Psoriatic Arthritis is an illness with many faces. It occurs in about 15% of patients with psoriasis, a chronic inflammatory skin disease affecting 2% of the United States population. The joint illness can manifest in a variety of ways and with varying degrees of severity, just like the skin condition.
PsA (pronounced "sor-ee-á-tick" arthritis) is typically grouped with reactive arthritis and ankylosing spondylitis (AS) as spondyloarthropathies (see related sections). These types of arthritis typically affect soft tissue structures including ligaments and bursa as well as the spine, especially the sacroiliac region.
While the cause of arthritis in some psoriasis sufferers is unknown, some doctors think that bacteria on the skin are to blame for the inflammation of the joints. Even so, there is no clear correlation between the intensity of arthritis and also the severity of psoriasis in a given patient. For instance, it is typical to observe severe, incapacitating arthritis in an individual who has minor psoriasis.
Moreover, some individuals (about 15% of all patients) develop arthritis before the onset of noticeable psoriasis.
Five subgroups of PsA patients have been identified: oligoarthritis, polyarthritis, joint participation limited to the fingertips, primarily spinal involvement, and arthritis mutilans, a debilitating condition.
In Psoriasis Arthritis, oligoarthritis represents the most typical pattern. Knees, ankles, fingers, and toes are commonly affected joints in these patients. When arthritis occurs in finger or toe joints, swelling of the entire digit is common, resulting in a “sausage” appearance. As opposed to rheumatoid arthritis (RA), joint involvement in PsA patients tends to be asymmetric, involving different joints on each side of the body.
With the exception of the fact that often just one sacroiliac joint is inflammatory rather than both joints as is characteristic in AS patients, polyarthritis patients are frequently difficult to identify from RA. Those with predominantly spinal involvement also resemble AS. Some people just experience edoema at the fingertip knuckles. Additionally, psoriasis involvement in the fingernails or toenails is very common in these people. Finally, arthritis mutilans has the ability to cause joint damage and deformity very quickly. Thankfully, this PsA variant is the least prevalent.
Rheumatologists concentrate on the joint disease, but in many individuals the psoriatic skin condition is so bad that it overshadows the arthritis. Similar to the arthritis it causes, psoriasis can take many distinct forms. Psoriasis typically manifests as scaly or silvery plaques with red bases that most frequently affect the scalp, knees, and elbows. Another kind known as "guttate psoriasis" exhibits the same scaly look but with thinner plaques that are shaped like "teardrops." A "pitted" appearance or damage at the base of the nails may be seen in some people whose condition primarily affects their nails. "Erythroderma," the most serious condition of psoriasis, is characterised by red, inflammatory skin that covers the entire body. Infections could arise from this type of psoriasis as a consequence of skin germs getting into the bloodstream.
PsA is primarily diagnosed by taking a history of the complaints and looking at the skin and joints. For this type of arthritis, there are no valid laboratory testing available. Moreover, many of the markers of inflammation that are usually seen in RA and other forms of arthritis may be entirely normal in a patient with active PsA. Findings such as joint swelling or evidence of spinal inflammation that fit into any of the above subsets of PsA, along with typical features of psoriasis, are the most important pieces of information that lead to a correct diagnosis.
X-rays may offer further evidence for PsA as well as demonstrating the severity of joint damage. Early in the phase of the illness, many people may have normal x-ray results, but in some, the degree of joint destruction may be fairly severe. The combination of erosions around joints and bony enlargement around these erosions is fairly unique to PsA. Near sites of inflammation, there also may be a “shaggy” appearance to the surface of the bone that also suggests PsA. In patients with spinal symptoms, sacroiliac joints, found near the junction of the pelvis and sacrum in the lower back, may appear inflamed or damaged on x-ray. As opposed to AS, however, PsA tends to involve only one, not both, sacroiliac joints.
Depending on how active the arthritis is, patients with PsA have access to a wide range of therapy choices. Reducing symptoms may be sufficient in people with lesser disease, but there are drugs that can stop the disease from developing in people with more comprehensive involvement individuals who are at concern for joint injury. Many of these treatments also fix the fundamental psoriasis, but in this article, we'll concentrate on treatments for PsA rather than the underlying skin condition.
Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in reducing joint pain and stiffness and may be adequate therapy in patients with milder PsA. Medications in this class include ibuprofen and naproxen, but some affected with PsA may demonstrate a greater response to indomethacin, even though stomach related side effects may limit who is able to take this drug. All traditional NSAIDs have stomach irritation or less commonly damage to the lining of the stomach and bleeding as possible complications. When using more recent NSAIDs like celecoxib (Celebrex) or valdecoxib (Bextra), these adverse effects are greatly diminished. Those with kidney disease may not be good candidates for taking NSAIDs, all of which may reduce the kidney’s ability to function. Corticosteroids such as prednisone may be effective in reducing short-term arthritis symptoms, but long-term use may result in unpleasant side effects (see Medications section). Moreover, withdrawing steroid therapy often results in a flare of psoriasis. For the most part, corticosteroids are best used for injections of acutely inflamed joints or soft tissues for temporary relief of symptoms.
Sulfasalazine (SSZ) When combined with NSAIDs, the slower acting drug sulfasalazine (SSZ), which is also used to treat RA, can further reduce swelling in PsA. The underlying skin issue is unaffected by this treatment. SSZ begins to work in approximately two to three months, and typical side effects include nausea, upset stomach, and allergic responses. Blood testing can be used to detect less prevalent but more severe adverse effects.
Methotrexate (MTX), When administered once weekly in doses of 7.5 to 20 mg (or more), methotrexate (MTX) is frequently successful in treating PsA's skin & joint diseases. Used in treating RA patients as well, MTX suppresses the immune system and in this way reduces the inflammation, thus possibly limiting the joint damage. Liver damage, reduction in blood cell counts, and infection are the major complications that can occur with MTX and must be monitored with blood tests regularly. These hazards are frequently justifiable given the benefit in patients with severe skin and/or joint problems.
Azathioprine (Imuran), cyclosporine (Neoral), leflunomide (Arava), mycophenolate mofetil (Cellcept), as well as the antimalarial medicine hydroxychloroquine are further "disease-modifying" medications used in RA and/or lupus and rheumatology that have been used to treat PsA. (Plaquenil). Compared to studies supporting the use of SSZ or MTX, the studies supporting the use of these drugs for the treatment of PsA are smaller & fewer in number. These medications are still viable alternatives for treating PsA in patients who have not responded to prior treatments or have shown negative effects from them.
Tumor necrosis factor (TNF) antagonists represent the most exciting and effective agents for treating aggressive PsA resistant to other therapies. These drugs prevent a protein called TNF, which is mostly in charge of the inflammation present in PsA and other types of arthritis, from doing its job. Etanercept (Enbrel) is the one TNF antagonist that the FDA has currently approved for the treatment of both PsA and psoriasis, although research has indicated that the other two medications, infliximab (Remicade) & adalimumab (Humira), are also safe and effective treatments. All of these drugs have the capacity to reduce or even stop joint degeneration, just like RA.
Infections and adverse injection site or infusions site reactions are among the adverse effects of TNF antagonists.
Patients with multiple sclerosis or severe heart failure should not take these medications, as they may make these conditions worse. Before beginning these medications, patients should be screened with a TB skin test because those with a past history of tuberculosis may suffer a relapse of their infection.
In order to take the medication(s) that will effectively treat all of the patient's concerns with a tolerable amount of side effects and expense, it is important to first establish the intensity of the arthritis and skin disease. We have now more tools than ever before to treat all forms of PsA thanks to recent advancements in therapy.
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