Psoriatic arthritis is a joint problem that often occurs with psoriasis – an immune system disorder that causes red, itching skin. Psoriatic arthritis occurs when the immune system begins to attack healthy cells in and around the joints. Psoriatic arthritis causes pain, stiffness, and swelling of the joints and can often cause significant fatigue that does not go away with rest. Psoriatic arthritis is usually mild but some serious cases can affect and even damage multiple joints.
In patients with psoriasis, age, and family history may increase the risk of psoriatic arthritis. There is no cure for psoriatic arthritis, but certain medications can help control inflammation, pain, and damage to joints. Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids injections, and methotrexate are often effective in relieving symptoms. Treatment may also include physical therapy and gentle, low-intensity exercise. In some cases, surgery may be needed to repair or replace damaged joints.
Managing psoriatic arthritis can become a lifelong challenge. Certain lifestyle choices including a healthy weight and physical activity seem to make reduce symptoms. Cold and hot packs and properly fitting footwear can also make a difference for some patients in living normal lives. Psoriatic arthritis is arthritis seen in individuals who have psoriasis. And we find that about 30% of individuals with psoriasis may have psoriatic arthritis to varying degrees. When you talk to a rheumatologist, or when you see patients from a rheumatologist.
There is a lot of arthritis but very little psoriasis. It may be that there is a sub-group of people with very little skin involvement, but their joints are very affected. Typically, the patient will complain of pain in the joint and stiffness in the morning that may last for half an hour or an hour, and as the day goes on, their symptoms improve. And there are a number of different subtypes of this arthritis–you can either define them as arthritis occurring along the spine, or arthritis that occurs on the fingers, the distal joints, or perhaps on a single joint.
There is often inflammation where tendons are attached to bones. The difference between arthritis and psoriasis in the skin is that the skin can recover. You have a patch of psoriasis, you treat it, and the skin goes back to normal for all intents and purposes. A joint that has been inflamed potentially scars, and you have the destruction of collagen that is life-long. It’s very important for us as dermatologists to recognize the early signs of arthritis because we now know there are these biologics, which are probably much better than older drugs, in trying to prevent the destruction of joints.
While you are most likely familiar with the rheumatic condition arthritis – you may not have heard of psoriatic arthritis. So what is this condition, what are the signs and symptoms, and what can help manage them? Psoriatic arthritis is a condition involving joint inflammation that usually occurs in combination with the skin disorder psoriasis. Psoriasis is a chronic inflammatory condition characterized by patches of red, irritated skin that are often covered by flaky white scales.
Signs and symptoms of psoriatic arthritis include stiff, painful joints with redness, heat, and swelling in the surrounding tissues. When the hands and feet are affected, swelling and redness may result in a “sausage-like” appearance of the fingers or toes. Other symptoms may include fatigue, exhaustion, and changes to the nails, and separation from the nailbed. The cause of psoriatic arthritis is unknown, however, some researchers believe it could be genetic.
Many patients are treated with nonsteroidal anti-inflammatory drugs called NSAIDs that help with reducing pain and decreasing swelling in the joints. Other treatment options may include disease-modifying antirheumatic drugs, tumor necrosis factors, joint injections with corticosteroids, and surgery. – 30 to 40 years is the peak age where people develop psoriatic arthritis, which is about a decade later than the peak age for psoriasis, for skin disease. People usually take 10 to 20 years to develop psoriatic arthritis. In terms of the disease course, it’s rather unpredictable.
Early symptoms with psoriatic arthritis are important. For example, in the Toronto cohort, it was shown that people who developed psoriatic arthritis the year before they were diagnosed had reported joint pain, fatigue, and stiffness. So, again, the symptoms, although they may seem-specific, are very important, and maybe the initial steps that patients experience even before they are diagnosed. Psoriasis is a relatively common skin disease.
It affects about 4% of Americans. And the form that is most associated with psoriatic arthritis is psoriasis that’s located on the scalp. Having psoriasis behind the ear or inside the ear also counts. Perianal psoriasis. And then of course there’s a more frequent form where classic psoriasis is localized on the knees and on the elbows. It’s very bothersome for patients, and there are degrees of this. And then the most classic form is what we call plaque psoriasis where people will develop these raised lesions. There’s a rash called guttate psoriasis, which looks like little drops of rain.
It’s just that they are spread all over. People tend to get this more often after strep throat. It’s most common in young people. That’s one form, in addition to the classic plaque psoriasis. There’s one called inverse psoriasis, where people tend to develop the rash in the skin folds. It tends to look different just because the skin in those areas has a different quality.
It’s not going to scale as much, but it’s going to be red, and it’s going to hurt, and it’s going to ooze fluid, and it’s very uncomfortable. Then there are more rare forms. About two to four percent of people with psoriasis will have a rash called pustular psoriasis. It looks like little pimples on the hands or on the soles of the feet. Of course, these are, again, itchy and tender. These pimples are sterile. There are no bacteria in it, so it’s not a real pimple. It’s just inflammation, but it looks like that. We see this in people with psoriatic arthritis as well.
Then, of course, therefore severe systemic forms where most of the skin, 80% to 90% of the skin is affected with a red rash. We call that erythroderma. When that is severe, that sometimes needs hospitalization and treatment with health and drugs to try and get the skin under control. Because if you think the skin is our largest organ, and it’s essential for the body to function properly and to be protected from everything else around you. Nail psoriasis can lookin many different ways.
The most common form is what we call nail pitting. There are small pits on the surface of the nail and, again, that can have different degrees of severity, from just a few pits on several nails to really, all the entire nail surface being changed by that. Then, the extreme form of pitting would be nail plate crumbling, where the nail can turn into a powder, and then it’s basically just disintegrating. Another form is what we call onycholysis when the nail lifts off the nail bed. The nails grow slowly, so even with treatment, it takes months for the nail to fully recover. But it’s definitely reversible with effective treatment.