Everything You Need to Know About Psoriatic Arthritis

Symptoms of PsA are different for each person. They can range from mild to severe. Sometimes, your condition will go into remission, and you’ll feel better for a while. Other times, your symptoms may get worse. Your symptoms also depend on the type of PsA you have.

General symptoms of PsA include:

• swollen, tender joints on one or both sides of your body
• morning stiffness
• swollen fingers and toes
• painful muscles and tendons
• scaly skin patches, which may get worse when joint pain flares up
• flaky scalp
• fatigue
• nail pitting
• separation of your nail from the nail bed
• eye redness
• eye pain (uveitis)

Spondylitis PsA, in particular, can also cause the following symptoms:

• spinal pain and stiffness
• pain, swelling, and weakness in your:
  • hips
  • knees
  • ankles
  • feet
  • elbow
  • hands
  • wrists
  • other joints
• swollen toes or fingers

Symmetric PsA affects five or more joints on both sides of your body. Asymmetric PsA affects fewer than five joints, but they can be on opposite sides.

Psoriatic arthritis mutilans is a rare form of arthritis that deforms your joints. It can shorten affected fingers and toes. Distal PsA causes pain and swelling in the end joints of your fingers and toes.

Photos of some psoriatic arthritis symptoms

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In PsA, your immune system attacks your joints and skin. Doctors don’t know for sure what causes these attacks. They think it stems from a combination of genes and environmental factors.

PsA runs in families. About 40% of people with the condition have one or more relatives with PsA. Something in the environment usually triggers the disease for those with a tendency to develop PsA. That could be a virus, extreme stress, or an injury.

The goal of PsA treatment is to improve symptoms like skin rash and joint inflammation.

Guidelines released in 2018 recommend the “treat-to-target” approach, which is based on a person’s individual preferences. A specific treatment goal and how to measure progress are determined, and then a doctor works with you to select treatments.

You have many different treatment options. A typical treatment plan will include one or more of the following:

Nonsteroidal anti-inflammatory drugs (NSAIDs)

These medications help control joint pain and swelling. Over-the-counter (OTC) options include ibuprofen (Advil) and naproxen (Aleve). If OTC options aren’t effective, your doctor may prescribe NSAIDs in higher doses.

If used incorrectly, NSAIDs can cause:

• stomach irritation
• stomach bleeding
• heart attack
• stroke
• liver and kidney damage

Disease-modifying antirheumatic drugs (DMARDs)

These medications decrease inflammation to prevent joint damage and slow the progression of PsA. They may be administered by various routes, including oral, injection, or infusion.

The most commonly prescribed DMARDs include:

• methotrexate (Trexall)
• leflunomide (Arava)
• sulfasalazine (Azulfidine)

Apremilast (Otezla) is a newer DMARD that’s taken orally. It works by blocking phosphodiesterase 4, an enzyme involved in inflammation.

DMARD side effects include:

• liver damage
• bone marrow suppression
• lung infections

Biologics

There are currently five types of biologic drugs for treating psoriatic disease. They’re categorized according to what they target and inhibit (block or lessen) in the body:

• tumor necrosis factor-alpha (TNF-alpha) inhibitors:
  • adalimumab (Humira)
  • certolizumab (Cimzia)
  • golimumab (Simponi)
  • etanercept (Enbrel)
  • infliximab (Remicade)
• interleukin 12 and 23 (IL-12/23) inhibitors:
  • ustekinumab (Stelara)
• interleukin 17 (IL-17) inhibitors
  • secukinumab (Cosentyx)
  • ixekizumab (Taltz)
  • brodalumab (Siliq)
  • bimekizumab-bkzx (Bimzelx)
• interleukin 23 (IL-23) inhibitors
  • guselkumab (Tremfya)
  • tildrakizumab-asmn (Ilumya)
  • risankizumab-rzaa (Skyrizi)
• T-cell inhibitors
  • abatacept (Orencia)

According to the treatment guidelines released in November 2018, these medications are recommended as first-line treatments.

You receive biologics through an injection under your skin or as an infusion. Because these medications dampen your immune response, they can increase your risk for serious infections. Other side effects include nausea and diarrhea.

Steroids

These medications can bring down inflammation. For PsA, they’re usually injected into affected joints. Side effects include pain and a slight risk of joint infection.

Immunosuppressants

Medications like azathioprine (Imuran) and cyclosporine (Gengraf) calm an overactive immune response, particularly for psoriasis symptoms. They’re not used as often now that TNF-alpha inhibitors are available.

Because they weaken the immune response, immunosuppressants can increase your risk for infections.

Topical treatments

Creams, gels, lotions, and ointments can relieve the itchy PsA rash. These treatments are available over the counter and with a prescription.

Options include:

• anthralin
• calcitriol or calcipotriene, which are forms of vitamin D-3
• salicylic acid
• steroid creams
• tazarotene, which is a derivative of vitamin A

Light therapy and other PsA medications

Light therapy uses medication, followed by exposure to bright light, to treat psoriasis skin rashes.

A few other medications also treat PsA symptoms. These include secukinumab (Cosentyx) and ustekinumab (Stelara). These drugs are injected under your skin. Stelara comes with a warning that it can increase your risk for infections and cancer.

There are things you can do at home to help improve your symptoms:

Add exercise to your daily routine, if you can

Keeping your joints moving can ease stiffness. Being active for at least 30 minutes per day will also help you lose excess weight and give you more energy. Ask your doctor what type of exercise is safest for your joints.

Biking, walking, swimming, and other water exercises are gentler on the joints than high impact exercises like running or playing tennis.

Limit alcohol and quit smoking

Smoking negatively affects your joints as well as the rest of your body. Ask your doctor about counseling, medication, or nicotine replacement to help you quit.

Also, it’s best to limit your alcohol intake, as it can interact with some PsA medications.

Relieve stress

Tension and stress can make arthritis flares even worse. Meditate, practice yoga, or try other stress-relief techniques to calm your mind and body.

Use hot and cold packs

Warm compresses and hot packs can ease muscle soreness. Cold packs can also reduce pain in your joints.

Move to protect your joints

Open doors with your body instead of your fingers. Lift heavy objects with both hands. Use jar openers to open lids.

Consider natural supplements and spices

Omega-3 fatty acids have anti-inflammatory properties. These healthy fats, found in many supplements, reduce inflammation and stiffness in joints.

While research suggests there are health benefits, the Food and Drug Administration (FDA) doesn’t monitor the purity or quality of supplements. It’s important to talk with your doctor before you begin taking supplements.

Turmeric, a potent spice, also serves up a dose of anti-inflammatory properties and may help reduce inflammation and PsA flare-ups. Turmeric can be added to any dish. Some people even stir it into tea or lattes, like golden milk.

While no single food or diet will cure PsA, a nutrient-dense and balanced diet can help reduce inflammation and ease symptoms. Helpful changes to your diet can pay off tremendously for your joints and body in the long run.

In short, eat more fresh fruits and vegetables. They help lower inflammation and manage your weight. Excess weight puts more pressure on joints that are already sore. Limit sugar and fat, which are inflammatory. Put an emphasis on sources of healthy fats, like fish, seeds, and nuts.

There are five types of PsA:

Polyarticular or symmetric PsA

This type affects the same joints on both sides of your body, so both your left and right knees, for example. Symptoms can be like those of rheumatoid arthritis (RA).

Symmetric PsA tends to be milder and causes less joint deformity than RA. But symmetric PsA can be disabling. About 40% of people with PsA have this type.

Oligoarticular or asymmetric PsA

This affects a joint or joint on one side of your body. Your joints may feel sore and turn red. Asymmetric PsA is generally mild. The data on its prevalence is mixed, showing that it may affect anywhere between 13–65% of people with PsA.

Distal interphalangeal predominant PsA

This type affects about 12% of people with PsA and involves the joints closest to your nails. These are known as the distal joints.

Spondylitis PsA

This type of PsA involves your spine and affects about 30% of people with PsA. Your entire spine from your neck to your lower back may be affected. This can make movement very painful. Your hands, feet, legs, arms, and hips may also be affected.

Psoriatic arthritis mutilans

This is a severe, deforming type of PsA. Somewhere between 2–21% of people with PsA have this type, depending on the different definitions of this type across various studies. Psoriatic arthritis mutilans usually affects your hands and feet. It can also cause pain in your neck and lower back.

About 90% of people who develop PsA have a history of psoriasis. That said, PsA doesn’t follow the same path for each person diagnosed with this condition and may not always begin with skin impact before moving to the joints.

Some people may only ever have mild symptoms and limited impact on their joints. For others, joint deformity and bone enlargement may ultimately occur.

It’s unclear why some people experience a faster progression of the disease and others don’t. However, early diagnosis and treatment can help ease pain and slow the damage to joints. It’s important you talk with your doctor as soon as you begin experiencing signs or symptoms that hint at PsA.

Early stage PsA

In the initial phases of this arthritis, you may experience mild symptoms like joint swelling and reduced range of motion. These symptoms may happen at the same time you develop psoriasis skin lesions, or they may occur years later.

NSAIDs are the typical treatment. These medications ease pain and symptoms, but they don’t slow PsA.

Moderate PsA

Depending on the type of PsA you have, the moderate or middle stage will likely see worsening symptoms that require more progressive treatments, like DMARDs and biologics. These medications can help ease symptoms. They may help slow the progression of damage as well.

Late-stage PsA

At this point, bone tissue is heavily affected. Joint deformity and bone enlargement are likely. Treatments aim to ease symptoms and prevent worsening complications.

To diagnose PsA, your doctor has to rule out other causes of arthritis, like RA and gout, with imaging and blood tests.

These imaging tests look for damage to joints and other tissues:

• X-ray: These check for inflammation and damage to bones and joints. This damage is different in PsA than it is in other types of arthritis.
• MRI: Radio waves and strong magnets make images of the inside of your body. These images can help your doctor check for joint, tendon, or ligament damage.
• CT scans and ultrasound: These can help doctors determine how advanced PsA is and how badly joints are affected.

Blood tests for these substances help assess any inflammation present in your body:

• C-reactive protein: This is a substance your liver produces when there’s inflammation in your body.
• Erythrocyte sedimentation rate: This reveals how much inflammation is in your body. But it can’t determine whether the inflammation is from PsA or other possible causes.
• Rheumatoid factor (RF): Your immune system produces this autoantibody. It’s usually present in RA but negative in PsA. An RF blood test can help your doctor tell whether you have PsA or RA.
• Joint fluid: An arthrocentesis removes a small amount of liquid from your knee or other joint. If uric acid crystals are in the fluid, you might have gout instead of PsA. A culture fluid test can rule out infection or sepsis.
• Red blood cells: A low red blood cell count from anemia is common in people with PsA.

No single blood or imaging test can determine if you have PsA. Your doctor uses a combination of tests to rule out other possible causes.

You’re more likely to get PsA if you:

• have psoriasis
• have a parent or sibling with PsA
• are between the ages of 30–50 (though children can get it, too)
• have had strep throat
• have HIV

PsA flare-ups make the condition worse for a period of time. Certain things can set off PsA flares. Everyone’s triggers are different.

To learn your triggers, keep a symptom diary. Each day, write down your symptoms and what you were doing when they started. Also note whether you changed anything in your routine, like if you started taking a new medication.

Common PsA triggers include:

• infections, like strep throat and upper respiratory infections
• injuries, like a cut, scrape, or sunburn
• dry skin
• stress
• cold, dry weather
• smoking
• excessive alcohol intake
• stress
• excess weight
• some medications, like lithium, beta-blockers, and antimalarial drugs

Although you can’t avoid all of these triggers, you can try to manage stress, stop smoking, and cut down your alcohol intake.

Ask your doctor if you take any medications known to set off PsA symptoms. If so, you might want to switch to a new drug.

How do I know if I have psoriatic arthritis or fibromyalgia?

Although psoriatic arthritis or fibromyalgia can occur together, they are different conditions. Psoriatic arthritis is an immune-mediated inflammatory condition, whereas fibromyalgia causes widespread musculoskeletal pain without inflammation.

It’s also associated with tiredness and cognitive difficulties similar to PsA but has unique underlying causes. For this reason, the symptoms can overlap, and it may be hard to tell the difference between the two without a proper diagnosis from a doctor.

Where does psoriatic arthritis usually start?

There isn’t one part of the body where PsA starts because it develops and progresses differently in each person. It may start in the skin, especially in people who already have psoriasis, but may also begin in the joints.

What complications are associated with psoriatic arthritis?

PsA puts you at risk for complications such as:

• psoriatic arthritis mutilans
• eye problems, like conjunctivitis or uveitis
• cardiovascular disease
• sacroiliitis, which is the inflammation of the sacroiliac joint (SI)
• depression

Can you prevent psoriatic arthritis?

As PsA is an autoimmune disease, it cannot be prevented. That said, there are strategies to prevent or reduce flare-ups, and manage the symptoms. This includes avoiding known triggers.

Everyone’s outlook is different. Some people have very mild symptoms that only cause problems from time to time. Others have more severe and debilitating symptoms.

The more severe your symptoms are, the more PsA will affect your ability to get around. People with a lot of joint damage may find it hard to walk, climb stairs, and do other daily activities.

Your outlook will be affected if:

• you received a diagnosis of PsA at a young age.
• your condition was severe when you got your diagnosis.
• a lot of your skin is covered in rashes.
• a few people in your family have PsA.

To improve your outlook, follow the treatment regimen your doctor prescribes. You might have to try more than one drug to find what works best for you.

Read this article in Spanish.