Arthropathic Psoriasis(also arthritis psoriatica, arthropathic psoriasis or psoriatic arthropathy) is a type of inflammatory arthritis that will develop in between 6 and 42% of people who have the chronic skin condition psoriasis. It is long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis. The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance. This often happens in association with changes to the nails such as small depressions in the nail (pitting), thickening of the nails, and detachment of the nail from the nail bed. Skin changes consistent with psoriasis (e.g., red, scaly, and itchy plaques) frequently occur before the onset of psoriatic arthritis but psoriatic arthritis can precede the rash in 15% of affected individuals. It is classified as a type of seronegative spondyloarthropathy.
Psoriatic arthritis (PsA) is a chronic, progressive, inflammatory arthropathy associated with psoriasis. The prevalence of PsA in patients with psoriasis ranges from 6% to 39% and is equally likely to occur in males and females.[rx],[rx] It is a heterogeneous chronic inflammatory disease that may affect peripheral and axial joints, entheses, skin and nails, and other organs. Treatment with nonsteroidal anti-inflammatory drugs, steroid, and disease-modifying antirheumatic drugs had been the backbone of traditional management of PsA for many years. Although for many years PSA had been considered a milder form of inflammatory arthritis, patients with PsA can have joint destruction, functional impairment, reduced quality of life and psychosocial disability to an extent comparable to that of patients with rheumatoid arthritis (RA)
Summary of key differences in PsA and RA
Psoriatic Arthritis
Rheumatoid Arthritis
Clinical/anatomical
▸ DIP joint and axial arthritis
▸ Often asymmetrical
▸ Enthesitis common
▸ MCP and wrist joints
▸ Predominantly symmetrical
Genetic
▸ HLA Cw6 and B27
▸ IL23 receptor
▸ HLA DRB1
Pathogenesis
▸ The absence of circulating autoantibodies
▸ Distinct vascular pathology
▸ T-lymphocyte predominance
▸ Early expression of vascular growth factors
▸ Circulating autoantibodies RF/ACPA
▸ T-lymphocyte and B-lymphocyte infiltrate
▸ Late expression of vascular growth factors
ACPA, anti-citrullinated protein antibodies; DIP, distal interphalangeal; DMARDs, disease modifying anti-rheumatic drugs; HLA, human leucocyte antigen; IL, interleukin; MCP, metacarpophalangeal; RF, rheumatoid factor; TNF, tumor necrosis factor.
Types of Psoriatic Arthropathy
Symmetric psoriatic arthritis – affects several joints in pairs on both sides of your body, like both elbows or both knees. It can be mild to severe. It destroys your joints over time, and they may stop working. That’s why you need treatment. For about half of people with this type, it can be disabling. The symptoms of symmetric psoriatic arthritis looks like rheumatoid arthritis.
Asymmetric psoriatic arthritis – typically affects only a few joints. They can be large or small and anywhere in your body. Fingers and toes may swell like sausages.
Spondylitis – affects the backbone. It can cause inflammation and stiffness between your vertebrae — the bones of your neck, spine, and lower back and pelvis. Spondylitis can also attack ligaments that connect muscles to bones and other connective tissue.
Arthritis mutilans– is the most severe and destructive form of psoriatic arthritis. Fortunately, it’s rare. It damages the small joints in your fingers and toes so badly that they become deformed.
Distal interphalangeal predominant – This type of psoriatic arthritis is found in about 5% of patients and is characterized by inflammation and stiffness in the joints nearest to the ends of the fingers and toes. Nail changes are often marked.
Causes of Psoriatic Arthropathy
The main contributing factors to the development of psoriatic arthritis are genetics, immunological factors and the environment.
Genetics
As in psoriasis of the skin, many patients with psoriatic arthritis may have a familial tendency toward the condition. However, a twin study found that arthritis was as common in dizygotic (fraternal) twins as in monozygotic (identical) twins so unknown environmental factors may also be important. First-degree relatives of patients with psoriatic arthritis have a 50-fold increased risk of developing psoriatic arthritis compared with the general population. It is unclear whether this is due to a genetic basis of psoriasis alone, or whether there is a special genetic predisposition to arthritis as well.
Immune factors
There is evidence to support the theory that psoriatic arthritis occurs as a result of an abnormal interaction between the immune system and the joints. People with psoriatic arthritis seem to have an overactive immune system as is evidenced by raised inflammatory markers, in particular, tumor necrosis factor (TNF), and increased antibodies and T-lymphocytes (infection-fighting cells).
Environment
Presumably some environmental factor tips the balance in favor of the development of psoriatic arthritis in an individual who is genetically predisposed to the condition. As yet no reliable environmental factor has been identified.
Symptoms of Psoriatic Arthropathy
In the 60’s and 70’s five clinical forms of PSA were distinguished by Moll and Wright:
The classic course of the disease with involvement of the distal interphalangeal joints (5% of cases).
The destructive form of arthritis (arthritis mutilans) (5% of cases)
The destructive form of psoriatic arthritis (arthritis mutilans). Numerous destructive changes in metacarpophalangeal and interphalangeal joints.
The destructive form of psoriatic arthritis (arthritis mutilations). Numerous destructive changes in joints of both hands. Ankylosis of the right wrist. Typical for PsA changes called “pencil-in-cup” involving metacarpophalangeal joints.
Symmetric polyarthritis indistinguishable from rheumatoid arthritis with a negative rheumatoid factor (approximately 15% of cases).
Asymmetric form involving a few interphalangeal joints (also distal) and metacarpophalangeal joints. It is the most common form of arthritis in psoriasis (approximately 70% of all cases).
A form resembling ankylosing spondylitis (5% of cases).
A group of diseases with similar clinical manifestation called seronegative spondyloarthropathies (SpA) has also been defined [RX]. The group includes:
Ankylosing spondylitis (AS).
Psoriatic Arthritis (PsA).
Spondylitis with associated bowel disease (or enteropathic spondylitis).
Reactive arthritis.
Undifferentiated spondyloarthropathies.
To support the diagnosis of seronegative spondyloarthropathies, the European Spondyloarthropathy Study Group (ESSG) created some clinical criteria. Basing on these criteria the assessment includes the following features:
Inflammatory back pain.
Arthritis.
Positive family history.
Psoriasis.
Inflammatory bowel disease.
Buttock pain.
Enthesitis.
Episodes of acute diarrhea.
Urethritis.
Sacroiliitis.
Onset of psoriasis and arthritis are as follows
Psoriasis appears to precede the onset of psoriatic arthritis in 60-80% of patients (occasionally by as many as 20 years, but usually by less than 10 years)
In as many as 15-20% of patients, arthritis appears before the psoriasis
Occasionally, arthritis and psoriasis appear simultaneously
In some cases, patients may experience only stiffness and pain, with few objective findings. In most patients, the musculoskeletal symptoms are insidious in onset, but an acute onset has been reported in one third of all patients.
Findings on physical examination are as follows
Enthesopathy or enthesitis, reflecting inflammation at tendon or ligament insertions into bone, is observed more often at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs
Dactylitis with sausage digits is seen in as many as 35% of patients
Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma
Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus
Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath
Subcutaneous nodules are rare
Ocular involvement may occur in 30% of patients, including conjunctivitis in 20% and acute anterior uveitis in 7%; in patients with uveitis, 43% have sacroiliitis.
Patterns of arthritic involvement
The patterns of psoriatic arthritis involvement are as follows
Psoriatic arthritis usually shows up between ages 30 and 50, but it may start in childhood. Both men and women get it. Many people have the skin disease psoriasis first.
Your doctor will look at your body and ask about the symptoms you’ve been having, which might include
Both psoriasis and psoriatic arthritis are related to your genes, so if you have a close family member with these skin or joint problems, you’re more likely to have them, too.
Laboratory tests ordered and rationale:
IgG foods – Food reactions have been associated with psoriatic arthritis pathogenesis and may contribute to inflammation. Many IgG reactions demonstrate intestinal hyperpermeability, also a factor in inflammatory arthritis. Removing offending foods, if present, will reduce systemic inflammation.
DQ genotype (celiac genes) and celiac panel – Celiac disease and psoriatic arthritis have been linked and share common inflammatory etiopathogenic features.
Inflammatory markers – Monitoring general inflammatory markers is standard practice for assessment of treatment efficacy.
Multiprofile panel – A comprehensive assessment including fatty acids, amino acids, organic acids, oxidative stress markers, and whole blood toxic metals. These tests assist in finding individual etiopathogenic factors that can affect treatment considerations. (Not all findings are discussed below. Panel results not grouped together)
Metabolic panel and lipids – General assessment of metabolic imbalances associated with inflammation
Thyroid panel – Subclinical hypothyroidism is frequently found in those with complex, chronic disease.
DNA microbial stool profile – Assessment of GI microbial status and GI function. GI imbalances are a common finding in inflammatory conditions.
Classification of psoriatic arthritis criteria
The Classification Criteria for Psoriatic Arthritis (CASPAR)consist of established inflammatory articular disease with at least 3 points from the following features:
A history of psoriasis (in the absence of current psoriasis; assigned a score of 1)
A family history of psoriasis (in the absence of current psoriasis and history of psoriasis; assigned a score of 1)
Dactylitis (assigned a score of 1)
Juxta-articular new-bone formation (assigned a score of 1)
RF negativity (assigned a score of 1)
Nail dystrophy (assigned a score of 1)
Laboratory Findings of Psoriatic Arthropathy
No specific diagnostic tests are available for psoriatic arthritis.The most characteristic laboratory abnormalities in patients with the condition are as follows:
Synovial fluid is inflammatory, with cell counts ranging from 5000-15,000/µL and with more than 50% of cells being polymorphonuclear leukocytes; complement levels are either within reference ranges or increased, and glucose levels are within reference ranges
Radiographic Studies of Psoriatic Arthropathy
Radiologic features have helped to distinguish psoriatic arthritis from other causes of polyarthritis. In general, the common subtypes of psoriatic arthritis, such as asymmetrical oligoarthritis and symmetrical polyarthritis, tend to result in only mild erosive disease. Early bony erosions occur at the cartilaginous edge, and cartilage is initially preserved, with the maintenance of a normal joint space. The following radiographic abnormalities are suggestive of psoriatic arthritis
Particularly sensitive for detecting sacroiliitic synovitis, enthesitis, and erosions; can also be used with gadolinium to increase sensitivity
May show inflammation in the small joints of the hands, involving the collateral ligaments and soft tissues around the joint capsule, a finding not seen in persons with RA.
CASPAR Criteria
The CASPAR criteria should also help to identify PsA early. While the criteria were established in patients who had the long-standing disease, they work just as well in patients with early disease[rx]– [rx]. However, the CASPAR criteria are based on the stem of inflammatory musculoskeletal disease.
Only rheumatologists can accurately make that diagnosis. To address this issue, the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) is developing criteria to identify inflammatory arthritis that can be used by non-experts [rx]. Since it is not feasible for all patients with psoriasis to be reviewed by a rheumatologist, several groups have developed screening tools that can be administered to patients
Ultrasound
The use of ultrasound may be helpful in identifying patients with PsA early, particularly among patients with psoriasis. Gisondi et al. performed an ultrasound study of entheses in 30 patients with psoriasis and 30 controls [rx]. They found that the entheses were thicker and the overall ultrasound score was higher in patients with psoriasis than in controls. They repeated the ultrasound assessment among the psoriasis patients 2 years later, and three of the 30 had developed PsA [rx]. However, a study that compared ultrasound in patients with PsA, patients with PsC, and healthy controls found that obesity is a confounder in distinguishing between the groups [rx].
Biomarkers
Since psoriasis usually precedes the development of PsA, and dermatologists have difficulty identifying inflammatory arthritis, it would be helpful if clinicians had a biomarker that would identify those individuals likely to develop the disease. In the past few years, we have seen several biomarkers tested for PsA. These include genetic, epigenetic, soluble, and cellular biomarkers [rx], [rx].
Isotope Examination
The scintigraphic examination is widely performed in patients with inflammatory joint diseases as a useful method of evaluating bone metabolism. It is based on the evaluation of an intense accumulation of radioisotope in areas of increased metabolism within the inflamed joints. Isotope examination is a very sensitive method providing an assessment of joints in a whole- body imaging in a single examination. This method, however, is limited due to its low specificity.
Early lesions period (0–6 months).
Isotope examination
– Ultrasound examination of joints found to be abnormal on isotope examination;
– Scintigraphy/ultrasound/MRI (alternatively) in case of symptoms suggesting the involvement of other joints.
Follow-up hand X-ray after 2 years.
Advanced lesions
Bilateral hand X-ray examination (if involved) every 2 years.
Ultrasound for monitoring activity of the inflammatory process.
Magnetic resonance imaging in case of axial skeleton involvement.
Ultrasonography
To examine large joints such as the knee joint or shoulder joint 5–7,5 Mhz ultrasound transducers can be used. Smaller carpal joints require the use of transducers with frequencies above 10 MHz. [rx].
The grayscale ultrasound scanning used for rheumatological diagnosing provides a possibility to visualize the intraarticular effusion and synovial hypertrophy [rx]. Intraarticular effusion appears as an anechoic area deformable under probe compression, whereas synovial hypertrophy takes a form of intraarticular masses with echogenicity comparable to soft tissues and non-compressible. An ultrasound scan is a sensitive method for detecting the formentioned lesions and is comparable to magnetic resonance imaging and arthroscopic examination [rx–rx].
Treatment of Psoriatic Arthropathy
Biological drugs currently licensed for PsA
Molecule
Mechanism of action
Route
Dosage
Infliximab
Chimeric monoclonal antibody against TNF-α
IV
5 mg/kg at weeks 0, 2, and 6 and every
6–8 weeks
Etanercept
Soluble TNF receptor p75-IgG1 fusion protein
SC
50 mg/week
Adalimumab
Fully human anti-TNF-α monoclonal antibody
SC
40 mg every
2 weeks
Golimumab
Fully human IgG1k anti-TNF-α antibody
SC
50 mg/month
Certolizumab pegol
Fab fragment of an anti-TNF-α monoclonal antibody
SC
400 mg at 0, 2, and 4 weeks and then 200 mg every
2 weeks
Ustekinumab
Fully human IgG1 monoclonal antibody against the shared P40 subunit of human IL-12 and IL-23
SC
45 mg at weeks 0 and 4 and then every 12 weeks (90 mg if weight >100 kg)
Secukinumab
Monoclonal antibody against IL-17A
SC
150 (or 300) mg at weeks 0, 1, 2, 3, and 4 and every
4 weeks thereafter or directly
150 mg/month
Abbreviations: PsA, psoriatic arthritis; TNF, tumor necrosis factor; IV, intravenous; SC, subcutaneous; IL, interleukin.
Currently approved biological drugs for PsA: efficacy data from registrative trials
(150 mg at weeks 0, 1, 2, 3, and 4 and then every 4 weeks)
48%
(16%)
51%
(15%)
35%
(7%)
21%
(1%)
Notes: The percentages within the brackets refer to the related placebo values.
*At week 12. Data are only presented for an illustrative purpose but not for a direct comparison.
Approach Considerations
The treatment of psoriatic arthritis is directed at controlling the inflammatory process. Although no clear correlation exists between joint inflammation and the skin in every patient, the skin and joint aspects of the disease often must be treated simultaneously.
EULAR recommendations
Based on evidence from systematic literature reviews and expert opinion, the European League Against Rheumatism (EULAR) developed 10 treatment recommendations, 5 overarching principles, and a research agenda for psoriatic arthritis. The recommendations are as follows
Adjunctive treatment with local corticosteroid injections should be considered; cautious use of systemic steroids, if administered at the lowest effective dose, can also be considered
TNF-inhibitor therapy should also be considered if a patient with active enthesitis and/or dactylitis does not show sufficient response to NSAIDs or local steroid injections
TNF-inhibitor therapy should be considered if a patient has active, predominantly axial disease that does not respond sufficiently to NSAIDs
Exceptional use of TNF-inhibitor therapy may be considered if a very active patient is DMARD-treatment naïve
If a TNF inhibitor produces an inadequate response, consideration should be given to replacing it with another TNF inhibitor
If adjustments are made in a patient’s therapy, then comorbidities, safety concerns, and other considerations beyond the psoriatic arthritis itself should be factored into the change
Treatment recommendations
Disease status
Treatment recommendation
Level of evidence*
Level of agreement†
Comments
Peripheral arthritis
Mild
NSAIDs
A
90.9%
For control of joint but not skin symptoms
NA
Intra-articular glucocorticoid injections
D
Maybe given judiciously to treat persistently inflamed joints, if care is taken to avoid injection through psoriatic plaques. Injections to anyone joint should be repeated with caution according to clinical judgment
Moderate or severe
DMARDs (specific recommendations follow):
For all patients with severe or moderate peripheral arthritis. Consider for mild disease if patients do not respond to NSAIDs or intra-articular steroids. No evidence supporting DMARDs ahead of TNF inhibitors, although the effect size for TNF inhibitors is much larger than that for traditional DMARDs
SulfasalazineLeflunomideMethotrexateCiclosporine
AABB
Moderate or severe
TNF inhibitors
A
For patients who fail to respond to at least one DMARD therapy. The three currently available TNF inhibitors (etanercept, infliximab and adalimumab) are equally effective for the treatment of peripheral arthritis and for the inhibition of radiographic progression. Patients with poor prognosis could be considered for TNF inhibitors even if they have not failed a standard DMARD
Skin disease
Moderate to severe
Phototherapy
A
69.2%
First-line therapies:Phototherapy includes UVB/nbUVB, oral PUVA, bath PUVA, with or without acitretin. An initial trial of phototherapy should be made, unless it is not appropriate or if psoriasis is in areas that preclude phototherapy (ie, scalp, groin, axilla). All forms of phototherapy are considered as a group, although many consider that PUVA therapy carries increased risk of skin cancer compared with other UV modalities. Aggressive immunosuppression should not follow extensive phototherapy (especially PUVA), given the increased risk of melanoma and non-melanoma skin cancer in this scenario
Methotrexate
A
Fumaric acid esters
A
TNF inhibitors
A
TNF inhibitors include etanercept, adalimumab and infliximab
Efalizumab
A
Cyclosporine
A
Cyclosporine should be limited to less than 12 consecutive months because of cumulative toxicity (ie, multiple courses) is not well studied
Acitretin
A
Second-line therapies
Alefacept
A
Sulfasalazine
A
Third-line therapies
Hydroxyurea
C
Leflunomide
A
Mycophenolate mofetil
C
Thioguanine
C
Nail disease
NA
Retinoids
C
69.2%
Oral PUVA
C
Cyclosporine
C
TNF inhibitors
C
TNF inhibitors include infliximab and alefacept
Spinal disease
Mild to moderate
NSAIDs
A
86.4%
For patients who fail therapies for mild to moderate disease
Physiotherapy
A
Education, analgesia, and injection of sacroiliac joint
A
Moderate to severe
TNF inhibitors
A
Infliximab, etanercept and adalimumab have all demonstrated efficacy in AS; the consensus was that similar treatment responses reported in AS were also likely to be observed in axial PsA
Enthesitis
Mild
NSAIDs, physical therapy, corticosteroids
D
87.9%
Moderate
DMARDs
D
Severe
TNF inhibitors
A
Evidence has been demonstrated for infliximab or for etanercept (in spondyloarthropathies)
Dactylitis
NA
NSAIDs
D
90.2%
Usually employed initially
NA
Corticosteroids
D
Many clinicians rapidly progress to injected steroids
Resistant
DMARDs
D
Nearly always in the context of co-existing active disease
*See Methods section of the manuscript for a description of categories and levels of evidence.
†Percentage of survey responders who agreed or strongly agreed (see supplementary material).
AS, ankylosing spondylitis; DMARD, disease-modifying antirheumatic drug; NA, not applicable or not specifically defined; NSAID, non-steroidal anti-inflammatory drug; PsA, psoriatic arthritis; PUVA, psoralen–ultraviolet light; TNF, tumor necrosis factor; UVB, ultraviolet B light.
British Society of Rheumatology Recommendations
The British Society of Rheumatology (BSR) issued guidelines for the treatment of adult psoriatic arthritis with biologic agents (particularly anti-TNF therapy). The BSR recommends considering anti-TNF treatment in patients with any of the following :
Active peripheral arthritis refractory to at least 2 conventional DMARDs
Peripheral disease refractory to 1 DMARD plus the presence of adverse prognostic factors
Severe persistent oligoarthritis that is affecting well-being and refractory to at least 2 DMARDs and intra-articular therapy
Axial disease
The BSR recommendations on response assessment include the following
Use the psoriatic arthritis response criteria as the clinical response criteria for peripheral disease
Use the psoriasis area severity index score for significant skin psoriasis
Safety recommendations include the following
Do not start or continue anti-TNF therapy in patients with serious active infection; use caution in those at high risk of infection
Screen all patients for infection with mycobacteria, human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV) before starting anti-TNF therapy
Consider prophylactic vaccination for tuberculosis and HBV in high-risk patients before initiating anti-TNF therapy
In patients with HIV, HBV, or HCV, initiate anti-TNF therapy only in those with well-controlled disease and appropriate monitoring; appropriate antiviral therapy for patients with HBV is also important
Avoid anti-TNF treatment in patients with a current or previous history of malignancy, unless there is a high likelihood of cure or the malignancy was diagnosed and treated more than 10 years ago
Regularly screen for skin cancers in patients who are receiving anti-TNF therapy and who have a history of current or previous malignancy
Discontinue anti-TNF therapy prior to pregnancy; restart anti-TNF treatment following the end of lactation or delivery if the mother is not breastfeeding
Consider an alternative anti-TNF agent in patients whose condition is refractory to a first anti-TNF agent; assess the treatment response as for the first agent
Treating psoriatic arthritis
The main aims of treatment will be to relieve your symptoms, slow the progression of the condition and improve your quality of life.
For most people, this involves trying a number of different medications, some of which can also treat psoriasis. Ideally, you should take one medication to treat both your psoriasis and psoriatic arthritis whenever possible.
Mild forms of the disease may respond to nonsteroidal inflammatory agents, which are occasionally given in combination with intra-articular glucocorticoid injections[rx]. Intra-articular corticosteroids may represent a therapeutic option in cases of mono- or oligoarticular joint involvement in PsA.
The systemic use of corticosteroids is not recommended due to a lack of evidence regarding its efficacy and due to the risk of severe adverse events and relapse of skin psoriasis upon discontinuation[rx]. Like NSAIDs, corticosteroids can help reduce pain and swelling. Corticosteroids can also be taken as a tablet, or as an injection into the muscle, to help lots of joints. However, doctors are generally cautious about this because the medication can cause significant side effects if used in the long term, and psoriasis can flare up when you stop using it.
Nonsteroidal anti-inflammatory drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed as initial therapy for both peripheral and axial disease[rx]. For example, according to the measurement by the American College of Rheumatology Responders Index 20 (ACR20), the treatment of PsA patients with celecoxib at a dose of 200 or 400 mg over two weeks increased their rates of clinical response by 21% and 11%, respectively[rx].
However, there was no difference in response between patients treated with celecoxib and untreated patients after 12 wk[rx]. Treatment with NSAIDs represents an option for the short-term symptomatic treatment of PsA[rx,rx].
Disease-modifying antirheumatic drugs (DMARDs) include methotrexate, oral and parenteral gold, cyclosporine, leflunomide, azathioprine and 6-mercaptopurine, antimalarial agents, D-penicillamine, colchicines, retinoids, photochemotherapy, somatostatin, and sulfasalazine[rx].
Moderate to severe forms of the disease are initially treated with the same therapy as in the mild form of the disease, but with the addition of DMARDs[rx]. The efficacy of methotrexate in the treatment of PsA is controversial; although this drug is occasionally used in combination with NSAIDs, its use should be carefully monitored due to the possibility of hepatotoxicity[rx,rx].
Cyclosporine is an efficacious option for the treatment of PsA, and its results may be potentiated by combination with adalimumab. Leflunomide may be used in the treatment of PsA but should be carefully monitored due to its hepatotoxicity. Sulfasalazine can be used in PsA to afford pain relief[rx,rx].
Anti-Tumor Necrosis Factor Agents
Current biological therapies for the treatment of moderate to severe psoriasis and PsA[rx–rx]. Adult patients who have had moderate to severe active PsA (at least three swollen and painful joints) for more than six months and those with psoriatic skin lesions or a history of psoriasis and an intolerance to NSAIDs or DMARDs over three months, whether combined or not combined with methotrexate, are the indications for the use of anti-tumor necrosis factor (TNF) agents (e.g., infliximab, etanercept, adalimumab, and golimumab)[rx,rx].
Although it is difficult to quantify the occurrence of adverse effects, there are no statistically significant differences in the safety profiles among the various anti-TNF drugs using for treatment of PsA[rx,rx].
Disease-modifying anti-rheumatic drugs (DMARDs)
Disease-modifying anti-rheumatic drugs (DMARDs) are medications that work by tackling the underlying causes of the inflammation in your joints.
They can help to ease your symptoms and slow the progression of psoriatic arthritis. The earlier you start taking a DMARD, the more effective it will be.
It can take several weeks or months to notice a DMARD working, so it’s important to keep taking the medication, even if it doesn’t seem to be working at first.
Biological Treatments
Biological treatments are a newer form of treatment for psoriatic arthritis. You may be offered one of these treatments if:
your psoriatic arthritis hasn’t responded to at least two different types of DMARD
you’re not able to be treated with at least two different types of DMARD
Biological drugs work by stopping particular chemicals in the blood from activating your immune system to attack the lining of your joints.
Some of the biological medicines you may be offered include
The most common side effect of biological treatments is a reaction in the area of skin where the medication is injected, such as redness, swelling or pain, although these reactions aren’t usually serious.
However, biological treatments can sometimes cause other side effects, including problems with your liver, kidneys or blood count, so you’ll usually need to have regular blood or urine tests to check for these. Biological treatments can also make you more likely to develop infections.
Biological medication will usually be recommended for three months at first, to see if it helps. If it’s effective, the medication can be continued. Otherwise, your doctor may suggest stopping the medication or swapping to an alternative biological treatment.
Alternative Therapies include the following
Massage therapy – A massage therapist trained in dealing with PsA can help relieve joint discomfort and release tight muscles and joints. A massage can provide significant relief from arthritis-related discomfort.
Acupuncture –This technique involves sticking needles into various pressure points to relieve chronic pain. No studies show its usefulness for PsA but some patients with chronic pain do find acupuncture helpful.
Acupressure – Acupressure involves putting pressure onto different points of the body to reduce pain and pressure, stimulate the immune system, and release tension.
Aromatherapy
Can also help you relax. A soothing scent could take the edge off of a stressful setting. But putting oils in bath water or directly on your skin might irritate it.
Probenecid – goes by the brand name of Benemid and Probalan, works as a preventive by reducing uric acid. It is mostly prescribed to gout sufferers whose kidneys don’t properly excrete uric acid so probenecid can help them increase excretion.
Lesinurad – goes by the brand name Zurampic and is the new kid on the block in helping lower uric acid levels in the blood. It’s often being used in combination with allopurinol to treat gout in those patients that can’t achieve their uric acid targets will only allopurinol.
Pegloticase – it is a medication for about 3% of the gout population who are intolerant to all other gout medication options. It is administered via intravenous infusion every two weeks and is considered a last resort option.
Physical Therapy
The rehabilitation treatment program for patients with psoriatic arthritis should be individualized and should be started early in the disease process. Such a program should consider the use of the following:
Modalities – Heat and cold treatments can temporarily relieve pain and reduce joint swelling; such treatments include soaking in a warm tub or placing a warm compress or cold pack on the painful joint
Orthotics – Upper and lower extremities, spinal
Assistive devices for gait and adaptive devices for self-care tasks: Including possible modifications to homes and automobiles
Education about the disease, energy conservation techniques, and joint protection
Possible vocational readjustments
With regard to the first item above, prolonged rest should be avoided to prevent the deleterious effects of immobility. In a very few people, psoriatic arthritis may cause extreme fatigue.
Steps in the management of psoriatic arthritis: a guide for clinicians.
Natural/Unani or Ayurvedic Treatments of Psoriatic Arthritis
Capsaicin, the natural ingredient found in cayenne pepper, eases arthritis pain in some people. It’s found in over the counter topical cream products such as Zostrix and Capzasin-P, which often need to be applied three to four times a day. Cayenne pepper has helped people with osteoarthritis, according to a study published in March 2014 in Progress in Drug Research, but it may have adverse effects on skin lesions. “Be sure to wash your hands with soap and water after applying,” Dr. Qureshi says.
Boxberry
The boxberry plant goes by several names, including Eastern teaberry and wintergreen. An infusion of this plant has been long-used by Native Americans as an anti-rheumatic. Extract from Eastern teaberry leaves showed anti-inflammatory effects in a study by Polish researchers published in December 2014 in the journal Molecules. Always apply according to package directions.
Oil of Wintergreen
As topical agents, oils of wintergreen, menthol, eucalyptus, and camphor are called counter-irritants because they create a distraction from real pain when applied to the nerve endings in the skin. These are the tingly ingredients in over the counter products like Icy Hot and other soothing balms. In research on animals, Chinese researchers found that oils of wintergreen (methyl salicylate 2) had anti-inflammatory effects on rats and reported their findings in March 2015 in International Immunopharmacology. But again, these oils could have a negative reaction on skin lesions.
Aloe Vera
This plant gel is often used as burn relief as well as an ingredient in moisturizers and body lotion that can soothe psoriatic skin because of its anti-inflammatory properties. It’s being studied as a medium to deliver prescription NSAIDs, according to a study published in June 2014 in Current Drug Discovery Technologies. Apply after showering and washing your hands. Aloe is available in gel and pill form, but the pills in particular may interact with some diabetes and other medications.
Fish Oil
Fish oil contains omega-3 fatty acids, which the body converts into anti-inflammatory chemicals. Fish oil is found in coldwater fatty fish such as mackerel, salmon, herring, tuna, halibut, and cod. Omega-3 fatty acids have a potent anti-inflammatory effect on chronic illnesses, including arthritis, according to research published in the June 2015 issue of the Journal of Physiology and Biochemistry.
Curcumin
The active ingredient in the common Indian spice turmeric, curcumin may help relieve arthritis symptoms because of its anti-inflammatory effects, according to research published in the January-February 2013 issue of BioFactors. Curcumin is available in concentrated supplements. The Food and Drug Administration says 1.5 to 3.0 grams of turmeric a day is safe. However, the National Psoriasis Foundation suggests working with a naturopathic practitioner to determine the correct dosage for you.
Willow Bark
Willow bark reduces arthritis pain in some people, according to a German study published in August 2013 in Phytomedicine: The International Journal of Phytotherapy and Phytopharmacology. Its active ingredient, salicin, reduces the production of pain-inducing chemicals in your nerves, Qureshi says. Willow bark is available over the counter in tablet form. It’s generally safe but may cause stomach upset, increased blood pressure, and skin rashes.
Probiotics
Researchers at the NYU School of Medicine found that people with recently diagnosed psoriatic arthritis had lower gut bacterial diversity than healthy people. Their findings were published in January 2015 in Arthritis & Rheumatology. Probiotics are friendly bacteria that can restore the good-bad bacteria balance and are found in foods such as yogurt as well as in supplement form. What’s more, a study published in June 2013 in Gut Microbes found that probiotics can have anti-inflammatory effects beyond the gut, including for diseases such as psoriasis and psoriatic arthritis.
Boswellia
Known commonly as Indian frankincense, boswellia has been shown to have an anti-inflammatory effect on some conditions including arthritis, according to Memorial Sloan Kettering in New York. In pill form, dosage is 300 to 400 milligrams three times per day, according to the Arthritis Foundation. Beware: Topical creams with boswellia may irritate psoriasis.
Vitamin D
There’s a correlation between psoriasis and psoriatic arthritis and low vitamin D levels, according to research published in July 2015 in The Journal of Dermatology. There’s no conclusive evidence that vitamin D is helpful for psoriatic arthritis, Qureshi says, but you might want to ask your doctor to test your D levels and discuss whether supplementation can help your symptoms. Good food sources include salmon and fortified foods such as milk.
Dead Sea Salts
Epsom salts to your warm (not hot) bath water and soaking in the tub for about 15 minutes may help remove scales and ease itching. Be sure to apply moisturizer to your skin as soon as you get out of the tub. You may see some improvement.
Capsaicin
Capsaicin is the ingredient in chili peppers that make them hot. Added to creams and ointments, capsaicin blocks nerve endings that transmit pain. Researchers from the University Medical Center Freiburg, in Freiburg, Germany, found OTC creams containing capsaicin may help reduce the pain, inflammation, redness and scaling associated with psoriasis. However, more research is needed to assess its long-term benefits and safety. Some people may feel a burning sensation where capsaicin ointment is applied.
Oats
Oats are considered one of nature’s best skin soothers. There is no scientific evidence to support the use of oats to relieve psoriasis symptoms. But many individuals with psoriasis report applying an oat paste or taking a bath in oats relieves their itchy skin and reduces redness.
Tea tree oil
Tea tree oil is from the leaves of a plant that is native to Australia. Tea tree oil is believed to have antiseptic qualities and can be applied to the skin. Some people find using shampoos with tea tree oil helps relieve their scalp psoriasis. However, there are no scientific studies to prove the effectiveness of tea tree oil on psoriasis. Use tea tree oil with care as some people may be allergic to it.
Homeopathic Medicines for Psoriatic Arthritis
Arsenic Album
Arsenic Album is one of the highly effective Homeopathic medicines for treating psoriasis. Indicative symptoms for use of Arsenic Album include rough patches of skin covered in scales. The patches may be brownish or blackish in colour. Roughness of the skin is very well marked.
Burning sensation in eruptions may arise. The skin may be oversensitive. Swelling may also be present on the skin along with dry, patchy eruptions.
Sulphur
For psoriasis with intense itching in psoriatic lesions, Sulphur is an excellent choice of Homeopathic medicine. Though itching is present throughout the day, it gets worse in during the evening and at night. Another unique symptom to look out for while prescribing Sulphur is that the Itching worsens with warmth.
Intense burning on the skin may also be felt. The skin is dry, unhealthy, dirty looking and covered in scales. Also, if the psoriasis worsens in damp weather, Sulphur will work best. It is also a good choice of Homeopathic medicine for psoriasis cases that have been suppressed with external applications such as ointments.
Arsenic Iodatum
A highly useful Homeopathic medicine for psoriasis with extreme exfoliation of abundant scales from the skin is Arsenic Iodatum. Beneath the scales, raw red skin is exposed. Dryness of skin with itching may also be present.
Petroleum
Petroleum is an appropriate choice of Homeopathic medicine for psoriasis that gets triggered during the winter. The skin is dry, hard, rough and very thick. Cracks on the skin may also be present.
Bleeding from the cracked skin may be observed. The skin may look dirty. Petroleum is also one of the majorly indicated Homeopathic medicines for psoriasis of the hands and psoriasis arising in skin folds. The affected skin may be very sensitive to touch.
Graphites Naturalis
Graphites Naturalis is one of the prominently indicated Homeopathic medicines for psoriasis of the scalp. It is useful where the scalp is covered in excessive scales. It is attended with intense itching. The scalp may emit foul odour and the hair may get matted together. Burning sensation on the scalp may arise in hot weather.
Antimonium Crudum
Antimonium Crudum is a very useful Homeopathic medicine for treating nail psoriasis. The person needing Antimonium Crudum has brittle nails. In some cases, the nails grow out of shape.
Nail discoloration is also observed. If there is pain under the skin of the nail, Antimonium Crudum is the ideal choice of Homeopathic medicine.
Rhus Tox
Rhus Tox is one of the best Homeopathic medicines for joint pains arising in psoriasis cases. A person who needs prescribing Rhus Tox will have highly inflamed and painful joints. Joint stiffness will be marked.
Warm applications on the affected joints bring relief. Movement, too, provides relief. On the other hand, exposure to cold air worsens joint pains.
Lifestyle tips to treat psoriatic arthritis
The symptoms of PsA often flare up during periods of stress or fatigue. It may help people with PsA to change their lifestyle to reduce stress since stress is associated with increased inflammation. Doing so also helps people to get adequate sleep so that the body can heal itself.
The following tips and suggestions may help
Relaxing – Using aromatherapy, breathing techniques, and keeping a journal may help manage stress and promote relaxation.
Getting gentle exercise – Exercise is recommended for people with PsA. They may find yoga and tai chi particularly useful for helping to loosen stiff joints and release stress.
Meditating – Meditation may result in a deeper level of relaxation that may help alleviate stress, so helping prevent or manage symptoms of PsA.
Getting enough sleep – Sleep is crucial to allowing inflammation to heal and to promoting good health.
Taking a warm bath – Spa therapy, including hydrotherapy like a warm bath, can loosen joints and ease pain and inflammation associated with PsA. These therapies can also promote relaxation and decrease stress.
Practicing mindfulness – Being mindful involves checking in with the body and taking stock of how its feeling. It also involves being aware of any situations that may cause unnecessary stress.
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