Psoriatic arthritis – Basics for the patient
Psoriatic arthritis (PsA) is a rheumatology disease which causes pain, stiffness and swelling in joints. It occurs in patients who have psoriasis or who have a close family member with psoriasis. Psoriasis is a skin disease. In it patients have red, thick patches on skin which are often covered with white or silver scales. People with very few patches of psoriasis can also have psoriatic arthritis. Some patients with arthritis don’t know that they have a psoriasis patch on the body. A Rheumatologist doctor can actually find one.
Psoriatic red patch on elbow with silver white flakes over it
Researches haven’t found exact cause of Psoriasis or Psoriatic arthritis. These are like autoimmune disease. To understand what is autoimmune disease, you can read here.
There is good evidence to say that psoriasis and psoriatic arthritis occurs due to collective combination of various factors. These can be genetic or environmental.
For example about 40 % of patients with psoriasis or psoriatic arthritis have family member with psoriasis or psoriatic arthritis. However psoriasis is not hereditary and not always passed from generation to generation. Many people can have genes which increases their chances of psoriasis or psoriatic arthritis. However, what makes only few of these people develop arthritis or psoriasis is not clear.
There is no clear-cut environmental cause identified. However, some infections or trauma can start psoriasis or psoriatic arthritis.
Basically many genetic factors and environmental factors might have to happen together for somebody to develop psoriasis or psoriatic arthritis. There is no one single factor identified.
- Psoriatic arthritis patients have pain and swelling in joints. It can involve any small joints (like hands, feet, finger joints, toe joints) or large joints (knee, ankle, wrist) of the body.
- Sometimes whole finger (foot or hand) can swell up like a hot dog or sausage. We call it ‘dactylitis’(dactyl means digit i.e fingers of hand and feet. Dactylitis – means inflammation of digits).
- They can also have pain in lower back which increases at night while sleeping and getting up in morning.
- Both joint pains and back pain can have significant stiffness especially in early mornings when one gets up from sleep.
- Patients can have swelling and pain at back of the heel (achilles tendon insertion), side of the hips or at the heel base (plantar fasciitis). These are not joints, but sites where tendons get attached. These sites are called entheses and inflammation in these sites is called ‘enthesitis’.
- Patients with psoriasis have red skin patches which are covered with white flakes. Some people have such lesion on head or scalp and is covered by hair. Such patients feel they have a lot of dandruff.
- Many patients with psoriasis and psoriatic arthritis have nail problems. Nails might have many small pits or yellowish discolouration, may be easily broken etc.
Psoriasis affecting nails – Many patients with nail psoriasis have psoriatic arthritis – JVO27 [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
Other issues than joint and bone pains in psoriatic arthritis patients
- 10-15 percent of psoriatic arthritis patients may have inflammation or redness of front part of the eye – This is known as ‘uveitis‘. Many a times patients present to eye doctor with red-eye (uveitis) and they refer to arthritis (rheumatologists) or skin specialists for diagnosis of psoriasis or psoriatic arthritis.
- Psoriatic arthritis patients are more overweight or obese than average – we don’t know the exact reason. Also many of these patients have very high uric acid (in these cases uric acid is not causing the arthritis). Psoriatic arthritis patients are also at increased risk of hypertension and heart or vessel blockage diseases compared to average normal people. However we can decrease these risks by changing lifestyle and medications.
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There is no single blood or any other test for diagnosis of psoriatic arthritis. Diagnosis of PsA is best made by people who see such patients routinely. In most parts of the world, a Rheumatologist will help to make a diagnosis of psoriatic arthritis. The diagnosis is made on the basis of combination of – presence of psoriasis in the patient or family member, history of patient, clinical examination to look for pattern of joints involved or nails and imaging. The doctors might use blood tests to rule out other arthritis. Imaging in the form of Xray or MRI may be used for diagnosis.
The aim of therapy is to control both psoriasis and psoriatic arthritis. Controlling the disease and inflammation improves quality of life by decreasing or stopping pain. It also helps prevent joint damage and decrease the risk of joint surgeries. The ideal aim is to achieve a state of remission (complete control with no signs of active disease). Since psoriatic arthritis is like an autoimmune disease, we need medicines to control the overactive immune system.
The following are commonly used therapies for psoriatic arthritis. Most drugs given in patients with psoriasis and psoriatic arthritis control both skin disease and arthritis. The therapy is continuously followed up and all measures are taken to prevent side effects. If patients body is not tolerating we change the drugs. At any given time most patients require more than one drug to control the disease, especially at the start.
- NSAIDS – Non steroidal anti-inflammatory drugs (eg : Etoricoxib, naproxen, ibuprofen, diclofenac etc.) : In many countries, they are commonly known as pain killers. However, we give them to control both pain and inflammation (swelling) in psoriatic arthritis. Controlling inflammation is very important for arthritis control. We have to sometimes give these drugs for long periods to help control inflammation. If given in the correct amount and in the right way, then they can be very beneficial.
- Disease modifying anti-rheumatic drugs (DMARDS) : These are medications, which regulate the ‘auto’ active immune system in PsA and control the disease so that disease doesn’t cause any damage. Eg : Methotrexate (Folitrax, Mexate, Neotrexate etc), Leflunomide (Lefno, Lefra, Arava, Cleft etc), Sulfasalazine (Saazo, Saaz, SSZ etc), Hydroxychloroquine (Hydroquine, HCQs, ZyQ, Plaquenil etc), Cyclosporine
- Apremilast (Brand names, Aprezo : Glenmark, Apraize : Ipca, Otezla : Celgene ) & Tofacitinib (Brand name : Xelzanj) : This is a drug which is like a DMARD, but it works by a unique function and is a new drug developed for Psoriatic arthritis. It is decently effective in controlling psoriasis and arthritis.
- Biologics DMARD’s or Biologics – In last 20 years, field of rheumatology has changed drastically. We initially had very few drugs to treat rheumatology diseases like PsA. Biologics drugs were developed after extensive and groundbreaking research. They target very specific molecules or pathways in the body and can give very good results in controlling rheumatic diseases. They have changed the lives of many psoriasis and psoriatic arthritis patients around the world.
Some common biologics used in Psoriatic arthritis :
Infliximab (Sample Brand Name: Remicade, Infimab, Remsima) ; Adalimumab (Sample Brand Name: Humira, Exemptia);
Etanercept (Sample Brand Name: Enbrel, Intacept, Etacept),
Secukinumab (Cosentyx, Scapho);
Ustekinumab (Stelara)
We decide which treatment to give to the patient depending on various factors below
- How bad is your disease?
- How many of your joints are involved?
- What do your blood tests and X-ray show?
- How your disease has progressed? What are your preferences? Are you planning pregnancy ?
- What side effects you feel with the medicines you try – do you have any other associated disease?
- It also sometimes might depend on what you can afford – this especially in a country like India where most insurance policies do not cover Psoriatic arthritis.
There is still no cure for PsA. But don’t get disappointed with this news. The treatment of PsA has changed dramatically. With proper treatment early in the disease, most people with PsA can lead a happy, pain-less or pain-free. PsA usually is a long term disease. But, some patients with PsA can have very mild disease. Their disease may become silence (remission) for long periods.
Psoriatic arthritis is a very severe arthritis. If we don’t control it early it can damage joints permanently (see image below). This can lead to many deformities. Many of these deformities are persistent and we cannot replace all damaged joints in the body. Poor control of this disease also leads to lot of pain and very poor quality of life. Early good treatment is very important to prevent or minimise any damage to joints.
Psoriatic arthritis patients who did not get proper allopathy treatment – deformities of hand joints, image below shows knee psoriasis (partially healed) in same patient.
Psoriasis knee (partially healed), same patient as above
PsA (psoriatic arthritis) is one of the most severe arthritis diseases. Early treatment with proven drugs can control disease very well and give a very good quality of life. In last 20 years, allopathy research has understood a lot about what drives PsA. There are drugs now designed to target pathways very specifically in RA.
Current allopathy treatments can control PsA by 60-80% in most cases. Some patients also go into a complete silent state known as remission.
There is no such specific new drug research in Ayurveda and homeopathy. Also there is very little research on effective control of psoriatic arthritis with these two modalities.
As mentioned above the side effects of allopathy medicines are monitored very closely and we change medicines if required. Ayurveda and herbal medicines have no proof of working in PsA and on top of that they can also have many side effects.
Eating healthy is the only dietary thing required for patients with psoriatic arthritis. There are very few specific diets which have shown to have some benefits in psoriatic arthritis patients. However, the evidence is not strong and in any case those diets mostly contain healthy foods.
Despite many claims, there is no good evidence that any specific diet can cure psoriasis or psoriatic arthritis.
- Have a healthy lifestyle : It may help patients to control their inflammation. it also helps patients with psoriatic arthritis to decrease increased risk of heart attacks and strokes. Eat healthy diet – lots of vegetables, fruits, nuts, dairy products, avoid sugar and refined foods etc. Stay active. Even mild home based exercises, walking and using stairs whenever possible etc are good ways to stay active – It helps PsA patients to keep muscles and bones strong. Avoid smoking or other addictions – smoking worsens psoriatic arthritis. Try to avoid / manage mental and physical stress. One can consider doing relaxation exercises – like meditation or mindfulness etc.
- Show an expert in psoriasis and psoriatic arthritis (like a dermatologist & rheumatologist) : Follow their directions
- Get educated about PsA : It is very important for patients to have good information and be educated about their disease, so that they can take better treatment decisions. They should ask their doctor to provide with patient information material
Read more : Learn how to plan and best manage pregnancy if you have Psoriatic arthritis
Yes, it is certainly possible. Both male and female PsA patients can conceive normally and have a healthy baby. However, one has to tell their doctor if they are planning a pregnancy. Certain drugs need change or stopping before if you are planning pregnancy. Do not wait till you get pregnant, tell your dermatologist and rheumatologist even when you are thinking of same. They will guide and adjust medications accordingly. It is better to plan pregnancy when your disease is controlled and your rheumatologist is happy for you to plan the same.
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Please read our disclaimer : Many times internet based articles are not written by certified medical writers or doctors. Do not believe them blindly. This article, however is written by a certified arthritis specialist doctor (rheumatologist) and not just any blogger. The information here is genuine and based on verified facts (as per the published post date). However, before taking any decisions based on this article, please make sure that you have read our disclaimer here.