Psoriatic Arthritis

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

Psoriatic arthritis is a chronic autoimmune 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 people who have psoriasis also develop an associated inflammation of their joints. Those who have inflammatory arthritis and psoriasis are diagnosed as having psoriatic arthritis.

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, it is possible to 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."

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 people 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.

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.

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

People with symmetrical polyarthritis have more than four inflamed joints, usually the same joints on both sides of the body. For example, someone may have inflammation in both wrists or in the knuckles of both hands. This pattern of arthritis can be very similar to the pattern of arthritis seen in rheumatoid arthritis.

Asymmetric oligoarthritis means that four joints or fewer are involved. This pattern of arthritis usually affects large joints, especially in the lower extremities. For example, a person with asymmetric oligoarthritis may have swelling of the right knee and the left ankle.

Spondylitis refers to inflammatory arthritis in the spine. Spondylitis can affect the neck, upper and mid back, low back, and/or the sacroiliac joints of the pelvis. It is important for the health care provider to differentiate between spondylitis, which is inflammatory arthritis in the spine, and age-related degenerative arthritis in the spine, as they are treated very differently.

A common pattern of psoriatic arthritis is when the arthritis is limited to the distal interphalangeal joints, which are the joints in the fingers that are located closest to the fingernails. Osteoarthritis (degenerative arthritis) can also affect these joints. A rheumatologist can help determine the type of arthritis that is present.

Arthritis mutilans is a very severe, deforming type of psoriatic arthritis. It affects many joints at the same time and causes severe inflammation and destruction of joints. Aggressive treatment is recommended to control this type of arthritis as soon as possible, as it is very disabling and painful. Fortunately, arthritis mutilans is less common than in the past, probably because of the effective medications now available for treatment of psoriatic arthritis.

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 during flare-ups. There is usually loss of range of motion of the involved joints. Sometimes, psoriatic joint inflammation in the fingers or toes can cause swelling of the entire digit (dactylitis), giving them a sausage-like appearance. Joint stiffness is a common arthritis 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 (sacroiliitis), causing other 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 joint damage. Fortunately, this form of arthritis is rare in patients with psoriatic arthritis.

People with psoriatic arthritis can also develop inflammation of the tendons (tendinitis), tendon insertion points on bone (enthesitis, inflammation of the entheses), 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.

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

Aside from arthritis and spondylitis, psoriatic arthritis can cause symptoms like 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.

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. Onycholysis, or separation of the nail bed, may also occur. 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 those 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.

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.

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 C-reactive protein and 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.

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 over-the-counter medications that are helpful in reducing joint inflammation, pain, and stiffness. Examples of NSAIDs include aspirin, ibuprofen (Advil, Motrin IB), naproxen sodium (Aleve), indomethacin (Indocin), tolmetin sodium (Tolectin), sulindac (Clinoril), and diclofenac (Voltaren). Their most frequent side effects include signs and symptoms like 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.

Patients who experience progressive joint destruction in spite of NSAIDs are candidates for more aggressive disease-modifying anti-rheumatic drugs (DMARDs). 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.

Cyclosporine (Gengraf, Neoral, Sandimmune) is another oral medication that can be used to treat psoriatic arthritis. It can be very effective but can cause side effects such as high blood pressure and kidney dysfunction. For this reason, a physician must monitor use very closely.

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.

Guselkumab (Tremfya) is an injectable biologic that blocks interleukin (IL)-23.

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.

Abatacept (Orencia) is a biologic medication that can be administered either by subcutaneous injection or intravenous injection. It is FDA-approved for the treatment of psoriatic arthritis. Abatacept works by blocking full activation of T cells, which are a main type of cell in the immune system. Inhibiting full T-cell activation decreases arthritic inflammation but may not work well for skin psoriasis.

Secukinumab (Cosentyx) and ixekizumab (Taltz) are injectable biologic medications used to treat adults with psoriatic arthritis. Secukinumab and ixekizumab are antibodies that bind to and block 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, secukinumab is given monthly or by monthly injections from the start according to the doctor's discretion. Ixekizumab is given as a loading dose and then an injection every 4 weeks. Patients are screened for tuberculosis prior to starting secukinumab or ixekizumab. There is an increased risk for infection when taking these biologic medications. Also, caution is advised in people with Crohn's disease or ulcerative colitis.

Tofacitinib (Xeljanz) is an oral medication that has also been proven to decrease joint inflammation in psoriatic arthritis. Tofacitinib is a JAK-inhibitor medication, which means that it inhibits janus associated kinases. Inhibiting these enzymes decreases the production of a number of different chemical messengers that cause inflammation. There is an increased risk of infection when taking tofacitinib. Patients are screened for underlying tuberculosis prior to starting tofacitinib. Those at risk for colon perforation should discuss this with their physician prior to starting Xeljanz. Caution is also advised in women who may desire a future pregnancy.

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.

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.

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.

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.

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.