The Empowered Patient's Guide to Psoriatic Arthritis

Psoriatic arthritis affects some people already diagnosed with psoriasis – but not all. Here's what you need to know about this inflammatory and painful condition, from identifying symptoms to managing treatments.  

Psoriasis. Arthritis. Psoriatic arthritis, right? Well, no. Psoriatic arthritis is its own unique condition. Not everyone who has psoriasis will develop psoriatic arthritis (PsA) and not all with PsA have psoriasis. The two diseases do, however, share the same root cause: the body’s immune system goes into overdrive, causing inflammation. In psoriasis, it manifests in thickened, scaly skin. And in PsA, it shows up as joint pain. What’s more, about 10% to 20% of people with psoriasis will eventually develop psoriatic arthritis, according to the US Centers for Disease Control and Prevention (CDC).1 If you are among the percentage of people diagnosed with this inflammatory condition, early treatment is important to relieve symptoms and prevent joint damage. Fortunately, a growing number of approaches are available that ease living with PsA.

 

SO, WHAT IS PSORIATIC ARTHRITIS EXACTLY?

Psoriatic arthritis is a type of arthritis that affects a minority of people already diagnosed with psoriasis. Psoriasis is a chronic skin condition that commonly causes thickened and scaly patches around joints and other areas where tissues attach to bones. According to the CDC, about 10 to 20% of people with psoriasis will develop psoriatic arthritis.1

So why do less than one quarter of people with psoriasis go on to develop PsA, and why do some people develop PsA without ever having psoriasis? Researchers don’t completely know, though both genetic and environmental factors likely play a role.

What is known is that, for most people, PsA starts about 10 years after developing psoriasis and typically begins between the ages of 30 and 50. Psoriasis must be present at some point in time for the diagnosis, but the skin manifestations may precede any joint disease for months or even years and occasionally no skin abnormalities are obvious until the arthritis has been well-established. About 80% of patients will have had psoriasis first or around the same time that the arthritis began. Nail and scalp involvement are more common in psoriasis patients who also have arthritis. The prevalence of PsA in patients with psoriasis is around 20% and is slightly higher in those with more extensive skin disease.2,3

Like other forms of systemic arthritis, PsA is both an autoimmune disease and an inflammatory disease –  meaning that the body’s immune system attacks healthy cells by mistake, causing inflammation and painful swelling.

 

Types of Psoriatic Arthritis and Where PsA Shows Up on the Body

Most people will experience psoriatic arthritis in a few joints – but there are different types and locations on the body where it may show up.

In fact, you may be told you have a specific type of PsA based on where the inflammation occurs. Some people experience asymmetric symptoms in which joints on one side of the body are affected, such as one wrist or one knee, while others have symmetric symptoms, involving the same joints on both sides of the body, such as both knees.

The most common types are:

  • axial spondyloarthritis (also called spondyloarthropathy or axSpA) which mainly affects your back, including your sacroiliac joints (these link your pelvis to your spine). About 40% of those with PsA joint pain experience spine and sacroiliac joint pain.4
  • distal, small joint polyarthritis, especially involving what are called the “distal interphalangeal (DIP) joints” – that’s your first knuckle from the top of the finger. About 50% of people with PsA experience inflammation in the entire finger – this is clinically termed dactylitis – you may hear people call it sausage digit or sausage finger.  Toes may also be affected.
  • symmetric, small joint polyarthritis, which affects multiple joints on both sides of your body and can be very similar to rheumatoid arthritis – a rheumatologist can help to differentiate
  • asymmetric oligoarthritis, meaning a few joints (less than 4) are affected on one side of your body, usually your lower body such as the knee, ankle, or foot.  

Many patients have more than one of these joint patterns, and, not infrequently, those with PsA affecting their spine may also have arthritis in their hands or feet.

As with any form of inflammatory arthritis, such as rheumatoid arthritis, PsA is mainly diagnosed by your symptoms and a physical exam by your doctor. Laboratory tests may look at erythrocyte sedimentation (ESR) or C-reactive protein (CRP) rates and X-rays of affected joints may be recommended.

Regardless of the type, early diagnosis and treatment are crucial to reduce inflammation, control pain, and prevent the disease from getting worse. Treatment choices will depend on how active the disease is. Fortunately, many options are now available.

BUT WAIT, PSA GETS MORE COMPLICATED: SYMPTOMS AND CAUSES

Psoriatic arthritis can progress over time. In some people, it only causes mild disease punctuated by severe symptoms during periods of more disease activity (called flares). In others, disease activity is more persistent. No matter which camp you’re in, early treatment is critical to relieve pain from affected joints, prevent joint damage, and to maintain your ability to walk and be active.5

Treatment will also help to reduce or prevent other health-related problems from developing, such as fatigue and depression (more on this later).

The good news is that if diagnosed and treated early (such as when you notice and pain and swelling in your hands or feet), many of these problems can be avoided or reduced. Learning to recognize the symptoms of PsA will help you and your doctor intervene to lessen the impact of the disease on your life and prevent potentially irreversible changes to your joints and bones.

Psoriatic Arthritis Symptoms

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, psoriatic arthritis symptoms, which can range from mild to severe, may include:6

  • joint pain and swelling that comes and goes
  • tenderness on the bottom of the foot or heel
  • pain and stiffness in the lower back and neck
  • stiffness in the joints, particularly upon waking
  • painful swelling in the toes and/or fingers
  • thickness and reddening of the skin with scales (flaky, silver or white patches)
  • pitted nails or separation of the nail from the nail bed
  • pink eye or other infections of the eye

Psoriatic Arthritis Causes

No one knows for sure what causes psoriatic arthritis. You may inherit a gene from your family that places you at increased risk of developing it, environmental factors may play a role, or both.

As noted, PsA develops most of the time in people who already have psoriasis (about 70%) and usually shows up between the ages of 30 and 50 (although it can be diagnosed in children). Both men and women are affected equally, and it is more common in whites than Blacks, Hispanics, or Asians.7

While the specific cause of PsA remains unknown, ongoing research is focusing on a few potential factors that may play a role, namely genetics. Up to 40% of people with PsA have a family member with it (most studies have been with an immediate family member).6 Research now shows that changes in a number of genes may put a person at higher risk of developing the disease.

Take the gene family called the human leukocyte antigen (HLA) complex. It may not only influence the risk of developing psoriatic arthritis, but also the type and severity of the disease. The HLA complex helps the immune system to recognize a foreign invader like a virus or bacteria, and normal variations in each HLA gene allow the immune system to react to a wide range of invaders. In some people, the frequency of certain HLA genes seems to increase their risk of developing PsA.8-10

 

WHAT ELSE TO EXPECT WHEN LIVING WITH PSORIATIC ARTHRITIS

With high levels of inflammation in your body, you may also experience fatigue and anemia, mood changes or depression (more on mental health below), or develop chronic widespread pain (fibromyalgia). Other potential conditions that you may be slightly more likely to develop:6

Your doctor will likely monitor these measures regularly.

 

HOW TO TREAT PSORIATIC ARTHRITIS

The main goals in managing PsA are to stop disease progression, reduce inflammation, treat skin symptoms, relieve pain, and keep your joints moving as much as possible.11 A dermatologist and rheumatologist (these doctors specialize in arthritis and autoimmune diseases) should coordinate your treatment plan. A physical therapist may also be helpful to help increase your flexibility and strength.11

For those people with psoriatic arthritis and psoriasis, your doctor will design a treatment plan that addresses both conditions.

The foundation of PsA treatment includes medications that control inflammation in the body and reduce pain. Medications may include the following and are usually recommended based on the severity of your PsA symptoms.

Mild Disease: The goal of treating mild PsA is primarily to ease pain and reduce inflammation. A number of anti-inflammatory drugs may be recommended, such as:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs include drugs like ibuprofen and naproxen sodium that can be purchased over-the-counter as well as prescription-grade NSAIDS, such as celecoxib or diclofenac.
  • Corticosteroids: These are more powerful anti-inflammatory drugs that are prescribed by a doctor and can be taken either by mouth or injected in the doctor’s office. These medications are only used for brief periods of time for disease flare-ups because of their adverse long-term side effects.

More Severe and Persistent DiseaseFor people who continue to have symptoms even after taking anti-inflammatory medications listed above – and if they have persistent inflammation of their joints – stronger drugs that target the immune system may be recommended. These medications may include:

  • Disease-modifying antirheumatic drugs (DMARDs): These anti-inflammatory drugs must be prescribed by a doctor and include as methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine.
  • Traditional Biologics: This class of drugs works to inhibit the activity of a substance in the body called “tumor necrosis factor” or TNF, which can cause inflammation and lead to diseases of the immune system. These medications are referred to as anti-TNF drugs or TNF inhibitors and include adalimumab, golimumab, etanercept, and infliximab.
  • New Biologics: This class of drugs inhibits the activity of a protein in the body called “interleukin (IL)” that promotes inflammation. These medications are referred to as interleukin inhibitors and include ustekinumab and secukinumab.

Recent guidelines from the American College of Rheumatology (ACR) suggest that people with active PsA disease try anti-TNF drugs first. If these don’t work, the ACR recommends considering one of the newer interleukin inhbitors.12

Other important components of PsA care may include weight loss (this can help lessen load on damaged joints), stopping smoking, and utilizing physical therapy. Physical therapy may be used in certain cases to strengthen your muscles around joints so they remain stable, and maintain motion. Patients with damaged joints may require an orthopedic evaluation and surgical intervention.

WHY YOUR MENTAL HEALTH MATTERS WHEN LIVING WITH PSORIATIC ARTHRITIS 

Living with a chronic condition that requires life-long management to ease pain and reduce disease progression can take its toll on a person’s mental and emotional reserves. Anxiety and depression are both prevalent in people with psoriatic arthritis, with data showing 1 in 3 patients with at least mild anxiety and 1 in 5 with at least mild depression.

Not only do anxiety and depression interfere with your quality of life, but they also are linked to greater disease activity.13 So it is important to recognize any mental or emotional challenges you may be feeling and seek help.

 

SELF-CARE

The Arthritis Foundation offers a number of health and wellness resources and lays out self-management tips to help take care of both your physical and emotional needs. Here’s a quick look:11,14,15

  • Get exercise: Staying active keeps your joints moving smoothly. As a bonus, it can help you maintain a healthy weight and reduce inflammation on joints. Low-impact exercises are best, such as walking, swimming, or biking.
  • Eat a balanced diet: Eating a healthy diet can help with weight and overall health. A good example of is the Mediterranean diet, which includes fish, nuts/seeds, fruits/vegetables, olive oil, and beans.
  • Rest when you can. Train your muscles to relax; try deep breathing exercises and pace yourself.
  • Follow a sleep routine. Getting good sleep can help to reduce daytime fatigue, pain, and mood shifts.
  • Manage stress: Stress can worsen PsA by making it harder to engage in exercise or other daily activities. Reduce stress in your daily routine with meditation, walking, listening to music, yoga, or tai chi.
  • Try out self-help devices to make daily tasks easier, such as electric can openers/food processors when cooking, long-handled tools for reaching items stored high or low, tub bars and handrails in the bathroom, and adjustable chairs and worksurfaces in offices. Occupational therapists are good resources to find a device recommendation (see our gadget guide as well).

 

WHAT CAN I DO RIGHT NOW?

  1. Get a correct diagnosis by working with a rheumatologist who can differentiate your symptoms from other conditions and provide an effective treatment plan. To find a rheumatologist by zip code. 
  2. Set up a care team that includes your rheumatologist and primary care doctor, as well as a dermatologist to manage any skin issues and a therapist to guide through potential mood changes, fatigue, and depression. You can also find resources to help with emotional difficulties with the National Alliance on Mental Illness (NAMI), Anxiety and Depression Association of America, the Arthritis Foundation (www.arthritis.org/health-wellness/healthy-living/emotional-well-being/anxiety-depression/treating-depression-and-anxiety-in-arthritis), or  Depression and Bipolar Support Alliance.
  3. Exercise – keep your joints moving.
  4. Keep a sleep and mood diary to track your sleep times and to see whether your mood is changing more than usual. If so, note these points and any other questions at your next doctor’s visit.
  5. Be an Advocate: Sharing your experience of living with psoriatic arthritis can help in supporting others with the condition, as well as doctors who care for them. Check out ways to get involved with the National Psoriasis Foundation walks and runs, Team NPF or the 50-state network.

 

CRUSH THE STIGMA

When you tell someone you have psoriatic arthritis, they may only hear the arthritis part of it as that is the most familiar to them. Many people don’t know there are different types of arthritis – they lump together osteoarthritis, rheumatoid arthritis, and psoriatic arthritis. You are in a good position to educate people on the differences and to share your experiences. Although all three of these conditions can share similar symptoms, there are important distinctions.

Rheumatoid arthritis, like psoriatic arthritis, is an autoimmune disease that causes damages to joints. Unlike psoriatic arthritis, rheumatoid arthritis does not damage the skin and is not linked with psoriasis. Also, people with rheumatoid arthritis have joint swelling, stiffness, and pain that usually begins the fingers/toes on both sides of the body rather than the back and pelvis joints, usually on one side of the body, in people with psoriatic arthritis.16

Osteoporosis, unlike both psoriatic arthritis and rheumatoid arthritis, is not an autoimmune disease but a condition caused by a loss of bone mass and change in bone structure in which the joint cartilage breaks down over time causing swelling, stiffness, and pain.17

 

FAQs

What are the first signs of psoriatic arthritis?

The first signs that you may have psoriatic arthritis include pain and swelling of your joints, such as your hands, feet, and wrists. You may also notice a small patch of red thickened skin that is scaly on areas of your body, which is a sign of psoriasis. You also may feel stiff and tired.

What are the types of psoriatic arthritis?

The most common are: axial spondyloarthritis(also called spondyloarthropathy or axSpA) which mainly affects your back and sacroiliac joints; distal, small joint polyarthritis, which affects your fingers and toes; symmetric, small joint polyarthritis, affects several joints on both sides of the body and is very similar to rheumatoid arthritis– a doctor can help to differentiate; and asymmetric oligoarthritis – meaning a few joints (less than 4) are affected on one side of your body, usually your lower body.

What organs does psoriatic arthritis affect?

Due to widespread inflammation, psoriatic arthritis can affect your internal organs but this occurs only in very rare cases and should not be a major concern. More common symptoms to watch out for – beyond joint pain and inflammation – are fatigue and anemia, mood changes or depression, high blood pressure/cholesterol, diabetes, and obesity.

Do certain foods trigger psoriatic arthritis flares?

There is no substantial evidence that diet impacts PsA disease or symptoms. If you wish to change what you eat and see if it helps, see anti-inflammatory diets for pain

Updated on: 08/12/20
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Psoriatic Arthritis Causes
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