Psoriatic Arthritis

Symptoms

Psoriatic Arthritis (PsA) is a type of arthritis that can create symptoms in the joints and skin. It usually affects people with a skin disease called psoriasis. It can be a tricky form of arthritis that can appear very different between patients.

Like other types of inflammatory arthritis, the main target of the immune system attack in PsA is the joints. Rarely, inflammation can also affect the eye with a condition called iritis.

Joint and Tendon Inflammation

PsA can cause various degrees of discomfort and problems with joint mobility. In most cases, only a few joints are affected at first. Over time, more joints can become affected.

Symptoms of joint pain and stiffness are usually worse in the morning or after periods of inactivity (such as sitting for a long time). In cases where PsA is not too severe, these symptoms usually get better after certain exercises and activities.

In advanced stages of PsA, the disease can also affect other parts of the body such as the tendons at the backs of the heels (achilles tendon), under the bottoms of the feet, around the knee, on the outside of the hips, or those between the ribs can become inflamed.

Psoriatic arthritis can affect the joints in different ways. There are five basic patterns:

  1. The most common pattern is for a few joints to be affected. In other words, PsA “picks on” a few different joints, like the knee, a wrist, or a finger.
  2. Sometimes many joints are affected. This type of PsA can look a lot like rheumatoid arthritis.
  3. Joints at the ends of the fingers or toes may be involved. PsA can cause fingers and toes to swell up like sausages, a condition called dactylitis.
  4. Joints in the spine are sometimes – but not often – involved. This usually happens later in the course of the disease. It is less common for the joints in the back to be involved from the start of PsA.
  5. The least common type of PsA is a very destructive form of the disease. It is called arthritis mutilans. This type of PsA can be especially painful.

Fatigue

Fatigue is a common symptom of PsA because the body’s immune system is activated (turned on) similar to when it is fighting the cold or a flu.

Skin Symptoms (Psoriasis)

In PsA, the immune system’s attack on the skin can cause it to become inflamed and appear red. In some cases, these areas may covered by a silvery-white scale called plaque.

In most people with PsA, the psoriasis is relatively mild and is usually experienced long before any arthritis symptoms. Many never realized that that they had this condition before their doctor suspected they might have PsA. Psoriasis can also sometimes hide in places like the scalp. It’s also possible for patients to have arthritis symptoms long before any psoriasis symptoms.

Fingernail or Toenail Symptoms

Psoriasis can affect the fingernails and/or toenails. When this happens, the nails can be pitted. In scome cases, the nails can lift off the nail bed.

Diagnosis

Psoriatic arthritis (PsA) is best diagnosed by a rheumatologist, a type of doctor that specializes in arthritis and autoimmune disease.

To diagnose PsA, physicians will take a careful and complete history and perform a thorough physical examination. Among many other considerations, they will look out for specific things that are signs of PsA such as dactylitis (swollen fingers and toes; “sausage fingers”), psoriasis, and noting which joints, if any, are painful and/or swollen. Based on this information, the doctor will likely order tests like blood tests and x-rays to confirm their diagnosis.

Common Tests to Diagnose PsA

Causes

Psoriatic arthritis occurs when the body’s immune system begins to attack its own joints as well as the skin. The reason for this is not well understood.

It is thought that genetics plays a role in who gets PsA because the disease tends to run in families. People who have family members affected by PsA have a higher chance of having PsA themselves. Sometimes, a whole family can be affected by the disease.

Treatments

PsA must be treated early and aggressively to avoid permanent damage to the joints and tendons, and reduce the risk of long-term inflammation in the body such as heart attack or stroke. People with PsA can lead active and productive lives with the right kinds of treatment.

Skin Care for Psoriasis

Skin care is often an important part of a PsA patient’s treatment plan. If psoriasis is severe, it can be helpful to consult a dermatologist.

Psoriasis can be improved with certain creams and lotions. Topical therapy (treatments applied directly to the skin) is often used together with other medications that control the joint inflammation seen in PsA.

Many people with psoriasis benefit from moderate exposure to sunlight. It’s important to avoid over-exposure, which can cause skin damage, and take steps to avoid sunburn.

Some of the medications used to treat the arthritis side of PsA are also helpful for psoriasis including corticosteroids (prednisone), some DMARDs, and some Biologics.

NSAID Medications for Inflammation and Pain

Non-Steroidal Anti-Inflammatory Drugs or NSAIDs are medications that reduce the inflammation of joints caused by PsA. They also help to reduce symptoms such as pain. There are about 20 different anti-inflammatory medications available, so if one doesn’t work for someone, their doctor can recommend another one to try.

Corticosteroids (prednisone)

Medications like prednisone can help control inflammation in some people. It can also help control symptoms of pain and stiffness. It is usually used in high doses for short periods of time. When used for long periods of time, prednisone can have side effects.

Some people with PsA also benefit from cortisone injections directly into affected joints.

People with PsA should to discuss the risks and benefits of using corticosteroids with their rheumatologist.

Analgesic Medications for Pain

Analgesic medications only control pain. They do nothing to control the disease or to prevent further joint damage. Analgesics can range from simple things like acetaminophen (paracetamol, Tylenol) to more potent narcotics like morphine.

Disease Modifying Anti-Rheumatic Drugs (DMARDs)

Disease Modifying Anti-Rheumatic Drugs (DMARDs) were initially used to treat rheumatoid arthritis, and they are also effective in treating people with psoriatic arthritis.

Methotrexate is the most commonly used DMARD to treat PsA. Methotrexate offers “two for one” treatment because it is effective at treating both the arthritis and psoriasis symptoms of PsA.

Other types of DMARDs work well for treating the arthritis of PsA, but are not as helpful for the skin. Other DMARDs that are commonly used include: Sulfasalazine, Arava (leflunomide), Gold (myochrisine), and Plaquenil (Hydroxychloroquine). A newer option that’s been found to work well in treating psoriatic arthritis is Otezla (apremilast).

Biologic Medications

Patients with PsA whose joint pain and stiffness aren’t adequately controlled by anti-inflammatory medications and DMARDs can be treated by a newer class of medications called biologics. These medications are extremely effective and can make a big difference for people with the disease. They can help improve the symptoms of both arthritis and psoriasis associated with PsA.

A type of biologic called anti-TNF biologics was first introduced in 1998. These work very well for many people with PsA. Today, a number of anti-TNF biologics are available including Humira, Remicade/Inflectra/Remsima, Enbrel, Cimzia, and Simponi. Newer biologics target other aspects of the inflammatory response, such as Cosentyx, which inhibits a signalling protein called IL-17.

With many biologic options to choose from, if one doesn’t work for someone, their rheumatologist may suggest another.

Living with PsA

The pain and stiffness caused by PsA can sometimes limit people’s normal activities, including work. There are many things people can do to lessen the impact of PsA on their work and daily routine.

We recommend adjusting features of the workplace to help make working with PsA easier. For example, people that sit for much of the day can adjust the position of chairs and desks for proper posture. Vehicle seats can be adjusted to make driving more comfortable and reduce stress on joints and affected tissues.

Those who find out they have PsA while they’re still young can consider choosing work that isn’t physically demanding on their joints and back.

Exercise is important to overall health. It also helps keep the joints moving properly, and helps protect them by strengthening the muscles around them.

The level and amount of exercise people with PsA can do depends on the activity of their disease.

A trained arthritis physiotherapist is the best person to help design an exercise program tailored to the needs of patients with PsA.

The following are some useful articles on exercising with arthritis:

Exercise and Arthritis: An article by arthritis physiotherapist Marlene Thompson

Exercising in a Flare: Another excellent article by Marlene Thompson on how to cope with flares through your exercise routine.

Alcoholic beverages are not an effective treatment for PsA, and they can interact with many medications.

Smoking is not healthy for people with PsA. It can make symptoms worse and harder to treat.

Research has shown that some arthritis medications do not work as well in people who smoke.

We recommend that smokers quit immediately to reduce the impact of their symptoms, improve the effectiveness of their medications, and improve their overall health.

Travel is still possible when you have PsA.

It is best for people with this disease to get organized well in advance of a trip to ensure a smooth, comfortable, and enjoyable time.

Check out our Travel Checklist page.

Though PsA does not particularly cause a loss of sex drive, it can cause pain, fatigue and emotional hardships. These hardships risk creating barriers to sexual needs, ability, and satisfaction.

People with PsA can take comfort knowing that sex and intimacy can be maintained. In many cases, it can help draw partners closer together, especially through improved communication.

For more information on intimacy and arthritis, a great book is: Rheumatoid Arthritis: Plan to Win by Cheryl Koehn, Taysha Palmer and John Esdaile.

Psoriatic Arthritis (PsA) has no effect on fertility. The chances of getting pregnant for people with PsA are the same as with people that don’t have it. PsA also has no known effects on the developing fetus or the newborn.

The two main issues doctors worry about with PsA and pregnancy are:

Following the basics of healthy eating can help improve health and well-being in everyone, including those with PsA. Keeping a healthy weight helps reduce the load on weight-bearing joints including the spine, hips, and knees, making it easier to live with the disease.

Unfortuantely, no special diet has ever been proven to significantly alter the course of PsA or any other types of arthritis.

In addition, no known natural remedies or complementary therapies have been proven to help PsA in any significant way.

People with PsA should consult with their doctor to make sure that any supplements or alternative therapies they consume will not negatively interact with their medications.

Its very important for people with PsA to attend regularly scheduled appointments with their rheumatologist, and promptly get any tests that are ordered by their doctors.

It is often very important that medications are taken exactly as prescribed. Patients should always talk to their doctor about any issues they experience, or if they would like to change anything.

Psoriatic Arthritis is a chronic disease and a rheumatologist is the best partner in helping patients achieve the best quality of life possible.

Additional Resources for People with PsA