Psoriatic Arthritis

  • Medical Author:
    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

  • Medical Editor: Catherine Burt Driver, MD
    Catherine Burt Driver, MD

    Catherine Burt Driver, MD

    Catherine Burt Driver, MD, is board certified in internal medicine and rheumatology by the American Board of Internal Medicine. Dr. Driver is a member of the American College of Rheumatology. She currently is in active practice in the field of rheumatology in Mission Viejo, Calif., where she is a partner in Mission Internal Medical Group.

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Psoriatic arthritis facts

  • Psoriatic arthritis is a chronic disease characterized by a form of inflammation of the skin (psoriasis) and joints (inflammatory arthritis).
  • Some 15%-25% of people with psoriasis also develop inflammation of joints (psoriatic arthritis).
  • The first appearance of the skin disease (psoriasis) can be separated from the onset of joint disease (arthritis) by years.
  • Psoriatic arthritis symptoms and signs include
  • Psoriatic arthritis belongs to a group of arthritis conditions that can cause inflammation of the spine (spondyloarthropathies).
  • People with psoriatic arthritis can develop inflammation of tendons, cartilage, eyes, lung lining, and, rarely, the aorta.
  • The arthritis of psoriatic arthritis is treated independently of the psoriasis, with exercise, ice applications, medications, and surgery.

What is psoriatic arthritis?

Psoriatic arthritis is a chronic disease characterized by a form of inflammation of the skin (psoriasis) and joints (inflammatory arthritis). Psoriasis is a common skin condition affecting 2% of the Caucasian population in the United States. Signs and symptoms include patchy, raised, red areas of skin inflammation with scaling. Psoriasis often affects the tips of the elbows and knees, the scalp and ears, the navel, and around the genital areas or anus. Approximately 15%-25% of patients who have psoriasis also develop an associated inflammation of their joints. Patients who have inflammatory arthritis and psoriasis are diagnosed as having psoriatic arthritis.

Psoriatic arthritis can cause swollen, red, and painfully inflamed joints.
Psoriatic arthritis can cause swollen, red, and painfully inflamed joints.

The onset of psoriatic arthritis generally occurs in the fourth and fifth decades of life. Males and females are affected equally. The skin disease (psoriasis) and the joint disease (arthritis) often appear separately. In fact, the skin disease precedes the arthritis in nearly 80% of people. However, the arthritis may precede the psoriasis in up to 15% of patients. In some patients, the diagnosis of psoriatic arthritis can be difficult if the arthritis precedes psoriasis by many years. In fact, some patients have had arthritis for over 20 years before psoriasis eventually appears! Conversely, patients can have psoriasis for over 20 years prior to the development of arthritis, leading to the ultimate diagnosis of psoriatic arthritis.

Psoriatic arthritis is a systemic rheumatic disease that also can cause inflammation in body tissues away from the joints other than the skin, such as in the eyes, heart, lungs, and kidneys. Psoriatic arthritis shares many symptoms with several other arthritic conditions, such as ankylosing spondylitis, reactive arthritis, and arthritis associated with Crohn's disease and ulcerative colitis. All of these health conditions can cause inflammation in the spine and other joints, and the eyes, skin, mouth, and various organs. In view of their similarities and tendency to cause inflammation of the spine, these health conditions are collectively referred to as "spondyloarthropathies."

Picture of the inflammation of spondyloarthropathy

Quick GuidePsoriatic Arthritis Symptoms, Treatment, Images

Psoriatic Arthritis Symptoms, Treatment, Images
Learn about psoriatic arthritis signs and symptoms.

Psoriatic Arthritis Symptoms and Signs

Psoriatic arthritis symptoms and signs include

  • joint aches and stiffness,
  • joint swelling,
  • joint warmth and redness,
  • joint pain and tenderness,
  • loss of range of motion of the affected joints.

If the spine is affected, there can be pain and stiffness in the low back, buttocks, neck, and upper back. Tendons can also become inflamed, and if Achilles tendinitis is present, other symptoms can include limping, pain with walking, and pain with climbing stairs. Enthesitis, or the inflammation of the areas at which ligaments and tendons meet the bone, is often a feature of psoriatic arthritis.

What causes psoriatic arthritis?

The cause of psoriatic arthritis is currently unknown. A combination of genetic, immune, and environmental factors is likely involved. In patients with psoriatic arthritis who have arthritis of the spine, a blood test gene marker called HLA-B27 is found in about 50%. Several other genes have also been found to be more common in patients with psoriatic arthritis. Certain changes in the immune system may also be important in the development of psoriatic arthritis. For example, the decline in the number of immune cells called helper T cells in people with AIDS (HIV infection) may play a role in the development and progression of psoriasis in these patients. The importance of infectious agents and other environmental factors in the cause of psoriatic arthritis is being investigated by researchers.

What are risk factors for developing psoriatic arthritis?

The major risk factor for developing psoriatic arthritis is having a family member with psoriasis. This relationship has been recognized as so significant that it is used as a helpful part of the health history for the doctor to aid in the diagnosis of psoriatic arthritis. It might be that stressful life situations could affect the immune system, allowing for the expression and/or exacerbation of psoriatic arthritis. However, precisely how these emotional issues are related to psoriatic arthritis has not been established.

What are the different types of psoriatic arthritis?

The type of psoriatic arthritis depends on the distribution of the joints affected. Accordingly, there are five types of psoriatic arthritis: symmetrical (both sides of the body), asymmetric and few joints, spondylitis, distal interphalangeal joints, and arthritis mutilans.

What are psoriatic arthritis symptoms and signs?

In most patients, the psoriasis precedes the arthritis by months to years. There can be tiny pitting nail changes of the finger and toenails. The type of psoriatic arthritis depends on the distribution of the joints affected. Accordingly, there are five types of psoriatic arthritis: symmetrical, asymmetric and few joints, spondylitis, distal interphalangeal joints, and arthritis mutilans.

The arthritis frequently involves the knees, ankles, and joints in the feet. Usually, only a few joints are inflamed at a time. The inflamed joints become painful, stiff, swollen, hot, tender, and red. There is usually loss of range of motion of the involved joints. Sometimes, joint inflammation in the fingers or toes can cause swelling of the entire digit, giving them the appearance of a "sausage." Joint stiffness is a common symptom and is typically worse early in the morning. Less commonly, psoriatic arthritis may involve many joints of the body in a symmetrical fashion, mimicking the pattern seen in rheumatoid arthritis. Psoriatic arthritis can also cause inflammation of the spine (spondylitis) and the sacrum, causing symptoms like pain and stiffness in the low back, buttocks, neck, and upper back. Occasionally, psoriatic arthritis involves the small joints at the ends of the fingers. A very destructive, though less common, form of arthritis called "mutilans" can cause rapid damage to the joints. Fortunately, this form of arthritis is rare in patients with psoriatic arthritis.

Patients with psoriatic arthritis can also develop inflammation of the tendons (tendinitis), tendon insertion points on bone (enthesitis), and around cartilage. Inflammation of the tendon behind the heel causes Achilles tendinitis, leading to pain with walking and climbing stairs. Inflammation of the chest wall and of the cartilage that links the ribs to the breastbone (sternum) can cause chest pain, as seen in costochondritis.

Aside from arthritis and spondylitis, psoriatic arthritis can cause fatigue and inflammation in other organs, such as the eyes, lungs, and aorta. Inflammation in the colored portion of the eye (iris) causes iritis, a painful health condition that can be aggravated by bright light as the iris opens and closes the opening of the pupil. Corticosteroids injected directly into the eyes are sometimes necessary to decrease inflammation and prevent blindness. Inflammation in and around the lungs (pleuritis) causes chest pain, especially with deep breathing as the lungs expand against the inflamed areas, as well as shortness of breath. Inflammation of the aorta (aortitis) can cause leakage of the aortic valves, leading to heart failure and shortness of breath.

In a majority of patients, psoriatic arthritis causes swelling and inflammation of the fingers and pitting and ridges in the fingernails.
In a majority of patients, psoriatic arthritis causes swelling and inflammation of the fingers and pitting and ridges in the fingernails.

Acne and nail changes are symptoms commonly seen in psoriatic arthritis. Pitting and ridges are seen in fingernails and toenails of 80% of patients with psoriatic arthritis. Interestingly, these characteristic nail changes are observed in only a minority of psoriasis patients who do not have arthritis. Acne has been noted to occur in higher frequency in patients with psoriatic arthritis. In fact, a syndrome exists that features inflammation of the joint lining (synovitis), acne, pustules on the feet or palms, thickened and inflamed bone (hyperostosis), and bone inflammation (osteitis). This syndrome is, therefore, named by the eponym SAPHO syndrome.

Quick GuidePsoriatic Arthritis Symptoms, Treatment, Images

Psoriatic Arthritis Symptoms, Treatment, Images

What types of doctors treat psoriatic arthritis?

Psoriatic arthritis is generally treated by rheumatologists, health specialists in diagnosing and treating arthritis and autoimmune diseases. Other doctors who may be involved in the care of patients with psoriatic arthritis include dermatologists and primary-care doctors, including family and general practitioners and internal medicine specialists. When surgical treatment is needed for severe joint disease, orthopedic surgeons can be consulted. Other health care givers can include occupational and physical therapists.

How does a health care professional diagnose psoriatic arthritis?

Psoriatic arthritis is a diagnosis made mainly on clinical grounds, based on the finding of psoriasis and the typical inflammatory arthritis of the spine and/or other joints. There is no laboratory test to diagnose psoriatic arthritis. Blood tests such as sedimentation rate may show an abnormal elevated result and merely reflect presence of inflammation in the joints and other organs of the body. Other blood tests, such as rheumatoid factor, are obtained to exclude rheumatoid arthritis. When one or two large joints (such a knees) are inflamed, arthrocentesis can be performed. Arthrocentesis is an office procedure whereby a sterile needle is used to withdraw (aspirate) fluid from the inflamed joints. The fluid is then analyzed for inflammation, infection, gout crystals, and other inflammatory conditions. X-rays may show changes of cartilage or bone injury indicative of arthritis of the spine, sacroiliac joints, and/or joints of the hands. Typical X-ray findings include bony erosions resulting from arthritis, but these may not be present in early disease. MRI scanning is sometimes used to identify early erosion of joints. The blood test for the genetic marker HLA-B27, mentioned above, is often performed. This marker can be found in over 50% of patients with psoriatic arthritis who have spine inflammation.

What is the treatment for psoriatic arthritis?

The medical treatment of the arthritis aspects of psoriatic arthritis is described below. The treatment of psoriasis and the other involved organs is beyond the scope of this article.

Generally, the treatment of arthritis in psoriatic arthritis involves a combination of anti-inflammatory medications (NSAIDs) and exercise. If progressive inflammation and joint destruction occur despite NSAIDs treatment, more potent medications such as methotrexate (Rheumatrex, Trexall), corticosteroids, and antimalarial medications (such as hydroxychloroquine [Plaquenil]) are used.

Exercise programs can be done at home or with a physical therapist and are customized according to the disease and physical capabilities of each patient. Warm-up stretching, or other techniques, such as a hot shower or heat applications are helpful to relax muscles prior to exercise. Ice application after the routine can help minimize post-exercise soreness and inflammation. In general, exercises for arthritis are performed for the purpose of strengthening and maintaining or improving joint range of motion. They should be done on a regular basis for best results.

Non-steroidal anti-inflammatory drugs (NSAIDs) are a group of medications that are helpful in reducing joint inflammation, pain, and stiffness. Examples of NSAIDs include aspirin, indomethacin (Indocin), tolmetin sodium (Tolectin), sulindac (Clinoril), and diclofenac (Voltaren). Their most frequent side effects include stomach upset and ulceration. The drugs can also cause gastrointestinal bleeding. Newer NSAIDs called COX-2 inhibitors (such as celecoxib [Celebrex]) cause gastrointestinal problems less frequently.

Quick GuidePsoriatic Arthritis Symptoms, Treatment, Images

Psoriatic Arthritis Symptoms, Treatment, Images

Disease-modifying antirheumatic drugs for psoriatic arthritis

Patients who experience progressive joint destruction in spite of NSAIDs are candidates for more aggressive disease-modifying drugs. Disease-modifying medications are important to prevent progressive joint destruction and deformity. These drugs include methotrexate, which is used orally or can be given by injection on a weekly basis for psoriatic arthritis as well as for psoriasis alone. It can cause bone-marrow suppression, as well as liver damage with long-term use. Regular monitoring of blood counts and liver blood tests should be performed during therapy with methotrexate.

Antimalarial medication, such as hydroxychloroquine (Plaquenil), is also used for persistent psoriatic arthritis. Its potential side effects include injury to the retina of the eye. Regular ophthalmologist examinations are suggested while using this medication.

Sulfasalazine (Azulfidine) is an oral sulfa-related medicine that has also been helpful in some patients with persistent psoriatic arthritis. Traditionally, Azulfidine has been an important agent in the medical treatment of ulcerative and Crohn's colitis. It should be taken with food, as it, too, can cause gastrointestinal upset.

Medical research has demonstrated effective treatment of both psoriasis and psoriatic arthritis with leflunomide (Arava), a medication that is also used for the treatment of rheumatoid arthritis.

Medications that block the chemical messenger known as tumor necrosis factor (TNF) are another treatment option for moderate to severe psoriatic arthritis. The TNF-blockers etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), golimumab (Simponi), and certolizumab pegol (Cimzia) are also referred to as biologic medications and can be very effective for severe psoriatic arthritis. They can significantly improve or eradicate both the psoriasis and the arthritis as well as stop progressive joint damage. These medications are given intravenously or by injections. There is an increased risk of infection while taking biologic medications and patients are screened for underlying tuberculosis prior to TNF-blocker administration.

Ustekinumab (Stelara) is an injectable biologic medication that is used to treat severe plaque psoriasis and psoriatic arthritis with or without methotrexate. This biologic works by blocking chemical messengers called interleukins. There is an increased risk of infections while taking ustekinumab.

Apremilast (Otezla) is an oral medicine approved for the treatment of patients with moderate to severe plaque psoriasis for whom phototherapy or systemic therapy is appropriate and for the treatment of adult patients with active psoriatic arthritis. Apremilast works by inhibiting an enzyme called phosphodiesterase 4 (PDE4). Apremilast can have side effects, including an increase in depression and gastrointestinal upset such as diarrhea and nausea.

Secukinumab (Cosentyx) is an injectable biologic medication used to treat adults with psoriatic arthritis. Secukinumab is an antibody that binds to and blocks interleukin 17, an important chemical messenger in the inflammation of the skin in psoriasis and the joints in psoriatic arthritis. After a month of weekly loading injections, it is given monthly, or by monthly injections from the start according to the doctor's discretion.

Corticosteroids are potent anti-inflammatory agents. Corticosteroids can be given by mouth (such as prednisone) or injected (cortisone) directly into the joints to reduce inflammation. Steroids can have side effects, especially with long-term use. These include thinning of the skin, easy bruising, infections, diabetes, osteoporosis and, rarely, bone death (necrosis) of the hips and knees.

While the relationship between the skin disease and joint disease is not clear, there are reports of improvement of the arthritis simultaneously with clearing of the psoriasis. Patients with psoriasis can benefit by direct sunlight exposure and are often treated with direct ultraviolet light therapy.

Finally, patients who have severe destruction of the joints may be candidates for orthopedic surgical repair. Total hip joint replacement and total knee joint replacement surgery are now commonplace in community hospitals throughout the United States.

What are psoriatic arthritis complications?

Psoriatic arthritis can be complicated by issues within the skin or the joints. The skin of psoriasis can become infected and require antibiotic treatments. The joints can become destroyed, deformed, and functionless. With aggressive medical treatment, however, these complications are generally avoidable. Psoriatic arthritis with eye, bowel, lung, or heart-valve inflammation can be complicated by disease in these areas. The degree of any injury depends on the location, the intensity, and duration of the inflammation.

What is the prognosis of psoriatic arthritis?

With aggressive treatment and monitoring of both the skin and the joints, patients can have an excellent outcome. It is particularly important to begin treatments early in the course of the arthritis for best results. Newer biologic medications can be extremely effective for those whose disease fails to respond to methotrexate or who cannot take it.

Is it possible to prevent psoriatic arthritis?

There is no method for the prevention of psoriatic arthritis. It is best to treat the skin optimally. Treatments that control the disease, in a sense, prevent recurrence of the arthritis. Because when they are discontinued, the inflammatory joint disease typically recurs.

Is there a psoriatic arthritis diet? Are there home remedies for psoriatic arthritis?

It has been shown that vitamin D might improve the arthritis of psoriatic arthritis. Research has shown this to be a helpful dietary modification. There is no other universally effective diet, or foods to avoid, for psoriatic arthritis. There are also no dependable home remedies for psoriatic arthritis. However, vitamin D supplementation may be beneficial for both the skin and joints. In Europe, people have bathed in the Dead Sea for psoriasis treatment.

What does the future hold for patients with psoriatic arthritis?

The future treatment of psoriatic arthritis will evolve as more effective and safe medicines are developed. Areas of clinical research involve treatment with medications that can alter the immune systems of patients with psoriatic arthritis. As the immune system changes and genetics are better defined in this illness, the efficacy of medical treatments will improve.

For more information about psoriatic arthritis, please visit the following site: National Psoriasis Foundation (http://www.psoriasis.org/).

REFERENCE:

Firestein, Gary S., et al. Kelley's Textbook of Rheumatology, 9th Edition. Philadelphia, PA: Saunders, 2013.

Last Editorial Review: 8/15/2017

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Reviewed on 8/15/2017
References
REFERENCE:

Firestein, Gary S., et al. Kelley's Textbook of Rheumatology, 9th Edition. Philadelphia, PA: Saunders, 2013.

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