Patient education: Psoriatic arthritis (Beyond the Basics)
- Dafna D Gladman, MD, FRCPC
Dafna D Gladman, MD, FRCPC
- Professor of Medicine
- University of Toronto
- Christopher Ritchlin, MD, MPH
Christopher Ritchlin, MD, MPH
- Professor of Medicine
- University of Rochester Medical Center
PSORIATIC ARTHRITIS OVERVIEW
Psoriatic arthritis is a type of arthritis that causes joint pain, swelling, and stiffness in people with psoriasis. Psoriasis is a chronic skin condition that causes patches of thick, inflamed red skin that are often covered with silvery scales.
Psoriatic arthritis affects men and women equally. Most people who develop psoriatic arthritis have skin symptoms of psoriasis first, followed by arthritis symptoms. However, in about 15 percent of cases, symptoms of arthritis are noticed before psoriasis appears. In another 15 percent of cases, psoriatic arthritis is diagnosed at the same time as psoriasis.
PSORIATIC ARTHRITIS RISK FACTORS
Researchers have not identified the exact cause of psoriatic arthritis. However, they believe that the disease develops due to a combination of genetic, immunologic, and environmental factors.
Genetic factors — About 40 percent of people with psoriasis or psoriatic arthritis have family members with psoriasis or psoriatic arthritis. This means that a close relative of a patient with psoriatic arthritis is about 50 times more likely to develop the disease than an unrelated person. If an identical twin has psoriatic arthritis, the other twin is very likely to have or to develop the condition.
Genetic researchers have identified areas on certain chromosomes that may increase the risk of developing psoriatic arthritis. Other genetic factors may contribute to the severity of disease.
Immunologic factors — A variety of immune system abnormalities have been noted in people with psoriatic arthritis.
Environmental factors — Exposure to certain infections may also contribute to the development of psoriatic arthritis. Some experts believe there is a link between streptococcal infection and the development of psoriasis and psoriatic arthritis, although the link has not been proven. Psoriatic arthritis also occurs more commonly in people infected with the human immunodeficiency virus (HIV) than in the general population.
Psoriasis frequently appears at sites where there is skin trauma. This is called the Koebner phenomenon. Some patients develop arthritis in an injured joint. Indeed, physical trauma has been identified as a risk factor for developing psoriatic arthritis among patients with psoriasis.
PSORIATIC ARTHRITIS SYMPTOMS
Symptoms of psoriatic arthritis include:
●Pain and tenderness in the joints (picture 1).
●Difficulty moving or stiffness in the joints and/or in the back. About half of all patients have morning stiffness lasting more than 30 minutes.
●Skin patches (also called plaques) that are dry or red, usually covered with silvery-white scales, which may have raised edges (picture 2).
●Nail abnormalities, such as pitted, discolored, or crumbly nails (picture 3).
Some people with psoriatic arthritis have more difficulty with stiffness and immobility than with joint pain. (See "Clinical manifestations and diagnosis of psoriatic arthritis".)
Patterns of psoriatic arthritis — Psoriatic arthritis tends to affect certain groups of joints. The following terms are used to describe patterns of psoriatic arthritis:
●Distal arthritis – This type of psoriatic arthritis affects the end joints of the fingers and toes.
●Asymmetric oligoarthritis – This type of psoriatic arthritis affects fewer than five small or large joints in the body but does not necessarily occur on both sides of the body. (For example, a person might experience joint pain in one elbow but not the other.)
●Symmetric polyarthritis – This type of psoriatic arthritis affects five or more joints on both sides of the body (ie, the right and left knee). It produces symptoms similar to those of rheumatoid arthritis.
●Arthritis mutilans – This type of psoriatic arthritis deforms and destroys the joints, and it is often accompanied by a shortening of the affected fingers or toes (picture 4).
●Spondyloarthritis – This type of psoriatic arthritis affects the joints of the spine.
Polyarthritis is the most common type of psoriatic arthritis, followed by oligoarthritis. Less than 20 percent of patients experience distal arthritis alone, but those who do may also have spondyloarthritis. Arthritis mutilans, the deforming type of arthritis, can occur along with any other pattern of arthritis, but is less common.
Associated problems — In addition to the joint pain and stiffness that psoriatic arthritis causes, there may also be swelling in the areas where tendons attach to bones, a condition called enthesitis. Sites that are commonly involved include the Achilles tendon attachment to the back of the heel, the attachment of plantar fascia (the tendon in the sole of the foot) to the heel, and the area that tendons attach to the pelvic bones. Another condition, tenosynovitis, can occur when the sheaths surrounding certain tendons, especially those in the hands and arms, become swollen and inflamed.
Almost half of people with psoriatic arthritis also experience dactylitis, which causes an entire finger or toe to swell (sometimes called sausage finger or toe). Dactylitis may be associated with progressive joint damage (picture 5). People with psoriatic arthritis sometimes develop swelling of the hands and feet that is not limited to the joints. This swelling may occur before any joint symptoms of psoriatic arthritis are noted.
Eighty to 90 percent of people with psoriatic arthritis have nail problems. They may develop pitted nails, which look as if someone has taken a pin and pricked the nail several times, or there may be early separation of the nail from the nail bed. The severity of a person's nail problems is often similar to the severity of the skin and joint problems (picture 3).
In some cases, people with psoriatic arthritis also experience eye problems. Inflammation of the structures of the eye can cause eye pain and redness and is referred to as uveitis or iritis.
Like patients with psoriasis, patients with psoriatic arthritis may be at increased risk of heart disease or stroke; certain medicines and lifestyle changes might help decrease this risk.
PSORIATIC ARTHRITIS DIAGNOSIS
Health care providers diagnose psoriatic arthritis by obtaining the medical history, performing a physical examination, and taking x-rays of the joints to check for inflammation and joint damage. Blood tests or joint fluid tests may be done to rule out other diseases, such as rheumatoid arthritis and gout.
In some cases, a magnetic resonance imaging test (MRI) may be used to detect joint and soft-tissue inflammation that cannot be seen on x-rays. Because psoriatic arthritis may be associated with a loss in bone mineral density, tests may also be used to determine if you are at risk for osteoporosis or have an increased risk of bone fractures. (See "Patient education: Bone density testing (Beyond the Basics)".)
Psoriatic arthritis may be confused with other forms of arthritis, such as rheumatoid arthritis and, occasionally, osteoarthritis. However, the skin lesions, nail problems, and specific patterns of inflammation observed in psoriatic arthritis allow clinicians to differentiate it from other forms of inflammatory arthritis.
Psoriatic skin disease may be treated with topical applications (creams or lotions) or phototherapy. Skin problems that are resistant to topical therapy may require the use of oral treatments (pills). Patients with moderate to severe psoriasis may require treatment with biologic agents. (See "Patient education: Psoriasis (Beyond the Basics)".)
Although effective in controlling the skin symptoms in most patients, none of these treatments work in all patients. Moreover, none can cure psoriasis; most patients have a flare of symptoms if treatment is discontinued. Thus, prolonged therapy is generally required.
PSORIATIC ARTHRITIS TREATMENT
Psoriatic arthritis treatment can help to relieve joint pain and stiffness, as well as the other symptoms of psoriasis . More detailed information is available separately. (See "Treatment of psoriatic arthritis".)
Weight loss — Up to 40 percent of psoriatic arthritis patients are obese. Several studies have demonstrated that weight loss can improve response to medical treatments for both psoriasis and psoriatic arthritis.
Exercise and physical therapy — Treatments such as heat, exercise, and physical therapy may also help to relieve the pain and stiffness associated with psoriatic arthritis. A separate article discusses exercise and arthritis. (See "Patient education: Arthritis and exercise (Beyond the Basics)".)
Nonsteroidal antiinflammatory drugs — Nonsteroidal antiinflammatory drugs (NSAIDs) can help to control inflammation and to relieve the pain of psoriatic arthritis. NSAIDs must be taken continuously and at a sufficient dose to have an antiinflammatory effect.
NSAIDs must usually be taken for several weeks before their full degree of effectiveness as an antiinflammatory is known. If the initial dose of an NSAID does not improve symptoms, a clinician may recommend increasing the dose gradually or switching to another NSAID.
●Nonselective NSAIDs include over-the-counter drugs, such as aspirin, ibuprofen, and naproxen, and a number of prescription-strength NSAIDs.
●Selective NSAIDs (also called cyclooxygenase [COX]-2 inhibitors) are as effective as nonselective NSAIDs and are less likely to cause gastrointestinal injury and side effects. Celecoxib (brand name: Celebrex) is the only COX-2 inhibitor available in the United States.
Detailed information about NSAIDs is available in a separate article. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)
Glucocorticoid injections — Glucocorticoids, also called steroids, can suppress inflammation and can relieve pain when injected into affected joints. Oral glucocorticoids are not usually recommended for people with psoriatic arthritis because they may cause a severe form of skin psoriasis.
Joint injections have few side effects, but some people experience a brief flare of pain after an injection. There is also a very small risk of joint infection.
Methotrexate — Methotrexate is a disease-modifying antirheumatic drug (DMARD) that reduces excessive production of skin cells and may also suppress the immune system. It is often recommended for people with multiple swollen joints caused by psoriatic arthritis, although convincing evidence of its effectiveness has not been demonstrated.
It is usually taken once per week as a pill or by injection. Treatment with higher doses may require that it be injected under the skin, which may be done by a patient or family member.
Taking folic acid or folinic acid can reduce the risk of certain methotrexate side effects, including risk of liver problems related to methotrexate. Patients who use methotrexate should not drink alcohol. The most serious potential side effects of methotrexate include liver toxicity, lung disease, and bone marrow suppression. (See "Patient education: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)".)
Sulfasalazine — Sulfasalazine (sulphasalazine, salazopyrin) is a DMARD that may be effective for the joint pain and skin lesions associated with psoriatic arthritis.
However, not all patients benefit from sulfasalazine, and many patients cannot tolerate it due to gastrointestinal side effects. Patients who are allergic to sulfa drugs should not use sulfasalazine. (See "Patient education: Sulfasalazine and the 5-aminosalicylates (Beyond the Basics)".)
Leflunomide — Leflunomide is a DMARD that can improve both skin and joint disease symptoms. (See "Patient education: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)".)
Possible side effects include diarrhea and elevated liver enzymes, and only about 40 percent of people with psoriatic arthritis benefit from this treatment. Experts may recommend leflunomide if you have not adequately responded to or have had side effects with methotrexate.
Cyclosporine — Cyclosporine is a drug that suppresses the immune system and is also used to treat severe psoriasis and psoriatic arthritis. It was used more in the past, before the availability of the tumor necrosis factor (TNF) inhibitors, but still may be helpful for some people with psoriatic arthritis. It may take three to four months before a response is seen. Adding cyclosporine to methotrexate may be more effective than either treatment alone. Side effects of cyclosporine can include reduced kidney function and high blood pressure.
Tumor necrosis factor inhibitors — TNF-alpha inhibitors are among the group of drugs called biologic DMARDs or biologic response modifiers. These drugs interfere with inflammation and the immune response. Drugs in this class include proteins that interfere with the actions of TNF, such as etanercept (brand name: Enbrel), adalimumab (brand name: Humira), infliximab (brand name: Remicade), and golimumab (brand name: Simponi). If a traditional DMARD, such as methotrexate, has been ineffective, a medication from this class of agents will often be effective.
Biologic agents, such as the TNF inhibitors, usually work rapidly, often within two weeks. They may be used alone or in combination with other DMARDs, NSAIDs, and/or glucocorticoid injections. Because of their very high cost, they are often reserved for people who have not responded fully to DMARDs or who cannot tolerate DMARDs in doses large enough to control psoriatic arthritis symptoms.
All biologic agents must be either injected or given intravenously, depending on the medication. Humira and Enbrel are injected under the skin by the patient, a family member, or a nurse. Intravenous infusion is necessary for Remicade; this is typically done in a doctor's office or an outpatient infusion center and takes one to three hours to complete.
Ustekinumab — A medication called ustekinumab (brand name: Stelara) is sometimes used in people who do not get better with the options listed above. This medication interferes with inflammation by blocking not TNF but another set of proteins involved in the immune response called interleukin (IL)-12 and IL-23. It may be used in patients who do not tolerate or have been unresponsive to anti-TNF agents. It has been shown to slow joint damage. It is injected under the skin by the patient, a family member, or a nurse. Like the TNF inhibitors, this drug increases the risk of infections and might increase the risk of cancer.
Secukinumab and ixekizumab — Secukinumab (brand name: Cosentyx) and ixekizumab (brand name: Toltz) are medications which, like ustekinumab, may provide alternatives to TNF inhibitors in some cases. They affect the immune response by interfering with a protein called IL-17. Both are given as an injection under the skin. They increase the risk of infections and might increase the risk of cancer.
Apremilast — Apremilast (brand name: Otezla) is a new medication for psoriatic arthritis that comes in pill form. Doctors are still learning about how best to use this medication. People taking apremilast should have their weight monitored regularly, because the medication can cause significant weight loss. Use of apremilast has also been associated with an increase in reports of depression compared with placebo, but it does not cause significant laboratory abnormalities. This medication has not been demonstrated to inhibit joint damage.
Lifestyle modification — Weight loss of 10 percent or more of body weight in obese patients can dramatically increase response to anti-TNF agents. A combination of exercise and weight loss may also lessen the chance of developing diabetes and may improve cardiovascular health in patients with psoriatic arthritis.
●Psoriatic arthritis is a type of arthritis that affects some people with psoriasis, a disorder that causes inflammation and thickening of the skin.
●Researchers have not identified the exact cause of psoriatic arthritis. However, they believe that the disease develops due to a combination of genetic, immune, and environmental factors. (See 'Psoriatic arthritis risk factors' above.)
●Psoriatic arthritis can cause joint pain, immobility, and stiffness; dry, red patches (plaques) also form on the skin. Some people also experience problems with their fingernails or eyes. (See 'Psoriatic arthritis symptoms' above and 'Associated problems' above.)
●Psoriatic arthritis tends to affect certain groups of joints. The most common type of psoriatic arthritis affects five or more joints on both sides of the body. (See 'Patterns of psoriatic arthritis' above.)
●Physical examination, x-rays, and, sometimes, magnetic resonance imaging (MRI) are used to diagnose psoriatic arthritis. Skin and nail symptoms, as well as the pattern of joint pain and stiffness, help to determine if arthritis is psoriatic or not. (See 'Psoriatic arthritis diagnosis' above.)
●Symptoms of skin psoriasis are usually treated with creams or lotions and, in some cases, with light therapy. (See 'Psoriasis treatment' above.)
●Heat and physical therapy may help to relieve joint pain and stiffness. Joint inflammation is often treated with medications given as pills or injections. (See 'Psoriatic arthritis treatment' above.)
WHERE TO GET MORE INFORMATION
Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Psoriasis (The Basics)
Patient education: Psoriatic arthritis in adults (The Basics)
Patient education: Disease modifying antirheumatic drugs (DMARDs) (The Basics)
Patient education: Psoriatic arthritis in children (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Bone density testing (Beyond the Basics)
Patient education: Psoriasis (Beyond the Basics)
Patient education: Arthritis and exercise (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient education: Joint infection (Beyond the Basics)
Patient education: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)
Patient education: Sulfasalazine and the 5-aminosalicylates (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
The following organizations also provide reliable health information.
●The Arthritis Society of Canada
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/ency/article/000413.htm, available in Spanish)
●National Psoriasis Foundation
- Mease PJ. Psoriatic arthritis - treatment update. Bull NYU Hosp Jt Dis 2011; 69:243.
- Turkiewicz AM, Moreland LW. Psoriatic arthritis: current concepts on pathogenesis-oriented therapeutic options. Arthritis Rheum 2007; 56:1051.
- Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Ann Rheum Dis 2005; 64 Suppl 2:ii3.
- Jones G, Crotty M, Brooks P. Interventions for psoriatic arthritis. Cochrane Database Syst Rev 2000; :CD000212.
- Heiberg MS, Kaufmann C, Rødevand E, et al. The comparative effectiveness of anti-TNF therapy and methotrexate in patients with psoriatic arthritis: 6 month results from a longitudinal, observational, multicentre study. Ann Rheum Dis 2007; 66:1038.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.