Psoriatic Arthritis

            Psoriatic arthritis is an inflammatory process that leads to pain and swelling in joints. It is linked to psoriasis, a skin disorder causing areas such as the scalp, elbows and knees to become inflamed and covered with silvery or grey scales. Up to 30% of people with psoriasis also get psoriatic arthritis. While the main cause is unknown, various theories implicate familial, infectious, and environmental sources. Joints that are commonly affected include the shoulders, elbows, wrists, fingers, knees, and toes. The sacroiliac joints, which are located in the lower back, can also be affected. Tissue surrounding the joints, tendons, and ligaments may also become inflamed.

Progression of psoriatic arthritis:

            Psoriatic arthritis affects men and women equally. The process makes itself evident at two different points in a person’s life. Psoriasis may start at any earlier age, commonly in the late teens. Arthritis makes its appearance later in life, anywhere during the patient’s 20s, 30s and 40s. However, in 15% of the patient population, arthritis appears first.

Presentation of psoriatic arthritis:

            How do you know that you may be developing or have psoriatic arthritis? You may see pain and swelling in the fingers or toes, otherwise called a “sausage” finger or toe. Joint range of motion may be reduced in the affected areas, and you may feel morning stiffness and fatigue. There may be pain and swelling over tendons and ligaments. Fingernails or toenails may lift up from the skin, or may start getting small holes in them, known as pits. The surrounding tissues may also be affected, such as muscles, skin, tendons, and ligaments. Other common features include:

·        tendonitis (swelling of tendons)

·        enthesitis (pain and swelling at sites where tendons and ligaments attach to the bone).

·        heel spurs, tennis elbow and tendonitis of the Achilles tendon (cord at the back of the heel).

There are two presentations of psoriatic arthritis.

1.      “Localized” psoriatic arthritis develops gradually, and presents with mild symptoms only. It usually affects less than five joints.

2.      “Generalized” psoriatic arthritis is more serious and affects five or more joints. This may lead to permanent joint damage and disability. Surgery may be necessary for these patients (see below).

Treatments:

There are many treatments available.  

Medications available:

·        Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are commonly used to treat psoriatic arthritis. This class of medication reduces pain and swelling of the joints and decreases stiffness. However, they do not prevent further joint damage. Over the counter NSAIDs include naproxen sodium and ibuprofen. Other prescription medications can be acquired from a doctor. As with any prescription or nonprescription drugs, there may be side effects such as stomach upset, kidney damage, diarrhea, and abdominal pain. COX-2 inhibitors (e.g. Celebrex®) are a specific kind of NSAID that may be prescribed if traditional NSAIDs are hard on your stomach, or if you have experienced stomach ulcers.  Never start any medication (including NSAIDs) without first discussing the risks with your physician.

·        Disease-modifying anti-rheumatic drugs (DMARDS)

People with severe psoriatic arthritis are often given disease modifying anti-rheumatic drugs (DMARDs). DMARDs try to stop psoriatic arthritis from getting worse. They can take about one to three months before they make a difference in pain and swelling. The following is a list of the common DMARDS:

1.      gold salts

2.      methotrexate

3.      sulfasalazine

4.      leflunomide (Arava®)

5.      hydroxychloroquinine

·        Corticosteroids

Corticosteriods are potent anti-inflammatory medications. They are indicated mostly for severe swelling.  While prednisone is an oral steroid that can be taken, other steroids may be injected directly into the affected joint. There are numerous side effects with prolonged oral use of this medication. Some common side effects include weight gain and osteoporosis.  Injected steroids also carry risks, including infection, bleeding, and potentially ligament or tendon damage.  Always discuss the pros and cons of any medication or procedure with your physician prior to the medication or procedure.

·        Biologic Response Modifiers (“Biologics”)

Biologics are DMARDs that are made up of genetically changed proteins based on substances that are normally in the body. They work by blocking specific parts of the immune system, called cytokines, which play a role in causing psoriatic arthritis. These should be taken with caution as a patient’s immune system can be compromised.

What else can a patient do to reduce joint damage?

Exercise! This helps to reduce pain, and maintain a healthy weight to prevent additional stress on the affected joints. However, a doctor’s guidance is needed for the appropriate exercise program to be implemented.  An anti-inflammatory diet under the direction of your doctor and nutritionist can also be helpful.

What else can be done for psoriatic skin conditions?

·        Use lotions and creams to prevent dry skin (lanolin cream, mineral oil, petroleum jelly, cocoa butter)

·        Avoid strong soaps with perfumes

·        Use a humidifier in your home

·        Light therapy, which combines a prescription medicine called psoralen, either in tablet form or added to a bath, with exposure to type A ultraviolet light

·        See a dermatologist for further evaluation

Other techniques to help relieve pain/relax muscles:

Applying heat helps relax aching muscles, and reduces pain and soreness.  Therefore patients may feel better after taking a hot shower. On the other hand, patients may feel better applying cold, which may help reduce the pain and swelling.  Therefore patients may feel better after applying an ice pack on the area that is sore.

When is surgery indicated?

The doctor may recommend surgery if there is severe joint degeneration. Damaged joints are replaced with synthetic (man-made) joints. This may be only indicated for patients with advanced psoriatic arthritis. Ultimately, it may improve range of motion and function.

Authors:  Ajay Nemade, B.A., Robert Wood Johnson Medical School, Piscatway, NJ.

    Joseph E. Herrera, D.O., Mount Sinai Hospital, New York City, NY