Psoriatic Arthritis

Psoriatic Arthritis and Psoriasis

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On average, psoriatic arthritis affects about 10-20% of patients who have psoriasis and generally occurs about 9 to 10 years after the onset of psoriasis. Often the diagnosis is delayed because patients with psoriasis are not aware that arthritis can develop as a result of their skin disease. Even some health care professionals are not aware of all the potential complications that can occur in patients with psoriasis. A delay in diagnosis is problematic because studies have shown that damage to the joints can occur in some patients when appropriate treatment is not started promptly.

How psoriatic arthritis differs from other forms of arthritis

Psoriatic arthritis is an autoimmune disorder, unlike osteoarthritis which develops primarily as a result of “wear and tear” on the joints. This means that, as with rheumatoid arthritis (RA), the immune system erroneously attacks the joints causing inflammation and damage. However, psoriatic arthritis falls into a group of disorders that is distinct from RA, known as the “seronegative spondyloarthropathies” or SPA, which share similar or overlapping features.

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This group includes psoriatic arthritis, ankylosing spondylitis, arthritis associated with inflammatory bowel disease such as ulcerative colitis or Crohn’s disease, and reactive arthritis (arthritis that occurs secondary to an infection such as food poisoning or bacterial infection). These disorders share some genetic and clinical features, and may share some biologic characteristics that lead to their development.

Symptoms

The diagnosis of psoriatic arthritis is based on symptoms and findings in the musculoskeletal system of a patient with current or past psoriasis or a family history of psoriasis. Joint symptoms typically include swelling, redness and warmth of a few or many joints, often in an asymmetric fashion.

What is frequently different about psoriatic arthritis when compared to RA is prominent involvement of tendons and “entheses,” the area where a tendon or ligament attaches to bone. “Enthesitis” is present in many common conditions such as tennis elbow, plantar fasciitis and Achilles tendonitis. When these problems are occurring repetitively or in a chronic, non-healing fashion in a patient with psoriasis, the diagnosis of psoriatic arthritis should be considered.

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Another common feature of psoriatic arthritis is dactylitis, often called “sausage digit.” This is a very painful and sometimes disabling problem which involves swelling of an entire finger or toe. We now know that dactylitis is due to swelling and inflammation of all the tissues within a digit including the joints, tendons, entheses and bone.

The spine can be involved in about 40 percent of patients, but it is rare for the spine to be the only area involved in psoriatic arthritis. Spine involvement is felt as inflammatory-type back pain. Inflammatory back pain is different than routine mechanical back pain in that it is slow as opposed to abrupt in onset, and gets better with activity and worse with rest. Inflammatory back pain frequently awakens sufferers from sleep at night.

Treatment

Once the diagnosis is made, a patient’s condition is characterized as mild, moderate or severe based on disease activity assessed in all five areas of involvement in psoriatic arthritis (PsA). These areas include: the severity of skin disease, arthritis, back pain/spine involvement, dactylitis and enthesitis.

Treatment is prescribed based on the severity of the disease, with milder therapies for mild cases and stronger medicines for severe disease that interferes with function.

Treatment may include non-medical interventions such as physical therapy and exercise. Weight loss is important for many patients with PsA, as increased weight has been shown to not only increase the risk of developing this disease, but also to decrease effectiveness of medicines.

Psoriatic arthritis can also increase risk of cardiovascular complications (hypertension, heart attack and stroke). Prescribed medications may include non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen), standard disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine, methotrexate and leflunamide) and biologic therapies such as Enbrel, Humira, Remicade, Cimzia, Simponi, Stelara, Otezla and Cosentyx.

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Biologic agents are medications that interfere with inflammatory activity in the body. These agents help with the symptoms of both psoriasis and arthritis and some may help stop progression of the disease. The possibility of serious side effects exists with these and all medications, and should be discussed carefully with a rheumatologist to fully understand the risks and benefits before starting any new therapy. New biologic agents are also in clinical trials and will be available for general use for psoriatic arthritis in the near future.

Psoriatic arthritis is a potentially progressive disorder that not only can affect skin, joints, tendons and spine, but also can increase the risk of heart attack and stroke. Early recognition of this condition that allows appropriate treatment to begin is essential for relieving ongoing symptoms and possibly preventing future damage and disability.

Additional information about psoriatic arthritis can be found Here.

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