Relafen) 

Disease-modifying antirheumatic drugs (DMARDs). This is a broad class of drugs that both work to relieve pain and slow the progression of joint damage. According to the National Psoriasis Foundation, the following are the most commonly prescribed DMARDs:

  • Antimalarials. Antimalarials can decrease the severity of symptoms in cases of rheumatoid and psoriatic arthritis. These drugs are often not effective at slowing progression and should therefore be used in cases of mild psoriatic arthritis or in combination with other treatments.
  • Corticosteroids. This type of drugs is particularly effective for the immediate treatment of severe pain, swelling and inflammation, though should not be used regularly or in excess due to potentially damaging side effects.
  • Like corticosteroids, corticotropins such as acthar are effective for short-term relief but not long-term treatment. Corticotropins are most often delivered in the form of injections for the most immediate relief.
  • Immunosuppressive drugs. These drugs help to address the overactive immune response at the heart of joint inflammation and swelling by suppressing the immune system. This can, however, leave patients more susceptible to contacting other infections and diseases. Commonly used immunosuppressive drugs include:
  • Imuran
  • Methotrexate
  • Cyclosporine
  • Cyclophosphamide
  • Biologics. While immunosuppressants interfere with broader immune function, biologics target specific immune cells and immune processes. They are preferred by some for their specificity, but are most commonly used when all other treatment methods have been unsuccessful. Biologics used in the treatment of psoriatic arthritis target T cells (immune response cells) and tumor necrosis factor-alpha (TNF-alpha) among other immune proteins. Commonly prescribed biologics include:
  • Enbrel
  • Humira
  • Remicade

Complementary and Alternative Treatment

There is significant evidence, both clinical and anecdotal, that suggests that alternative/complementary modes of treatment can be effective in the treatment of psoriatic arthritis. Popular forms of alternative and complementary therapies include:

  • Mind/body therapies, such as yoga and tai chi, which can help to decrease stress and inflammation in the body while increasing strength and flexibility.
  • Diet therapy. Many people report significant improvements their psoriatic arthritis symptoms after adopting a new diet, either by introducing new foods or cutting out others. One such diet is the paleo diet, which encourages the consumption of unprocessed meats, fruits, and vegetables, and discourages the consumption of grains.
  • Acupuncture, a form of traditional Chinese medicine that uses the insertion of needles at particular points around the body to restore the flow of bodily energy, or chi.
  • Herbal therapy, in the form of tea or extracts. Herbs that may help to lessen the severity of psoriatic arthritis symptoms include:
    • Turmeric, which has strong anti-inflammatory properties and can reduce swelling in the joints. Turmeric has blood-thinning properties and should not be used in excess, especially for patients with certain heart and blood conditions. Talk to your doctor before regularly consuming turmeric.
    • Mahonia Aquifolium, or Oregon Grape, which is strongly anti-microbial, can help to lessen flare-ups of psoriasis on the skin surface. 

Some alternative and complementary therapies interact dangerously with certain medications. Talk to your doctor before beginning any new treatment regimen

Care Guide

If you are caring for a loved one with psoriatic arthritis, consider the following:

  • Listen with open ears. Often the best trait in a caregiver is a willingness to listen. Be sure to take time to talk with your loved one about their feelings and concerns, and do your best to facilitate open communication.
  • Be flexible. Psoriatic arthritis may impose new limits on your loved one’s energy levels or mobility. To accommodate this, you may have to make modifications to the activities you previously enjoyed together, or find new things to enjoy. Do your best to remain flexible in habits old and new.
  • Read up on Psoriatic Arthritis, including its causes and treatments. This will make you an informed companion at doctors’ visits and will help you and your loved one to make the right decisions throughout the treatment process.
  • Minimize stress where you can for both you and your loved one. Stress can worsen the severity of psoriatic arthritis symptoms and lessen your capacity for caregiving.

When To Contact A Doctor

Mild joint pain can be a normal part of aging. However, if your joint pain becomes disruptive to daily life or is accompanied by skin rashes, itching, or flaking, you should contact your doctor and ask about psoriatic arthritis.

If you are currently undergoing treatment for psoriatic arthritis and experience any of the following, contact your doctor:

  • Fever
  • Nausea
  • Changes in appetite
  • Irregular heartbeat**
  • Excessive sweating
  • Worsening pain or swelling
  • Discoloration of the skin around the affected joints

** This may be a sign of a heart attack in combination with shortness of breath, chest pain, and numbness. Call 911 immediately

Questions For Your Doctor

To find a doctor near you, visit www.healthgrades.com.

To find an arthritis specialist, visit The American College of Rheumatology

To find a dermatologist, visit The American Academy of Dermatology

Questions For A Doctor

You may want to ask your doctor the following questions:

  • How severe is my psoriatic arthritis?
  • Which joints are affected?
  • What type of psoriatic arthritis do I have?
  • Am I likely to develop other health conditions related to my psoriatic arthritis?
  • What are the available treatment methods?
  • Are there complimentary treatment methods available?
  • Is my condition likely to progress?
  • Will I experience limitations to my physical mobility?