Psoriatic Arthritis

There are several different types of psoriatic arthritis, including:

• Arthritis mutilans, which is the most severe form of psoriatic arthritis. It is much less common than other forms of psoriatic arthritis and affects the fewest number of people.

• Asymmetric psoriatic arthritis, which is the second most common type of psoriatic arthritis. This is often a mild form of psoriatic arthritis that affects joints on one side of the body and possibly different joints on the other side.

• Distal psoriatic arthritis, which affects the ends of the fingers and toes. Often the fingernails and toenails are also affected. Dactylitis, also known as “sausage digits,” occurs when an entire finger or toe becomes swollen.

• Enthesitis, which is inflammation where tendons and ligaments insert into the bone. This condition often affects the foot, heel, ribs, spine and pelvis.

• Spondylitis, which is inflammation in the spinal column

• Symmetric psoriatic arthritis, which is the most common type of psoriatic arthritis. This condition affects the same joints on both sides of the person’s body (symmetrically) at the same time.

Systemic psoriatic arthritis symptoms can mimic those of rheumatoid arthritis. Symptoms of asymmetric psoriatic arthritis may be mistaken for osteoarthritis. Also, psoriatic arthritis symptoms appear differently in every person. Sometimes the symptoms are mild, and sometimes they’re severe. They may come on slowly or suddenly. Many people experience flares, which are times when symptoms become much worse, and then periods of remission.

The most common symptoms of psoriatic arthritis are:

• Fatigue

• Foot or heel tenderness

• Intermittent or constant joint pain, especially accompanied by warmth or swelling

• Morning joint stiffness

• Neck or lower back pain or stiffness

For individuals with psoriasis as well, symptoms include:

• Crumbling or powdery nails, or nails lifting from the nail bed

• Thickened, red patches of skin covered with white or silvery scales

Many people also have other symptoms that are unlike those experienced with rheumatoid arthritis. These include:

• Dramatically swollen fingers and toes, often characterized as “sausage-like”

• Inflammation and pain inside the eye (uveitis)

For some people, the signs and symptoms of PsA arise before they ever have exhibited any symptoms of skin psoriasis. When this happens, it usually affects people with multiple relatives who have psoriasis or arthritis.

If you have a personal or family history of psoriasis, be alert for these early symptoms of psoriatic arthritis:

• Fingernail pitting or separation of the fingernails or toenails from the nail bed

• Heel tenderness or pain along the bottom of the foot

• Intermittent joint pain and swelling

• Joint redness or warmth, especially if accompanied by sausage-like swelling of the fingers or toes

• Lower back or neck pain and stiffness

• Morning joint stiffness, particularly in the fingers and toes

• Tiredness that never goes away

Because some of these symptoms are shared by conditions like osteoarthritis or rheumatoid arthritis, see a specialist—typically a rheumatologist—for an accurate diagnosis. The treatment plans for these types of arthritis differ significantly, and early diagnosis can lead to treatment with the greatest chance of success. If you also have skin symptoms, you may be under the care of a dermatologist as well.

The exact cause of psoriatic arthritis is not known. The inflammation of the disorder is caused by the body’s immune system mistakenly attacking healthy joint tissues.

The Streptococcus family of bacteria that causes illnesses like strep throat represents one known trigger of psoriatic arthritis. Once triggered, the immune system then inappropriately attacks healthy joint tissue, causing pain, stiffness and swelling.

Nearly half of people who develop PsA have relatives with either psoriasis or arthritis, which may suggest psoriatic arthritis can be inherited. Certain variations of genes within the so-called HLA gene complex or other specific genetic mutations increase the risk of psoriatic arthritis. These variations can be inherited and passed down from one generation to the next. Lifestyle or environmental factors (such as a past infection) not related to your genetics are thought to play a role as well.

Certain risk factors can increase your chances of developing psoriatic arthritis. These risk factors include:

• Age between 30 and 50, although children can develop the condition, too.

• Caucasian ethnicity, though people of all ethnicities can develop the condition.

• Family history of psoriasis or psoriatic arthritis

• Skin psoriasis. Up to 30% of people with psoriasis develop psoriatic arthritis, but the incidence may be lower depending on diagnosis variables.

While there is no way to prevent psoriatic arthritis, you can take steps to reduce the number and severity of your flares. You can help minimize psoriatic arthritis symptoms by taking these steps:

• Eating a diet with foods that reduce inflammation, such as fatty fish, berries, olive oil, and beans

• Exercising and stretching regularly

• Getting quality sleep

• Maintaining a healthy weight

• Reducing stress

• Staying up-to-date on your psoriasis medication and following your doctor’s treatment plan

If your doctor or dermatologist suspects you may have psoriatic arthritis, he or she may recommend you see a rheumatologist. These specialists excel at diagnosing autoimmune diseases like PsA. There is no specific test for psoriatic arthritis. Instead, doctors make a diagnosis based on a combination of factors, and by ruling out other conditions.

Your doctor will perform a physical examination to look for symptoms, such as joint pain, stiffness, warmth, swelling, and nail changes. He or she will consider your medical history, including the frequency and progression of your symptoms, as well as any family history of psoriasis or psoriatic arthritis.

You likely will undergo imaging scans (X-rays, MRI) to check for joint damage, as well as simple blood tests to rule out diseases with similar symptoms, such as gout and rheumatoid arthritis (RA). The presence of rheumatoid factor (RF) in blood test results often indicates RA; most patients with psoriatic arthritis are RF-negative.

The goal of psoriatic arthritis treatment is to preserve joint health and reduce inflammation and joint pain. Your treatment plan will depend upon the type and severity of your psoriatic arthritis, as well as your overall health.

Medications represent the primary treatment for psoriatic arthritis. These include:

• Biologic drugs to block, or at least dampen the disease process. Biologics are not a cure for psoriatic arthritis, but they reduce the body’s ability to produce certain immune compounds that promote inflammation. Biologics for psoriatic arthritis include TNF-alpha inhibitors, such as adalimumab (Humira) and certolizumab (Cimzia); PDE4 inhibitors, such as apremilast (Otezla); and drugs that target specific interleukins, such as secukinumab (Cosentyx). These drugs carry a significant adverse event profile and can lead to potentially life-threatening complications. Doctors turn to biologic drugs when more conservative treatments are not sufficient and the patient is found to be a good candidate for a specific targeted therapy.

• Corticosteroid injections to reduce joint inflammation and pain when nonsteroidal anti-inflammatory drugs (NSAIDs) don’t work or do not provide enough pain relief

• Disease-modifying antirheumatic drugs (DMARDs) like methotrexate or cyclosporine to reduce inflammation and decrease joint damage. Doctors begin DMARDs primarily if other treatments are not adequate.

• Over-the-counter NSAIDs like ibuprofen or naproxen, which are often the initial treatment of choice for psoriatic arthritis

• Small-molecule inhibitors target enzymes involved in the body’s inflammatory response. Examples include apremilast (Otezla), approved in 2015 for people with psoriatic arthritis, and tofacitinib (Xeljanz), approved in late 2017 for adults with active disease. Both drugs, which come in pill form, show improvement in joint pain and swelling.

Exercise is important for maintaining joint range of motion, no matter what type of arthritis you have. A physical therapist can teach you how to isolate and strengthen certain muscles to give your joints a boost and help you move.

If you’re diagnosed with psoriatic arthritis, your doctor may also recommend certain lifestyle changes to reduce your risk of experiencing cardiac effects or diabetes. Anyone with psoriasis or psoriatic arthritis should eat a heart-healthy diet including foods that reduce inflammation and achieve a healthy body weight to maintain a high quality of life.

As a complement to your medical treatment, some alternative therapies can help ease symptoms of psoriatic arthritis. Always talk to your doctor before starting complementary treatments to discuss any possible risks and how to mitigate them.

Alternative medicine for psoriatic arthritis may include:

• Acupuncture, which has been reported to relieve symptoms of several chronic pain conditions. Make sure to find a licensed, experienced acupuncturist.

• Massage, which can help stretch muscles and ease stiff joints. Tell the massage therapist about your psoriatic arthritis and, if you also have psoriasis, explain that it is not contagious.

• Physical therapy, which your doctor may recommend along with medical treatment. Rehabilitation can help you maintain mobility and learn coping skills to continue activities of daily life.

Left untreated, psoriatic arthritis can permanently damage joints. It also puts you at risk for certain other medical conditions, including type 2 diabetes and cardiovascular disease. Thankfully, there are several medications for psoriatic arthritis that improve joint pain and swelling and reduce the potential for joint damage.

Although some psoriatic arthritis medicines have side effects, your doctor will tailor the dose to your specific symptoms and intensity of the disease. In this way, you are not taking more medicine than you need for symptom relief and good quality of life. Still, discuss the risks and benefits of any psoriatic arthritis treatment with your doctor. Some people experience few or no medication side effects, and others experience very mild complications that pass. Your doctor will work with you to develop a treatment plan with the fewest risks and highest benefits.