Psoriatic Arthritis

In this section, you or a loved one can find out more about medical treatments, research studies and practical information about psoriatic arthritis. Read on to find answers to some of your questions as well as links to other information. Being informed is an important first step towards becoming an active decision-maker in your care plan.

Psoriatic arthritis (PsA) is a form of arthritis that develops in up to 30% of people who have psoriasis. Psoriasis is an inflammatory condition characterised by the rapid overproduction of skin cells. In psoriasis, as underlying cells reach the skin's surface and die they result in lesions called plaques that are red and often covered with loose, silver-coloured scales; these lesions may be itchy and painful, and they sometimes crack and bleed. PsA is characterised by psoriasis and inflammation of joints which results in pain, swelling and stiffness. Inflammation leading to pain and swelling of the areas where tendons and ligaments insert into bone (called entheses) can also occur. PsA-related inflammation can affect various parts of your body, including your fingers, toes and back, and can range from relatively mild to severe. PsA symptoms may come and go, and you may experience flare-ups when your symptoms are worse than usual.

There is no cure for psoriatic arthritis so treatment focuses on controlling symptoms and slowing joint damage. Without treatment, the chronic inflammation of psoriatic arthritis can cause progressive damage to joints, leading to disability.

The exact cause of PsA is not known, but genetics, immune system dysfunction and environmental factors may each contribute to the development of PsA. Some people may have genes that make them more likely to develop PsA – although simply having these genes does not mean the disease will develop. However, someone who has a relative with PsA is at higher risk of developing the disease. It is hypothesised that a stress to the body, such as physical trauma or an infection may trigger PsA in those people who have those particular genes.

Psoriatic arthritis usually occurs after the onset of psoriasis, and often can begin slowly. In addition to the presence of skin plaques associated with psoriasis – which can appear anywhere on the body, but are most often seen on elbows, knees, the lower back and scalp – joint inflammation can begin in as little as one joint, but then can affect additional joints over weeks or months.

The severity of psoriatic arthritis symptoms can be very different from person to person. It is impossible to predict how it will affect you — some people have more skin problems than joint problems; in others, it may be the opposite.

It is common in psoriatic arthritis to see nails become rough, ridged and thick, with changes like pitting, splitting, cracking and separating from the skin.

In addition to the joints, PsA can cause inflammation in the entheses, which is where tendons and ligaments insert into the bone – this is called enthesitis. Enthesitis occurs in up to half of people with psoriatic arthritis¹, most often in the elbows, heels, the bottom of feet and the outer hip area.

Fingers can become swollen and “sausage-looking” — this is called dactylitis. Dactylitis occurs in up to half of people with psoriatic arthritis². Over time, joints in the hands may even change shape, lock or fuse together. The toes can be similarly affected.

In up to a quarter of people with PsA, inflammation of tissue within the eye, called uveitis, also occurs³. Conjunctivitis, which is inflammation of the tissue covering the white of the eye, is also common.

Yes, as symptoms vary from person to person, so do treatment options. Your doctor can explain the differences, benefits and side effects of each. It is likely that you will try different therapies or combinations before finding what works best for you. Treatment options may include:

Medical treatments

The general approach to treating psoriatic arthritis is to reduce inflammation in the skin and the joints and prevent long-term damage to the joints. Psoriatic arthritis medications are divided into two general categories: those that relieve symptoms, and those that can relieve symptoms and modify progression of the disease. Some medications can have a positive effect on both skin and joint symptoms.

Four types of medication are used to treat the symptoms of arthritis in PsA:

• NSAIDs: Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications that can be used to treat the inflammation, and thus the pain and swelling of PsA. NSAIDs do not control the disease; they only treat symptoms.The most common side effects associated with NSAID use are indigestion, heartburn, and stomach and abdominal pain. They can also alter the protective lining of the stomach and gut, making you susceptible to ulcers and bleeding, so you should avoid taking more than one NSAID at a time. As with all the medical treatments, before starting any NSAID, discuss with your doctor if this is the appropriate treatment for you.
• Corticosteroids: Physicians use corticosteroids as fast-acting medications for particularly severe and painful symptoms of psoriatic arthritis. Corticosteroids work by reducing inflammation. Oral corticosteroids can be associated with significant side-effects, so they are usually taken for limited periods of time. Corticosteroids can also be injected directly into a joint or the area where tendons and ligaments insert into bone (enthesis).Side effects of oral corticosteroids may include fluid retention, increased appetite and weight gain, difficulty sleeping, acne, increase in blood pressure, increase in blood sugar levels and mood swings.
• DMARDs: Disease-modifying anti-rheumatic drugs (DMARDs) are prescription medications that relieve psoriatic arthritis symptoms. DMARDs may also improve psoriasis symptoms. Different patients will respond differently to treatment with DMARDs. Sometimes weeks or months of treatment may pass before there is a noticeable difference in pain and joint swelling. During this time, you might also be prescribed a steroid or NSAID to help control symptoms.
•  Biologics: Biologic response modifiers, or “biologics” for short, are medications specifically designed to target your body’s immune system. Biologics are used to slow the progression of psoriatic arthritis, help prevent joint damage, and ease joint swelling, tenderness and pain. Biologics may also improve psoriasis symptoms.Biologics can take time to work. Some people notice symptom relief quickly (within a week), while it may be months before other patients experience symptom relief. Biologics may be used alone or may be combined with other medications, such as DMARDs or NSAIDs, to treat PsA. Biologics are often prescribed to people who fail to respond to other PsA therapies.

Other treatments are available to treat psoriasis as described in Psoriasis

Incorporating healthy lifestyle habits into your PsA treatment plan can help you to manage PsA symptoms.

• Exercise to ease pain and stiffness: Regular physical activity and exercise can help maintain joint mobility and strengthen the supporting structures of your joints. Consult your doctor prior to starting any exercise programme. Consulting a physiotherapist who is experienced in treating PsA may also be useful in determining the best exercise plan for you.
• Care for your skin: Proper skincare will help you manage some psoriasis symptoms that accompany PsA. Please see Psoriasis for suggestions.
• Maintain a healthy weight: Maintaining a healthy body weight can minimise strain and pressure on your joints. Adopting healthy eating habits can help you to sustain a healthy weight and leave you feeling more energetic.
• Modify activity to avoid symptom exacerbation:

          Some ways to modify your daily activities if you have joint pain are to:

            o   Use gadgets to twist open lids

            o   Enlarge the grip on tools and kitchen utensils

            o   Push doors open using your body instead of just your fingers

            o   Lift heavy objects with two hands and carry them close to your body

            o   Use a reacher to pick up items from the ground

            o   Use a computer wisely: make sure your neck, wrists and lower back are in relaxed and neutral positions. Take a break and stand up every half hour or so to alleviate overly repetitive motions or overly stagnant activity

            o   Balance periods of activity and rest: do not sit or stand all day

• Relax to handle stress: Stress can lead to an increase in blood pressure, interrupt sleep and may contribute to psoriatic arthritis symptoms. The first step is to identify stress triggers; then relaxation and coping skills can be developed to improve your overall well-being and give you a greater sense of control over your PsA.
• Temperature therapy: Both heat and cold can help reduce arthritis pain. The choice of using heat or cold should be based on how it makes you feel.
  • Heat: A stiff back and joints may benefit from application of heat. A warm shower or bath, or a warm compress may help relax the muscles and relieve stiffness and pain in your joints and back.Caution should be used to prevent burns.
  • Cold: For swollen joints applying a cold compress (or a plastic bag of ice cubes wrapped in a towel) for about 15 minutes can help constrict blood flow and decrease pain and swelling. Caution should be used to prevent circulation problems or frostbite.

Please note that the information on this website is intended for informational purposes only and should not be used as a substitute for seeking medical advice or treatment from a healthcare professional. You should not use this information to diagnose or treat a medical condition or health problem. Speak to a healthcare professional if you have any questions about your health, medical condition, symptoms or treatment options.

¹ Gladman DD, Chandran V. Observational cohort studies: lessons learnt from the University of Toronto Psoriatic Arthritis Program. Rheumatology (Oxford) 2011; 50:25–31.

² Helliwell PS, Firth J, Ibrahim GH, Melsom RD, Shah I, Turner DE. Development of an assessment tool for dactylitis in patients with psoriatic arthritis. J Rheumatol 2005;32:1745–50.

³ Cantini F, Nannini C, Cassarà E, Kaloudi O, Niccoli L. Uveitis in Spondyloarthritis: An Overview. J Rheumatol Suppl. 2015 Nov;93:27-9.

Additional Resources:

https://www.psoriasis.org/

The National Psoriasis Foundation strives to provide the help patients need to best manage their psoriasis or psoriatic arthritis, while promoting research to find a cure.

arthritisbroadcastnetwork.org

The information in this website is not medical advice – it offers evidence-based information and support that helps people better understand their form of arthritis, and helps them talk to their own rheumatologist and family physician about their symptoms and their health