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Psoriatic Arthritis

Arthritic Psoriasis

Psoriatic arthritis (arthritis psoriatica, arthropathic psoriasis) is an inflammatory arthritis associated with psoriasis. The pathogenesis of psoriatic arthritis is unknown.

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Presentation

The intervals of attack of the disease alternate with periods of remission. The signs and symptoms include the following.

Joint inflammation

Based on the type of joint involved, psoriatic arthritis can be categorized into:

  • Symmetric
  • Asymmetric
  • Spondylitis (spinal involvement), causing difficulty in bending forwards
  • Distal interphalangeal joints
  • Arthritis mutilans

Typical sign and symptoms of psoriatic arthritis related to the joints include the following.

A large number of findings are also seen in the other organs and systems of the body. These include the following.

  • Dermatological abnormalities: Acne, deformities of the nails (such as Beau lines, leukonychia,pitting, ridging and cracking) along with scaly patches on the skin (psoriasis) are commonly seen.
  • Eye abnormalities: Iritis (inflammation of iris) and uveitis are the commonly seen abnormalities of the eye.
  • Lung involvement: Lung involvement occurs in the form of chest pain and pleuritis.
  • Involvement of bone and cartilages: This includes costochondritis and osteitis. Respiratory difficulties are also seen when ribs and sternum get involved.
  • Cardiovascular involvement: Cardiovascular involvement consists of aortitis and heart failure.
Splenomegaly
  • Here we describe a case of visceral leishmaniasis infection in a 65-year old Greek male with psoriatic arthritis treated with methotrexate, who presented with high grade fever, chills, splenomegaly, pancytopenia and polyclonal hypergammaglobulinaemia.[ncbi.nlm.nih.gov]
Swelling of the Finger
  • Painful, sausage-like swelling of the fingers and/or toes. Thickness and reddening of the skin with flaky, silver white patches called scales. Pitting of the nails or separation from the nail bed. Tiredness. Pink eye or other eye infections.[niams.nih.gov]
  • The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance.[en.wikipedia.org]
  • But PsA commonly causes a unique type of swelling in your fingers or toes. With PsA, you may actually notice a “sausage-like” swelling in your fingers and toes around your joint before you notice any symptoms in your joints themselves.[healthline.com]
  • A Surprising Cause of Joint Pain Got pain and swelling of the fingers and spine? It could be psoriatic arthritis. Learn more What Is Psoriatic Arthritis? PsA: An Autoimmune Disease Causes of Psoriatic Arthritis Can PsA Be Prevented? Psoriasis vs.[sharecare.com]
Reiter's Syndrome
  • ’s syndrome As with ankylosing spondylitis and Reiter’s syndrome, bone proliferation is a major feature.[learningradiology.com]
  • syndrome ) tends to involve feet hands[radiopaedia.org]
  • The other disorders are juvenile ankylosing spondylitis, inflammatory bowel disease, and Reiter's syndrome.[stanfordchildrens.org]
  • syndrome Ankylosing spondylitis There are no diagnostic blood tests for psoriatic arthritis but tests may be done to help confirm the diagnosis and rule out other causes.[dermnetnz.org]
Family History of Arthritis
  • Approximately 40 percent of affected individuals may have a family history of arthritis or psoriasis.[rarediseases.org]
  • The following factors influence how severe your psoriatic arthritis will be: Clinical pattern (see symptoms) Symptoms beginning when you are young Severity of skin symptoms Female sex Family history of arthritis Rarely, complications such as joint dislocations[emedicinehealth.com]
Toe Pain
  • Other symptoms of psoriatic arthritis include: swollen fingers and toes pain in the buttocks, lower back, or neck caused by inflammation in the spine (spondylitis) fatigue pain and/or swelling in the back of your heel caused by inflammation of the Achilles[arthritis.org.nz]
Pitting Nails
  • Psoriatic arthritis occurs in about 30% of people with psoriasis (a skin condition causing flare-ups of red, scaly rashes and thickened, pitted nails).[msdmanuals.com]
  • Contact your dermatologist if you have psoriasis and any of these signs or symptoms: A very noticeable swollen finger or toe Swollen and tender joints Stiffness when you wake up or sit for hours that fades as you move Nails that are pitted Nail separating[uclahealth.org]
  • nails uveitis sacroiliitis Imaging Radiographs indication to confirm diagnosis recommend views affected joints findings bone proliferation and bone resorption pencil-in-cup deformity of DIP, demonstrating erosive changes Studies Labs negative rheumatoid[step2.medbullets.com]
  • Symptoms of psoriatic arthritis include: Swollen, painful, hot, red joints – frequently in the knees, ankles, and feet Swollen fingers or toes that appear like "sausages" Joint stiffness that is worse in the mornings Pitted nails, or nails separating[onhealth.com]
  • There can be tiny pitting nail changes of the finger and toenails. The type of psoriatic arthritis depends on the distribution of the joints affected.[medicinenet.com]
Koebner Phenomenon
  • Some patients with psoriasis experience an event known as a Koebner phenomenon, where new lesions develop at sites of previous cutaneous trauma.[medpagetoday.com]
  • Trauma to a joint sometimes triggers psoriatic arthritis and is considered the articular equivalent of the Koebner phenomenon (appearance of a psoriatic plaque in the area of trauma to the skin). C.[clinicaladvisor.com]
Arthritis
  • Arthritis mutilans has also been called chronic absorptive arthritis, and may be seen in rheumatoid arthritis as well.[en.wikipedia.org]
  • This type of arthritis is solely prevalent in psoriatic arthritis and does not occur in any other form such as rheumatoid arthritis or osteoarthritis.[psoriasis.qualitycarebyleo.com]
  • C5a levels were increased in both rheumatoid arthritis and psoriatic arthritis synovial fluid compared to osteoarthritis, and in blood from rheumatoid arthritis compared to healthy subjects.[ncbi.nlm.nih.gov]
  • The mean duration in patients who developed psoriasis prior to arthritis was over 10 years, while that in patients preceded by arthritis was less than 5 years.[ncbi.nlm.nih.gov]
Back Pain
  • Do you wake up at night because of low back pain?; 4. Have you had pain in your heels?; 5. Has a doctor ever diagnosed you with psoriatic arthritis?) with a dichotomous response, demonstrated high sensitivity and specificity for predicting PsA.[ncbi.nlm.nih.gov]
  • PATIENTS AND METHODS: Two patients with psoriasis and recent-onset inflammatory back pain (IBP) with no known arthritis are presented. A final diagnosis of AL based on magnetic resonance imaging (MRI) findings was made.[ncbi.nlm.nih.gov]
  • Some people also experience neck or lower back pain. Causes The exact cause of developing psoriatic arthritis is not known.[rheumatologyspecialistcare.com.au]
  • pain Heel pain Swelling on the back of your leg above your heel Treatment for Psoriatic Arthritis Treatment usually involves treating both the skin condition and the joint inflammation.[uclahealth.org]
Joint Swelling
  • The psoriasis usually develops months to years before the joint swelling and pain. Causes The cause of psoriatic arthritis is not yet known. Since it is known to run in families it may be partly inherited.[orthop.washington.edu]
  • Joint swelling occurs with psoriatic as well as other types of arthritis. But PsA commonly causes a unique type of swelling in your fingers or toes.[healthline.com]
  • During a physical exam, the health care provider will look for: Joint swelling Skin patches (psoriasis) and pitting in the nails Tenderness Inflammation in the eyes Joint x-rays may be done.[nlm.nih.gov]
Asymmetrical Arthritis
  • These include: asymmetric arthritis – usually affects one side of the body, or different joints on each side symmetrical polyarthritis – often affects several joints on both sides of the body distal interphalangeal arthritis – affects the joints closest[healthdirect.gov.au]
  • X-ray findings that are characteristic of psoriatic arthritis include: Changes affecting the joints at the end of the fingers ( distal interphalangeal joints) Asymmetrical joint involvement (particularly asymmetrical arthritis of the sacroiliac joints[dermnetnz.org]
  • The arthritis associated with psoriatic arthritis comes in five forms: Arthritis that affects the small joints in the fingers and/or toes Asymmetrical arthritis of the joints in the extremities Symmetrical polyarthritis, a type of arthritis similar to[stanfordchildrens.org]
  • Asymmetric Arthritis Can occur in any joint, but not necessarily the same joints on both sides of the body. Fingers and toes can become enlarged and "sausage-like."[psoriasis.com]
Joint Deformity
  • deformities Please rate topic.[step2.medbullets.com]
  • Over time, the muscles and ligaments around the bone, the cartilage and the bones themselves become damaged, which can lead to joint deformities.[arthritis.org.nz]
  • Early treatment can help avoid gross joint deformities. With early diagnosis, preventive measures and treatment, the prognosis of the disease is usually excellent with long life expectancy.[symptoma.com]
  • The arthritis mutilans type is characterized by joint deformity with the small joints of the hands and feet most impacted. Neck pain and low back pain are also associated with this type of psoriatic arthritis.[arthritis.about.com]
Neglect
  • Expert commentary: The foot and ankle remains a neglected area in PsA. Problems with the foot and ankle should be prioritised as they can significantly impact on patients' quality of life.[ncbi.nlm.nih.gov]

Workup

Diagnosis is made on the basis of:

  • Blood tests
    • Erythrocyte sedimentation rate (ESR)
    • Rheumatoid factor levels
    • HLA-B27 genetic marker
    • Anti–cyclic citrullinated peptide (anti-CCP)
  • Arthrocentesis 
  • Skin biopsy of psoriatic lesions
  • Imaging techniques
    • X-rays (bone defects)
    • Magnetic resonance imaging
    • Computerized tomography imaging
    • Ultrasounds
HLA-B27
  • While a number of genes are linked to PsA, the highest predictive value is noted with HLA-B27.[spondylitis.org]
  • […] factor-α, and other inflammatory markers recruit T-cells into the skin and joints osteoclasts are exposed to inflammatory molecules in the psoriatic joint, triggering osteoclast activation and causing osteolysis Associated conditions skin psoriasis other HLA-B27[step2.medbullets.com]
  • Genetic defects: HLA-B27 is a genetic marker for the disease. Reduced immune defenses : Helper T cell count is usually low.[symptoma.com]
  • People with a certain gene ( HLA-B27 ) and those who have affected family members are at increased risk of psoriatic arthritis of the spine. The cause of psoriatic arthritis is unknown. Resources In This Article[msdmanuals.com]
  • A genetic marker HLA-B27 is found in more than 50% of psoriatic arthritis patients with spinal inflammation. Other genes common in psoriatic arthritis patients have also been found.[onhealth.com]

Treatment

Complete cure of psoriatic arthritis is not possible. However, treatment of symptoms can help the patients to live with this disease.

Conservative treatment is done through:

  • Exercise
  • Physiotherapy

Medical treatment of the disease is done with:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin or indomethacin
  • Disease-modifying anti rheumatic drugs
    • Methotrexate [1]
    • Sulfasalazine [2] [3]
    • TNF-blockers (adalimumab, etanercept, infliximab) [4][5]
    • Cyclosporine [6]
    • Leflunomide [7] [8]
  • Corticosteroids like prednisone [9]
  • Immunosuppressants
  • Analgesics
  • Anti-malarial drugs (chloroquine) [10]

Treatment of secondary disorders like hypertension should also be done.

Surgical options include:

  • Joint replacement (Total hip joint replacement, knee joint replacement surgery)
  • Arthroscopic synovectomy
  • Arthrodesis
  • Arthroplasty

Prognosis

The disease may be mild causing occasional attacks and flares or severe causing acute joint damage. Early treatment can help avoid gross joint deformities. With early diagnosis, preventive measures and treatment, the prognosis of the disease is usually excellent with long life expectancy. Newer medications are proving to be more effective, resulting in an even better prognosis.

Etiology

Most of the cases of psoriatic arthritis are idiopathic with unknown etiology. Known causes that can trigger the disease include the following.

  • Genetic defects: HLA-B27 is a genetic marker for the disease.
  • Reduced immune defenses : Helper T cell count is usually low.
  • Autoimmune mechanism
  • Environmental factors
  • Infections (post-streptococcal)
  • Family history of psoriasis or psoriatic arthritis

Epidemiology

5-30% of the patients with psoriasis develop psoriatic arthritis. The disease usually develops during the fourth and fifth decade of life, being most common at the age of 30 to 50. Males and females are equally affected. A familial predisposition to psoriatic arthritis exists.

The disease is more prevalent amongst the Caucasians as compared to people of African or Asian origin. The condition is not infectious.

Sex distribution
Age distribution

Pathophysiology

The exact underlying mechanism of psoriatic arthritis is unknown. However, autoantibodies against the body’s own tissues are thought to be the underlying mechanism of psoriatic arthritis. The normal joint cells are destroyed. Overproduction of skin cells also occurs.

Response to anti-TNF α therapy suggests the involvement of activated T cells and tumor necrosis factor alpha (TNF-α) in the pathophysiology of the disease. Major histocompatibility complex (MHC) and non-MHC loci may also be involved.

Prevention

  • Vitamin D supplementation can help prevent psoriatic arthritis.
  • Physical activity helps maintain the muscle movements and range. Moderate stretching and endurance exercises are especially helpful.
  • Physical activity also helps combat the disorders that develop secondary to immobility caused by arthritis. These include hypertension, hypercholesterolemia, diabetes and obesity. Even simple walking constitutes a good exercise.
  • Weight reduction can help reduce undue strain on the joints and can prevent the aggravation of developing arthritis.
  • Dietary changes like fish oil can help prevent psoriatic arthritis. Fresh fruits and vegetables should also be incorporated in diet.
  • Keeping the inflamed joints warm with hot water bottle and warm clothing can help reduce the pain and stiffness. Keeping them cold with cold ice packing can help reduce swelling. The cold packs should not be applied directly.
  • Splinting can help rest the involved joints but complete immobilization should be avoided.

Summary

Psoriatic arthritis is a chronic, inflammatory disorder that affects the joints and is closely related to psoriasis (a skin disorder). Tissues other than joints can also be involved. In about 80% of the cases, arthritis follows psoriasis but in approximately 15% of the cases, it precedes psoriasis. Multiorgan inflammation can develop leading to wide spread signs and symptoms of the disease.

The disease is usually managed with non-steroidal antiinflammatory drugs (NSAIDs) and disease modifying anti-rheumatic drugs (DMARDs). If the disease is diagnosed early, gross deformities of the joints can be prevented and the patients have a very good prognosis.

Patient Information

Psoriatic arthritis is a disease of joints that is closely related to a skin disorder, called psoriasis. The disease develops mainly due to gene abnormalities as well as defect in body’s immune mechanisms. The simplest way to prevent psoriatic arthritis is to maintain the physical activity. Vitamin D supplements and incorporation of calcium containing foods in diet (milk etc.) can also prevent the development of this disease.

The disease manifests as pain and swelling in the joints leading to restriction of movements. The patient may experience difficulty in walking. Development of raised skin patches is also a common finding of this disease. As the disease progresses, eyes, lungs, bones and even heart can become involved. The disease is treated by the use of pain killers along with other agents. If the disease is diagnosed and treated early, there is good long term quality of life.

References

Article

  1. Parasca I, Bolosiu HD, Rus V, Dutu A. [The treatment of severe psoriatic arthritis with methotrexate in a weekly "mini-pulse" dosage plan]. Medicina interna. 1991;43(1-2):150-153.
  2. Seideman P. Sulphasalazine treatment of psoriatic arthritis. British journal of rheumatology. Dec 1990;29(6):491-492.
  3. Goupille P, Valat JP. Sulfasalazine: a definitively efficient treatment for psoriatic arthritis. The Journal of rheumatology. Apr 1996;23(4):791-792.
  4. Bongiorno MR, Pistone G, Doukaki S, Arico M. Adalimumab for treatment of moderate to severe psoriasis and psoriatic arthritis. Dermatologic therapy. Oct 2008;21 Suppl 2:S15-20.
  5. Cauza E, Spak M, Cauza K, Hanusch-Enserer U, Dunky A, Wagner E. Treatment of psoriatic arthritis and psoriasis vulgaris with the tumor necrosis factor inhibitor infliximab. Rheumatology international. Nov 2002;22(6):227-232.
  6. Salvarani C, Macchioni P, Olivieri I, et al. A comparison of cyclosporine, sulfasalazine, and symptomatic therapy in the treatment of psoriatic arthritis. The Journal of rheumatology. Oct 2001;28(10):2274-2282.
  7. Babic-Naglic D, Anic B, Novak S, Grazio S, Martinavic Kaliterna D. [Treatment of rheumatoid and psoriatic arthritis--review of leflunomide]. Reumatizam. 2010;57(2):161-162.
  8. Pchelintseva AO, Korotaeva TV, Godzenko AA, Korsakova Iu L, Stanislav ML, Denisov LN. [Results of leflunomide treatment of psoriatic arthritis]. Terapevticheskii arkhiv. 2007;79(8):22-28.
  9. Jajic I. [Intravenous use of high doses of corticosteroids in the treatment of severe cases of ankylosing spondylitis, rheumatoid and psoriatic arthritis]. Reumatizam. 1983;30(3):54-59.
  10. Jajic Z, Jajic I, Grazio S. [Chloroquine in the treatment of psoriatic arthritis]. Reumatizam. 1995;42(2):7-9.

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Last updated: 2018-06-22 04:03