Psoriatic Arthritis

Psoriatic Arthritis Overview

Psoriatic arthritis is a form of inflammatory arthritis that can affect some of the millions of Americans who have psoriasis. Psoriasis is a skin disease that causes a red, scaly rash, most commonly over the elbows, knees, ankles, feet, hands, and other areas.

Are there different types of psoriatic arthritis?

There are five types of psoriatic arthritis. It is important to know which type of psoriatic arthritis you have and to understand the characteristics so that it may be treated properly.

Symmetric psoriatic arthritis: Symmetric arthritis affects the same joints — usually in multiple matching pairs — on opposite sides of the body. Symmetric psoriatic arthritis can be disabling, causing varying degrees of progressive, destructive disease and loss of function in 50% of people with this type of arthritis. Symmetric psoriatic arthritis resembles rheumatoid arthritis.

Asymmetric psoriatic arthritis: Asymmetric arthritis typically involves one to three joints in the body — large or small — such as the knee, hip, or one or several fingers. Asymmetric psoriatic arthritis does not affect matching pairs of joints on opposite sides of the body.

Distal interphalangeal predominant (DIP): Distal interphalangeal predominant psoriatic arthritis involves primarily the small joints in the fingers and toes closest to the nail. DIP psoriatic arthritis is sometimes confused with osteoarthritis, a chronic disease that causes the deterioration of joint cartilage and bone as well as bone spurs at the joints.

Spondylitis​:​ Spondylitis affects the spinal column and may cause inflammation and stiffness in the neck, lower back, spinal vertebrae, or sacroiliac region (pelvic area), making motion difficult. Spondylitis also can attack connective tissue, such as ligaments, or cause arthritic disease in the joints of the arms, hips, legs, or feet.

Arthritis mutilans: Arthritis mutilans is a severe, deforming, and destructive form of psoriatic arthritis that primarily affects the small joints in the fingers and toes closest to the nail. This leads to lost function of the involved joints. It also is frequently associated with lower back and neck pain. Fortunately, this type of psoriatic arthritis is rare.

Who is at risk for psoriatic arthritis?

Affecting men and women equally, about 10% to 30% of people with psoriasis develop psoriatic arthritis. Psoriatic arthritis may develop at any age, but usually affects people between the ages of 30 and 50. While the cause is not known, genetic factors, along with the immune system, likely play a role in determining who will develop the disorder.

As many as 40% of people with psoriatic arthritis have a family history of skin or joint disease. Having a parent with psoriasis triples the chance of getting psoriasis yourself and thus increases the chance of developing psoriatic arthritis.

What triggers psoriatic arthritis?

Certain factors may trigger psoriasis, including the following:

  • Injury to the skin: Injury to the skin has been associated with plaque psoriasis. For example, a skin infection, skin inflammation, or even excessive scratching can trigger psoriasis.
  • Sunlight: Most people generally consider sunlight to be beneficial for their psoriasis. However, a small minority find that strong sunlight aggravates their symptoms. A bad sunburn may worsen psoriasis.
  • Streptococcal infections: Some evidence suggests that streptococcal infections may cause a type of plaque psoriasis. These bacterial infections have been shown to cause guttate psoriasis, a type of psoriasis that looks like small red drops on the skin.
  • HIV : Psoriasis typically worsens after an individual has been infected with HIV. However, psoriasis often becomes less active in advanced HIV infection.

Drugs: A number of medications may aggravate psoriasis. Some examples are as follows:

Lithium: Drug used to treat bipolar disorder
Beta-blockers: Drugs used to treat high blood pressure
Antimalarials: Drugs used to treat malaria

Emotional stress: Many people see a worsening of their psoriasis when emotional stress is increased.

Smoking​:​ Cigarette smokers have an increased risk of chronic plaque psoriasis.

Alcohol: Alcohol is considered a risk factor for psoriasis, particularly in young to middle-aged men.

Hormone changes: The severity of psoriasis may fluctuate with hormonal changes. The disease frequency peaks during puberty and menopause. A pregnant woman’s symptoms are more likely to improve than worsen during pregnancy, if any changes occur at all. In contrast, symptoms are more likely to flare in the period after childbirth, if any changes occur at all.

What are the symptoms of psoriatic arthritis?

Symptoms include pain and swelling in the hands, wrists, elbows, shoulders, knees, ankles, feet, and spine; morning stiffness; and fatigue similar to that of rheumatoid arthritis(inflammatory arthritis). Psoriatic arthritis can also cause inflammation in other areas of the body, including the eyes.

How is psoriatic arthritis treated?

Treatment for psoriatic arthritis consists of twice daily moist heat or cold applications, exercises, and nonsteroidal anti-inflammatory drugs (NSAIDs). If there is little improvement or if there are permanent changes visible on an X-ray, then a disease-modifying antirheumatic drug (DMARD) or a biologic drug will be added to help prevent long-term joint damage. Enzyme inhibitors such as apremilast (Otezla) can also be prescribed to block proteins that cause the inflammation.

Is there a cure for psoriatic arthritis?

There is no cure for psoriatic arthritis. But use of biologic agents have made remission a real possibility.

An accurate and early diagnosis of psoriatic arthritis will help you avoid the damage and deformity it can cause.

Your doctor will make a decision based on:

  • Your symptoms
  • A physical exam
  • Your medical history and your family’s
  • Lab tests

No single thing will diagnose psoriatic arthritis, but blood tests, imaging, and other tests can help your doctor. He may want to give you certain tests that check for rheumatoid arthritis, because it can look a lot like psoriatic arthritis.

Along with your symptoms, the most telling signs are the skin and nail changes you get with psoriasis, or specific changes in your X-rays.

Symptoms and Family History

Psoriatic arthritis usually shows up between ages 30 and 50, but it may start in childhood. Both men and women get it. Many people have the skin disease psoriasis first.

Your doctor will look at your body and ask about the symptoms you’ve been having, which might include:

  • Joint pain, stiffness, and swelling
  • Fatigue
  • Tenderness, pain, or swelling where tendons and ligaments attach to bones
  • Swollen fingers or toes
  • Patches of red, itchy skin
  • Thick silver or gray scaly areas on your skin
  • Changes or problems with your fingernails or toenails
  • Redness and swelling in your eye

Both psoriasis and psoriatic arthritis are related to your genes, so if you have a close family member with these skin or joint problems, you’re more likely to have them, too.

Blood Tests

Erythrocyte sedimentation rate (sed rate or ESR) gives a rough idea of how much inflammation is in your body, which could be caused by psoriatic arthritis. But higher levels can come from other autoimmune diseases, an infection, a tumor, liver disease, or pregnancy, too.

Rheumatoid factor (RF) and anti-CCP antibody tests can rule out rheumatoid arthritis. People with that condition may have higher levels of these in their blood.

More than half of people who have psoriatic arthritis with spine inflammation will have the genetic marker HLA-B27. You can get tested to find out if you do.

People with psoriatic arthritis may have mild anemia, or not enough healthy red blood cells.

X-Rays

These can show cartilage changes or bone and joint damage that suggests arthritis in your spine, hands, or feet. Psoriatic arthritis usually looks different on X-rays than rheumatoid arthritis does.

Bone Density

Because psoriatic arthritis may lead to bone loss, your doctor may want to measure your bone strength. You could be at risk for osteoporosis and fractures.

Psoriatic arthritis can affect both the inside and outside of your body. The main goal of treatment is to control the inflammation that causes your joints to swell and ache. That will ease your pain and help prevent further damage.

Medications can often help manage psoriatic arthritis, but when they don’t, surgery might be an option. Your treatment will depend on how severe your condition is. You may need to try more than one thing before you and your doctor find what works.

NSAIDs

If your arthritis is mild, your doctor may recommend a non-steroidal anti-inflammatory drug (NSAID). It stops your body from making the chemicals that cause inflammation.

You can get NSAIDs over the counter and by prescription. The most common are aspirin, ibuprofen, and naproxen.

What’s good for your joints may be hard on other parts of your body, though. NSAID side effects can include heart attacks, strokes, stomachaches, ulcers, or bleeding — especially if you take large doses over a long time. To help, your doctor may prescribe a drug called misoprostol that will protect your stomach lining, or something that will lower acid and prevent ulcers, such as omeprazole.

You doctor may also suggest a different NSAID, celecoxib (Celebrex).

DMARDs and Biologics

If your disease is more severe or doesn’t respond well to NSAIDs, your doctor may prescribe a disease-modifying antirheumatic drug (DMARD). These can slow or stop pain, swelling, and joint and tissue damage. They’re stronger than NSAIDs, and they may take longer to work. The most commonly used DMARDs are:

  • Cyclosporine (Gengraf, Neoral, Sandimmune)
  • Leflunomide (Arava)
  • Methotrexate (Otrexup, Rasuvo, Rheumatrex, Trexall,​)
  • Sulfasalazine (Azulfidine)

If those don’t work, your doctor may prescribe a biologic. These are a newer type of DMARD. These medications block a protein that causes inflammation. They include:

  • Adalimumab (Humira)
  • Adalimumab-atto (Amjevita), a biosimilar to Humira
  • Certolizumab pegol (Cimzia)
  • Etanercept (Enbrel)
  • Etanercept-szzs (Erelzi), a biosimilar to Enbrel
  • Golimumab (Simponi)
  • Infliximab (Remicade)
  • Infliximab-dyyb (Inflectra), a biosimilar to Remicade
  • Ustekinumab (Stelara)

You can often take biologics as a shot under your skin, but for some, you’ll need to go to your doctor’s office to get the medicine through your vein (IV). You’ll probably also take methotrexate.

Biologics work well for many people, but they have downsides. They’re expensive, and they can have side effects and risks. You may get dizzy, feel sick like you’ve got a cold, or have a reaction where you get your shot.

They can also lower your immune system’s response. When you’re taking one, let your doctor know if you get the flu or another infection. You’ll be tested for tuberculosis (TB) before starting your biologic and checked while you’re on it. You’ll also get tested for hepatitis B and C.

A biologic can raise your chances of getting lymphoma, a blood cancer, although this is rare.

Enzyme Inhibitor

Apremilast (Otezla) is a new kind of drug for long-term inflammation diseases like psoriatic arthritis. It’s a pill that works by blocking a specific enzyme, a kind of protein, called PDE-4. That helps to slow other reactions that lead to inflammation.

You may lose weight when you’re taking it, so your doctor will want to watch how you’re doing. Other possible side effects include diarrhea, nausea, headache, and mood changes or depression.

Steroids

Corticosteroids are powerful anti-inflammatory drugs that relieve severe pain and swelling. You take them by mouth or inject them directly into a joint or muscle. They’re not the same as the muscle-building type of anabolic steroids.

Prednisone is a common steroid. It can help for a short time, but it might make the skin rash worse.

Doctors prescribe steroids only when you really need them. If you use them for a long time, you could have serious side effects such as brittle bones, weight gain, hypertension and diabetes.

Surgery

Most people with psoriatic arthritis will never need surgery. But when nothing else has worked, surgery can relieve pain, help an affected joint work, and allow you to move more.

A procedure called synovectomy removes the diseased lining of a joint. If the damage is very bad, you may need surgery to replace your joint, called arthroplasty. When a joint can’t easily be replaced, joint fusion might make it stronger, more stable, and less painful.

Turn on the evening news, and you’ll likely see the commercial with golfer Phil Mickelson talking about his psoriatic arthritis (PsA). It’s a type of swelling in the joints that happens in people who have psoriasis. That’s a skin condition that causes red, scaly (and itchy) patches on the elbows, knees or scalp. About 30% of the people who have psoriasis get PsA.

Could changing your diet help you feel better?

The Psoriasis​ ​Foundation says there’s no real evidence it’ll have a major impact. It did find that many people with psoriasis had milder symptoms when they ate healthier foods, though.

With that in mind, let’s look at some of the most popular diets and how they might help if you have psoriatic arthritis.

Weight Loss

This is a basic diet to help you shed extra pounds. A 2014 study found that people who were overweight had a greater risk for psoriatic disease. Another study found that people who lost weight had less-severe psoriasis. Doctors aren’t sure why this is, but they do know that fat tissue releases proteins that cause swelling.

In a weight-loss diet, you limit fats, sugars, and carbohydrates. You eat more fruits, vegetables, lean meats, and low-fat dairy items. When you lose weight, you’ll not only feel better — you’ll lower your risk for getting other diseases, too, like diabetes and high blood pressure.

Anti-Inflammatory

PsA causes swelling. So do certain foods, like fatty red meats, dairy, refined sugars, processed foods, and vegetables like potatoes, tomatoes, and eggplants.

Avoid them and choose fish, like mackerel, tuna, and salmon, which have omega-3 fatty acids. Those have been shown to reduce inflammation. Carrots, sweet potatoes, spinach, kale, and blueberries are good choices, too.

Paleo

Also called the “caveman diet,” this way of eating favors meat, fish, eggs, fruits, and vegetables. You’ll avoid all grains, beans, sugary snacks, and dairy (all items cavemen never ate).

Doctors have no proof that the Paleo diet stops the symptoms of PsA. But you could have less swelling because you’re not eating fatty foods and dairy products.

Gluten-Free

Research shows that as many as 25% of people with psoriasis may be sensitive to this protein that’s found in wheat and barley. It’s used in processed foods as a thickener. It’s not found in fruits and vegetables, rice, meat, beans, potatoes, and dairy.

Talk to your doctor before you start this diet. He may test your blood to see if you’re allergic to gluten.

Mediterranean

A 2014 study showed that eating a diet high in extra-virgin olive oil could make psoriasis symptoms less severe. That’s because it has omega-3s. It also contains oleocanthal, which relieves swelling. If you choose this way of eating, you’ll get to have lots of cold-water fish, whole grains, fruits, and vegetables.

Don’t get started with any of these diets until you get your doctor’s OK. That way he can keep track of the changes you’re making and determine whether they’ll help or worsen your PsA symptoms.

Also, get exercise along with any food changes you make. It’s good for your joints and will also ease swelling and arthritic pain.

You can soothe your psoriatic arthritis symptoms — or even stop them before they start — with a combo of exercise, medicines, and other treatments.

Your doctor can tell you exactly what you need to do. Chances are, these tactics will be high on his list, right next to taking your medicines.

Get Moving

Are you cautious about exercise? Get out there. Just make sure you stick with what your doctor says is OK for you — probably low-impact activities like walking, swimming, or biking. Make sure you pace yourself, too.

When you make exercise a habit, you can:

  • Ease arthritis symptoms.
  • Improve how you move.
  • Get stronger and more flexible.
  • Keep your weight healthy, which takes pressure off your joints.
  • Help your heart.
  • Boost your mood.
  • Give yourself more energy.

You can work out on your own or with the help of a physical therapist. Warm up first, so your muscles can ease into it.

One of your best options is water therapy, also called hydrotherapy or aqua therapy. It’s an exercise program held in a pool. The water takes some of the weight off your joints, so it may be easier for you to do well.

Whatever exercise you choose, make sure it’s one you’ll like enough to do it regularly. Also, try to be active throughout your day. You can garden, give the dog an extra walk, and fit in some stretches while you’re at your kid’s sports practice.

Use Hot and Cold

Moist heat can relax achy muscles and relieve stiffness and joint pain. You can use a warm towel, hot pack, or take a warm bath or shower.

Coldness can cut back on swelling and ease pain. You can cool down with a bag of ice or with frozen veggies wrapped in a towel.

3 Ways to Protect Your Joints

You don’t have to give up the things you love to do. Just look for ways to do them that take the stress off your joints.

The way you walk, sit, stand, or hold things can help. Change your position at work, at home, and throughout the day. Sit and stand up straight, and don’t arch your back. Good posture helps you feel better.

Make these three things a habit:

1. Pace yourself​:​ Switch between heavy, hard, or repetitive tasks and light or easy tasks. Make sure you take breaks.

2. Be kind to your joints​:​ Put as little stress on them as possible. Use larger, stronger joints when you can, instead of smaller ones. For example, wear a shoulder bag rather than a handheld purse.

3. Get an assist​:​ Many helpful devices — like canes, grab bars, extra-thick pens, luggage carts, or sit/stand stools — can make your day easier. Ask an occupational therapist which ones would help you.

It’s natural to have flare-ups, but then you’ll have times where you feel better. If you notice any new symptoms, tell your doctor. That’ll help keep things in check so you don’t have more joint damage. You can keep your symptoms under control with treatment.​

For more information, please visit our LEARN section.​

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