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The double trouble of psoriatic arthritis

By Louis Neipris, M.D., Staff Writer, myOptumHealth

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Psoriatic arthritis is a disease that deals the body a double blow. Both skin and joints are affected by this autoimmune disorder. After months or years living with the troublesome rash, some people with psoriasis start to have aching and swelling of the fingers or other joints. For others, joint pain starts first, followed by rash. At the heart of the problem is an immune system that overreacts and attacks its own tissues. Psoriatic arthritis can't be cured, but treatment can control symptoms. Early diagnosis and treatment are essential. If left untreated, joint damage can be permanent.

Who gets psoriatic arthritis?

Psoriatic arthritis affects men and women equally. It usually appears between 30 and 50 years of age, but it can develop in children, too.

What are the symptoms?

The telltale sign of this condition is the combination of rash and joint pain. The typical skin rash of psoriasis is characterized by patches of raised, reddish skin covered by a silvery-white scale. Some rashes may have white pustules. But the rash does not always appear before the joint pain. Tender, swollen joints, especially the hands and feet, are another hallmark of psoriatic arthritis. In some people, fingers and toes may swell giving them a "sausage" appearance. Other joints may also be involved, including the back, neck and hips. Joints may be involved on one or both sides of the body.

A small percentage of people have a very destructive arthritis, affecting mostly joints in the hands.

Other symptoms may include:

• Reduced range of motion of involved joints
• Tender spots in the back of the heel and arch of the foot
• Morning stiffness
• Tiredness or fatigue
• Redness and irritation of the eyes
• Separation of the nail from the nail bed or a pitted appearance that looks like a fungal infection

What causes psoriatic arthritis?

The exact cause of psoriatic arthritis is not known. There is probably a combination of genetic (inherited) and environmental (acquired) factors involved. About 40 percent of people with psoriatic arthritis have a family member with this condition, suggesting that there is a genetic link. Some cases may relate to an infection, such as a strep throat, which can rev up the immune system. The immune system, while trying to protect against infection, may react against the body's own tissues, including the joints.

How is it diagnosed?

Your doctor will ask you a series of questions, such as which joints are painful, whether you have a skin rash and when the pain and rash began. Your doctor will look for swollen and painful joints, including fingers and toes, as well as skin and nail changes seen in psoriasis. Your doctor may also order:

• Imaging. This may include x-ray, MRI or CT scans to look for joint damage. Special ultrasound techniques are now being studied as a way to check for joint inflammation and response to treatment.
• Skin biopsy. This may be needed to rule out other types of rash.
• Blood tests. These help determine the type of arthritis and the level of inflammation.

Your primary care doctor will probably refer you to a rheumatologist (a doctor who specializes in arthritis).

How is psoriatic arthritis treated?

Treatment depends on your level of pain. Some people only need treatment for a flare-up. Others need daily medication to control symptoms. Medications used to treat psoriatic arthritis include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). These include ibuprofen (Motrin, Advil) or naproxen (Aleve). They are used as first-line therapy.
• Disease-modifying agents (DMARDs). These include sulfasalazine (Azulfidine) and methotrexate (Rheumatrex), cyclosporine (Neoral, Sandimmune) and leflunomide (Arava). These drugs are used to treat more severe symptoms. They can also be used to help prevent joint damage and progression of the disease.
• Biologic medications. These drugs may help slow or stop the disease. They include the TNF alpha blockers infliximab (Remicade), etanercept (Enbrel) and adalimumab (Humira). These drugs may be used if conventional therapies don't work. But they are expensive and can raise the risk of infections, such as tuberculosis.
• Steroid injection. Injecting a corticosteroid, an anti-inflammatory drug, directly into the affected joint may help relieve pain. This may be used if one joint is primarily involved.

For psoriasis skin rash:

Some of the same drugs used to treat joint symptoms may also help the skin rash. Other treatments may include:

• Ointments and creams can be applied directly to the rash. Some help to reduce inflammation and itching, others help to remove overlying scales.
• Light therapy or phototherapy involves regularly exposing the skin to a special light.

Your doctor may also suggest that you try:

• Exercise. Make time for it each day, even 5 to 10 minutes at a time. Regular exercise can help to lessen pain, maintain your range of motion and improve flexibility. Gentle stretching is one example of exercise that may help with morning stiffness. You may find it easier to move in the water. Try swimming or water aerobics, which put less stress on your joints. Always check with your doctor first to see what type and how much activity is right for you.
• Maintain a healthy weight. Less weight puts less strain on your joints. You reach/maintain a healthy weight by lowering calories, taking in only what you need in proportion to your level of activity. Go for healthy choices, including low-fat sources of protein, whole grains and at least five servings of fruits and vegetables every day. NOTE: Do not attempt to lose weight if you are pregnant. Ask your doctor about a healthy diet.
• Use heat and cold therapy. Apply heat to stiff joints for a few minutes at a time. Apply an ice pack to inflamed areas to reduce swelling. Do not use hot or cold therapy if you have circulation problems or have any nerve damage.

View the original The double trouble of psoriatic arthritis article on myOptumHealth.com 

SOURCES:

• Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 2: psoriatic arthritis: Overview and guidelines of care for treatment with an emphasis on the biologics. Journal of the American Academy of Dermatology. 2008;58(5):851-864.

• American College of Rheumatology. Psoriatic arthritis. Accessed: 08/10/2009

• National Psoriasis Foundation. Psoriatic arthritis. Accessed: 08/10/2009

• Fitzgerald O. Psoriatic arthritis. In: Firestein GS, Budd RC, Harris ED, McInnes IB, Ruddy S, eds. Firestein: Kelley's Textbook of Rheumatology, 8th ed. Philadelphia, PA: W.B. Saunders; 2008.

• American Academy of Dermatology. Psoriasis and psoriatic arthritis. Accessed: 08/10/2009

• National Psoriasis Foundation. Diagnosing psoriatic arthritis. Accessed: 08/10/2009