It is important for your overall care and health to be informed about psoriatic arthritis (PsA).
The more you know about PsA, the better you can work with your rheumatologist and other care providers to manage it. It is your condition, and you should understand it. Use this information as a stepping stone to have informed and empowered conversations with your doctor to take part in shared decision-making.
Psoriatic arthritis (PsA) is a type of inflammatory arthritis that can occur in some patients with psoriasis. It is a chronic inflammatory disorder in which the body’s own immune system attacks its own tissues including the joints and skin. Usually, our immune system uses inflammation to fight off disease or heal an injury, then shuts off the inflammation — but in psoriatic arthritis it doesn’t shut off. This results in scaly patches on the skin, and painful, stiff, and swollen joints. However, PsA is not just a joint or skin disease. Inflammation from immune system overactivity can affect many other parts of the body.
Psoriasis and psoriatic arthritis are distinct conditions, but they are connected. In fact, data show that up to 30 percent of people with psoriasis will go on to develop PsA and 85 percent of people with PsA also have skin psoriasis.
The disease usually strikes first between the ages of 30 and 50 but it can begin as early as childhood. Because PsA is chronic, it is long-lasting and usually doesn’t go away on its own, so you may need to be treated for the rest of your life.
Symptoms of PsA may be obvious or not, and can sometimes mimic and be mistaken for other conditions, especially in the early stages. The symptoms of psoriatic arthritis may develop slowly or appear rapidly. While it may take a while to suspect that PsA is the cause of your symptoms, recognizing your symptoms is the first step to managing them.
Symptoms of PsA can be different for each person, but there are common symptoms that affect nearly all patients. Some are specific to the joints and skin, while others are most systemic. Consider joining ArthritisPower, a patient research registry and symptom tracker that allows you to track your symptoms to discuss with your doctor.
Psoriatic Arthritis Symptoms
● Joint pain, swelling, redness (can affect any joint butmost common in fingers, wrists, hands, knees, feet, and ankles)
● Stiffness, which is typically worse in morning or afterprolonged periods of rest
● Fatigue or general lack of energy
● Eye pain and/or swelling (uveitis, iritis)
● Dactylitis, or puffy, swollen (sausage-like) fingers and toes
● Pitting or crumbly areas on your finger nails or toe nails
● Pain, swelling, and tenderness at your entheses — areas where tendons or ligaments attach to bones
● Stiffness and pain in the spine, neck, lower back, or hips
● Psoriasis, or silvery, scaly patches of skin found on your knees, elbows, scalp, or lower back
Types of Psoriatic Arthritis
● Asymmetric oligoarthritis: affects different joints on each side. Symptoms can range from very mild to severe, and any joint can be affected.
● Symmetric polyarthritis: affects the same joints on the left and right sides of the body. This is the most common type of PsA, occurring in roughly half of people with the condition.
● Distal arthritis: impacts the end joints of your fingers and toes (the distal interphalangeal joints), and can cause nail changes.
● Spondyloarthritis: symptoms of the spondylitis type of PsA include stiffness, pain, and impaired movement in the neck and spine. Other joints may also be involved.
● Arthritis mutilans: causes inflammation and damage to the joints of the hands and feet, resulting in bone loss, or osteolysis, in those joints.
There’s no single cause of psoriatic arthritis. As with other inflammatory and autoimmune conditions, it’s generally considered to result from a combination of genetic and environmental factors. Here’s a look at some of the most important PsA risk factors.
Psoriatic arthritis can be tricky to diagnose, as there is no single test to diagnose PsA. To figure out what’s causing your symptoms and whether or not you have PsA, your doctor will likely consider a few areas listed below. The more information you can supply your doctor about your symptoms and medical history, the better.
Medical history
Your doctor might ask you about the onset of your symptoms, when they get better or worse, if you have other inflammatory conditions, and if there is a family history of relatives with psoriatic arthritis, psoriasis or other inflammatory or autoimmune conditions.
Physical exam
Your doctor will be looking for signs of swollen and painful joints, certain patterns of arthritis, and skin and nail changes typical of psoriasis. They may physically feel for tenderness in certain joints and places around your body.
Your doctor may order various blood tests for a more complete picture of your PsA. Some include:
Imaging tests
X-rays can help in detecting joint damage from PsA but may be normal in early stages. MRI and ultrasound scanning can be done to help confirm or judge the severity of PsA. Occasionally skin biopsies (small samples of skin removed for analysis)are needed to confirm psoriasis.
While there is no cure for PsA, there are a variety of very effective treatments available to reduce inflammation, relieve symptoms, and help you function better in everyday life. Early treatment for PsA is key to avoid joint damage. Many patients will require a combination of medications and may go through a trial and error process to find the right ones for them. Many patients will also need to change their treatment regimen over time.
Here’s a look at how different kinds of PsA medications work to help manage your disease:
Nonsteroidal anti-inflammatory (NSAIDs) like ibuprofen (Motrin, Advil) and naproxen sodium (Aleve) can be used for pain relief but don’t prevent joint damage.
Glucocorticoids (steroids), also called corticosteroids or “steroids,” can be used short-term for relief of pain and/or swelling during PsA flares or as a bridge between disease-modifying treatments. Careful conversation with your rheumatologist is recommended to evaluate the risk and benefit of long-term use of glucocorticoids for PsA. Glucocorticoids can be taken as an injection or orally.
Disease-modifying antirheumatic drugs, or DMARDs. DMARDS help stop the underlying disease process driving PsA inflammation. The most commonly used DMARD for PsA is methotrexate.
Conventional DMARDs include pills such as sulfasalazine (Azulfidine), leflunomide (Arava), Imuran (Azathioprine), Hydrozxychloroquine (Plaquenil), Cyclosporine (Neoral, Sandimmune), and methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo) which comes in pill and injection form. It’s important to note that DMARDs are controversial with PsA and don’t have a favorable impact as in other diseases like RA. However, your doctor may think they are important for you.
Biologic DMARDs
Biologic DMARDs can reduce inflammation and pain by targeting specific pathways in the immune system.
TNFi biologics can reduce inflammation and pain by targeting tumor necrosis factor proteins (TNF)that send signals to your body to turn on inflammation. TNFi biologics include adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel),golimumab (Simponi, Simponi Aria), and infliximab (Remicade).
Other biologics:
These block other immune system signals that turn on inflammation and pain. For PsA, these medications include abatacept (Orencia) , ustekinumab (Stelara), guselkumab (Tremfya), risankizumab (Skyrizi), secukinumab (Cosentyx), ixekizumab (Taltz), brodalumab (Siliq), anakinra (Kineret) apremilast (Otezla), baricitinib (Olumiant), tofacitinib (Xeljanz), and upadacitinib (Rinvoq).
Biosimilars have become available in recent years. As their name implies, these drugs are very similar to the original biologic drugs they are made to resemble. Biosimilars available for PsA include Infliximab-dyyb (Inflectra), Infliximab-abda (Renflexis), Infliximab-axxq (Avsola). More biosimilars will be available coming soon.
Here are some additional articles to help you understand the symptoms, causes, diagnosis, and treatment for psoriatic arthritis.
https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Psoriatic-Arthritis
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-psoriatic-arthritis
https://medlineplus.gov/genetics/condition/psoriatic-arthritis/
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