Psoriatic Arthritis: (PsA)

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Psoriatic Arthritis: (PsA)

What is psoriatic arthritis?

Psoriatic arthritis is a chronic inflammatory disease that affects about a third of patients who suffer from the skin condition psoriasis. Psoriasis usually presents with red, silver, scaly patches on the skin. Most patients with psoriatic arthritis (PsA) develop psoriasis skin rash first and then the arthritis, however sometimes the arthritis develops first, before the psoriasis. A family history of psoriasis is an important clue that a patient may have psoriatic arthritis, in the appropriate clinical situation, when they do NOT have a history of psoriasis.

Who can develop psoriatic arthritis?

About 30% of those who suffer from psoriasis are known to develop psoriatic arthritis. It occurs equally in men and women and is most commonly present in middle-aged populations. Psoriatic arthritis can occur in early childhood as well and appears to affect whites more than other races. 

Where does psoriatic arthritis occur?

Psoriatic arthritis can occur in any joint but is most commonly seen in larger joints but can occur in many different locations - such as where bones and tendons or ligaments join, known as enthesis. Enthesitis, or inflammation of the enthesis, is one of the hallmark signs of psoriatic arthritis. Dactylitis (sausage digits) is the other hallmark sign of PsA. Examples of the most common locations in the body seen with psoriatic arthritis include:

  • Spine (also known as spondylitis)
  • Back of heel (Achilles tendonitis / enthesitis)
  • Elbow
  • Fingers (Dactylitis - sausage digits)
  • Toes (Dacylitis - sausage digits)
  • Pelvis (also known as sacroiliitis) 
  • Wrists
  • Ankles
  • Knees

Causes

What is the cause of psoriatic arthritis?

As with many other autoimmune conditions, the cause of psoriasis and PsA is not known, however, it is believed that in genetically predisposed individuals, a trigger (stressful event - infection, physical or mental stress) causes the body’s immune system to attack healthy skin and joint tissue, causing the psoriasis and inflammation arthritis. 

What risk factors are there for developing psoriatic arthritis?

There are some common traits or risk factors associated with developing psoriatic arthritis. They include:

  • Genetics- People with a family history of psoriatic or other arthritic conditions are very prone to developing psoriatic arthritis. It can be as high as a 40% chance of developing the condition.
  • Environmental factors- There is some research contributing to the development of psoriatic arthritis to different environmental triggers. Some triggers of concern include:
  1. Bacteria such as streptococcal seen in strep throat
  2. Viruses
  3. Infections, as it activates the immune system
  4. Physical trauma
  5. Stress
  • Age - Psoriatic arthritis is most common after the age of 30.

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$89

Initial Visit

$75

Follow Up

Symptoms

What are the symptoms of psoriatic arthritis?

Psoriatic arthritis symptoms can vary from person to person and usually involves occasional flares of pain, warmth, stiffness, and swelling to any joint. It can affect one joint or multiple joints at the same time and can also affect both sides of the body. Other common symptoms seen may include:

  • Fatigue
  • Anemia
  • Mood disturbances
  • Sausage like swelling of toes and fingers (Dactylitis)
  • Heel pain (Enthesitis)
  • Achilles tendinitis
  • Plantar fasciitis
  • Pitted nails
  • Rash
  • Low-grade fever

Is there an app that can help me track my PsA symptoms? 

YES - Arthritis Power is a free app created by the non-profit CreakyJoints. Within this app, you can track your pain, fatigue, sleep, and other symptoms. Assessment questions are asked on a regular basis that help you have a thorough understanding of your symptoms. Plus, by customizing the tracking, you make it more personal to your needs. In addition, medications and labs can be logged. If you want to learn more about Arthritis Power, please go to YouTube to watch this instructional video: https://www.youtube.com/watch?v=gMTyA8DCb2I 

Can serious health problems arise from psoriatic arthritis?

There is some research that links psoriasis with the development of other medical conditions such as high blood pressure, high cholesterol, obesity or diabetes. A small community of those with this arthritis may develop a more debilitating form known as arthritis mutilans. This form permanently disfigures the small bones in the hand- mostly the fingers. Lastly, psoriatic arthritis may cause eye problems known as conjunctivitis or uveitis resulting in painful, red eyes and blurred vision.

Diagnosis

How is psoriatic arthritis diagnosed?

A thorough medical history and physical examination are always recommended for accurate diagnosis of psoriatic arthritis as it can mimic other medical conditions like rheumatoid arthritis. Our practitioners at TeleMed2U may be able to help with the diagnosis of psoriatic arthritis if you may be concerned you may have this condition. They may ask if you have a prior history of the skin condition psoriasis or a family member who may have this condition. They will also examine your joints for stiffness, swelling, redness, and pain or look for skin or nail changes associated with psoriasis.

Are there any diagnostic tests that can be performed to confirm psoriatic arthritis?

Diagnostic testing may be helpful with diagnosing this condition by ruling in, or out, other arthritic conditions that may mimic these symptoms. Some tests that may be performed include:

  • Joint fluid analysis- fluid is usually removed from the affected joints and examined through a microscope. If urate crystals are seen, this may confirm gouty arthritis instead of psoriatic arthritis. Infection can also be examined as this would be the cause of infectious arthritis.
  • Rheumatoid factor-  an antibody test seen in rheumatoid patients and rarely seen in psoriatic arthritis. Helpful in ruling out this type of arthritis as they have very similar symptoms. A low level of rheumatoid factor can be seen in up to 10% of patients with PsA
  • C-reactive protein- if elevated, it can confirm inflammation of the body, however, it is not specific to psoriatic arthritis. If you are sick, your CRP may also be elevated.
  • X Rays- helpful with detecting joint damage.
  • MRI- helpful with the examination of the tendons, joints, and back where psoriatic arthritis may present.

Treatment

What are treatment options for psoriatic arthritis?

As with most arthritic conditions, treatment focuses on the management of symptoms and the prevention of permanent joint damage, as there is no cure for this disease. Since symptoms can vary over time, so will treatment options. A major concern with this arthritis is joint damage, so early treatment and intervention are key. Although medications appear to be the most common method for the management of psoriatic arthritis, TeleMed2U rheumatologists also offer integrative, holistic treatment approaches as well, based upon a “S.E.N.S.E.” - ible approach: Stress management, Exercise, Nutrition, Sleep & positive social Engagements. 

Here are the different types of medications currently available for psoriatic arthritis : 

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)- usually the initial treatment option for this condition, especially in milder cases. 
  • Corticosteroids- can be useful for the treatment of swollen, painful joints especially in injection form.
  • Disease-modifying antirheumatic drugs (DMARDs)- usually used when NSAIDs fail to manage symptoms or if patients have many symptomatic joints. Helpful with slowing the progression of joint damage. Examples include:
  1. methotrexate* (Rheumatrex, Trexall, Otrexup, Rasuvo)
  2. leflunomide (Arava)
  3. hydroxychloroquine (Plaquenil) - usually avoided because it can cause psoriasis symptoms to flare up
  4. sulfasalazine (Azulfidine)  

*If you are taking methotrexate, make sure you are also taking a folic acid supplement like MTX Advanced Support: https://theralogix.com/products/mtx-support-folic-acid-b12-supplement 

  • Immunosuppressants- helps to manage the immune system responsible for the condition
  1. azathioprine (Imuran)
  2. reserved for only severe cases of psoriatic arthritis  
  3. cyclosporine (Neoral, Sandimmune, Gengraf)
  • Biologic response modifiers (biologic agents)- used in the form of injection of infusions. Examples include:
  1. TNF-Inhibitors: adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) or infliximab (Remicade - IV)
  2. IL-17 Inhibitors: ixekizumab (Taltz) or secukinumab (Cosentyx)
    IL-12/23 Inhibitors: ustekinumab (Stelara) - can also treat psoriasis as well as psoriatic arthritis
  3. T-Cell Blockers: abatacept (Orencia) - can treat PsA but NOT psoriasis
  4. JAK Inhibitor: tofacitinib (Xeljanz)
  • New drug- decreases inflammation by targeting an enzyme responsible for its development
  1. Apremilast (Otezla)

If medications fail, what are other treatment options available?

Surgery may sometimes be needed to repair the damaged joint, especially if deformity develops. Joint replacement surgery is traditionally used in these situations, but your surgeon would decide what the best option is based on the severity of the joint. Physical and occupational therapy may also be beneficial for the treatment of psoriatic arthritis. These treatment modalities are used to help strengthen and increase flexibility to the body.

Is exercise helpful for treatment against psoriatic arthritis symptoms?

Like with most arthritic conditions, exercise is vital to helping with the stiffness and pain in the affected joints. A healthy lifestyle involving exercise and proper diet is also helpful with keeping weight under control that puts less pressure on the joints and reduces further damage.

If psoriatic arthritis is not treated properly, it can become disabling for those involved. Our physicians at TeleMed2U are capable of developing an effective treatment plan for your psoriatic arthritis which can be done from the comforts of your home.

Information

Medically reviewed by:

Dr Roy Kedem, MD

Dr Zenon Andreou studied medicine at University College London, graduating in 2006. His postgraduate training was in hospitals in and around London and he trained for four years in Otolaryngology before completing his training in General practice

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Your copay
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Initial Visit

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