Psoriatic Arthritis

Psoriatic Arthritis

Psoriatic Arthritis (PsA) is a disease that combines the sore, swollen joints of Arthritis with Psoriasis. It is a form of Arthritis that affects some people with Psoriasis (a condition that highlights red patches of skin coated with silvery scales). There is no permanent cure for Psoriatic Arthritis, so the main focus is on controlling symptoms and preventing damage to the joints. 

Psoriatic Arthritis - Overview

  • Psoriatic Arthritis (PsA) is a disease that combines the sore, swollen joints of Arthritis with Psoriasis. 
  • It is a form of Arthritis that affects some people with Psoriasis (a condition that highlights red patches of skin coated with silvery scales). 
  • In most people, Psoriasis develop first and are later diagnosed with Psoriatic Arthritis, but joint problems can sometimes occur before skin patches appear.
  • Stiffness, Joint Pain, and Swelling are the main signs and symptoms of Psoriatic Arthritis. 
  • Psoriatic Arthritis (PsA) can affect any part of the body, including the fingertips and spine, ranging from relatively mild to severe. 
  • In both Psoriasis and Psoriatic Arthritis, disease flashes may alternate with periods of remission.
  • There is no permanent cure for Psoriatic Arthritis, so the main focus is on controlling symptoms and preventing damage to the joints. 
  • Without treatment, Psoriatic Arthritis may be disabling.

Types of Psoriatic Arthritis (PsA) are as follows:

Symmetric PsA:

This type of Psoriatic Arthritis (PsA) affects the same joints on both sides of the body, so both the right and left knees. Symptoms can be similar to those of Rheumatoid Arthritis (RA).
Symmetric PsA tends to be milder and cause less joint deformity than RA. However, symmetric PsA can be disabling. About half of people with Psoriatic Arthritis (PsA) have Symmetric PsA.

Asymmetric PsA:

Asymmetric PsA affects a joint or joints on one side of the body. The joints may feel sore and turn red. Asymmetric PsA is generally mild. It affects about 35% of people with Psoriatic Arthritis (PsA).

Distal Interphalangeal Predominant PsA:

This type involves the joints closest to the nails. These are known as the distal joints. It occurs in about 10% of people with Psoriatic Arthritis (PsA).

Spondylitis PsA:

This type of PsA involves the spine. The intact spine from the neck to the lower back may be affected. Spondylitis PsA can make movement very painful. The hands, feet, legs, arms, and hips may also be affected.

Psoriatic Arthritis Mutilans:

Psoriatic Arthritis Mutilans is a severe, deforming type of PsA. About 5% of people with Psoriatic Arthritis (PsA) have this type. Psoriatic Arthritis Mutilans usually affects the hands and feet. It can also cause pain in the neck and lower back.

Psoriatic Arthritis - Symptoms

Both Psoriatic Arthritis (PsA) and Psoriasis are chronic diseases that get worse over time. Still, the patient may have periods when the symptoms improve or go into remission, alternating with times when symptoms become worse.

Psoriatic Arthritis (PsA) can affect joints on just one side or both sides of the body. 

The symptoms and signs of Psoriatic Arthritis (PsA) often resemble those of Rheumatoid Arthritis. Both diseases cause joints to become swollen, stiff, painful, and warm to the touch.

Psoriatic Arthritis is more likely also to cause:

  • Swollen Fingers and Toes: Psoriatic Arthritis (PsA) can cause painful, sausage-like swelling of the fingers and toes. The patient may also develop swelling and deformities in the hands and feet before having significant joint symptoms. 
  • Foot Pain: Psoriatic Arthritis (PsA) can also cause pain at the points where ligaments and tendons attach to the bones, especially at the back of the heel (Achilles Tendinitis) or in the sole (Plantar Fasciitis).
  • Stiff Joints: Stiffness in joints are common in Psoriatic Arthritis (PsA). They are typically worse early in the morning.
  • Enthesitis: A patient with Psoriatic Arthritis (PsA) can get inflammation where a muscle connects to a bone (such as the Achilles tendon behind the heel). It might hurt while walking and climbing stairs.
  • Lower Back Pain: It happens when some people develop a condition called Spondylitis due to Psoriatic Arthritis (PsA). Spondylitis mainly causes inflammation in the joints between the vertebrae of the spine and in the joints between the spine and pelvis (Sacroiliitis).
  • Nail Pitting: Most people with Psoriatic Arthritis (PsA) see tiny dents, called pitting, and ridges in the nails.
  • Nail Separation: In some Psoriatic Arthritis (PsA), the entire nail pulls away from the nail bed. The separated might be opaque with a yellow, white, or green tint. This condition is known as Onycholysis.
  • Chest and Rib Pain: Chest and Shortness of Breath does not happen often but can be symptoms of Psoriatic Arthritis (PsA). Chest and Rib Pain might occur when the chest wall and the cartilage that links the ribs to the breastbone get inflamed. It is also rare, but the lungs or the aorta (the large blood vessel that leaves the heart) could be affected.
  • Fatigue: Both the inflammation process and medications patients take for Psoriatic Arthritis (PsA) can leave them feeling tired and mentally drained. 

Symptoms can vary from mild to severe. It is necessary not to ignore the signs and symptoms, even if they come and go. Knowing the early signs of Psoriatic Arthritis (PsA) will help patients get better treatment and manage it on time.

Psoriatic Arthritis - Pre-Procedure

A precise and early diagnosis of Psoriatic Arthritis (PsA) will help avoid the damage and deformity it can cause.

The Diagnosis for Psoriatic Arthritis (PsA) include:

Physical Examination:

During the exam, the doctor will:

  • Closely examine the joints for signs of tenderness or swelling
  • Press on the soles of the feet and around the heels to find tender areas
  • Check the fingernails for pitting, flaking and other abnormalities

There is no single test that can confirm a diagnosis of Psoriatic Arthritis (PsA). But some types of tests can help rule out other causes of joint pain, such as Rheumatoid Arthritis or Gout. The test may include:

Imaging Tests:

  • X-rays: X-rays can help pinpoint changes in the joints in Psoriatic Arthritis (PsA) but not in other arthritic conditions.
  • Bone Density Scan: The doctor will perform Bone Density Scan to measure bone strength because Psoriatic Arthritis (PsA) may lead to bone loss. The patient could be at risk for Osteoporosis and Fractures.
  • Magnetic Resonance Imaging (MRI): MRI uses radio waves and a strong magnetic field to produce very detailed images of both soft and hard tissues in the body. This imaging test may be used to check for problems with the ligaments and tendons in the feet and lower back.
  • CT Scans and Ultrasounds: These examinations can help doctors determine how advanced Psoriatic Arthritis (PsA) is and how badly joints are affected.

Laboratory Tests:

  • Rheumatoid Factor (RF): Rheumatoid Factor (RF) is an antibody that’s often present in the blood of people with Rheumatoid Arthritis (RA), but it is not usually in the blood of people with Psoriatic Arthritis (PsA). For that reason, this test can help the doctor distinguish between the two conditions.
  • Joint Fluid Test: Using a needle, the doctor can remove a small fluid sample from one of the affected joints, often the knee. Uric acid crystals in the joint fluid may indicate that the patient has Gout rather than Psoriatic Arthritis (PsA).
  • Blood Tests: Blood Tests can help to confirm Psoriatic Arthritis and rule out other conditions, like Rheumatoid Arthritis.
  • Erythrocyte Sedimentation Rate (ESR): ESR gives a rough idea of how much inflammation is in the body caused by Psoriatic Arthritis (PsA). But higher levels can come from other autoimmune diseases, an infection, a tumour, liver disease, or pregnancy, too.
  • HLA-B27: This is a genetic marker that helps diagnose Psoriatic Arthritis (PsA) with spine inflammation.
  • Iron Tests: Iron tests helps to diagnose patient with Psoriatic Arthritis (PsA) who may have mild anaemia, or not enough healthy red blood cells.
  • C-Reactive Protein: This is a substance the liver produces when there is inflammation in the body.

Psoriatic Arthritis - During Procedure

There is no cure exists for Psoriatic Arthritis (PsA). The treatment focuses on controlling inflammation in the affected joints to prevent joint pain and disability.

Treatment type may include:

Medications:

Drugs used to treat Psoriatic Arthritis (PsA) are:

  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can help relieve pain and reduce inflammation. Over-the-counter NSAIDs include Ibuprofen (Advil and Motrin IB) and Naproxen Sodium (Aleve). Stronger NSAIDs are available by prescription.
    Side effects of NSAIDs may include heart problems, stomach irritation, and liver and kidney damage.
  • Disease-Modifying Anti-Rheumatic Drugs (DMARDs): These drugs can slow the progression of Psoriatic Arthritis (PsA) and helps to save the joints and other tissues from permanent damage.
    Common DMARDs are Methotrexate (Trexall and Otrexup), Leflunomide (Arava), and Sulfasalazine (Azulfidine).
    Side effects vary but may include bone marrow suppression, liver damage, and severe lung infections.
  • Immunosuppressants: These medications act to tame the immune system, which is out of control in Psoriatic Arthritis (PsA).
    Drugs include Azathioprine (Imuran, Azasan) and Cyclosporine (Gengraf, Neoral, and Sandimmune). These medications can increase a patient’s susceptibility to infection.
  • Biologic Agents: Biologic agents are also known as biologic response modifiers. Biologic agents are a newer class of DMARDs that includes Abatacept (Orencia), Adalimumab (Humira), Golimumab (Simponi), Certolizumab (Cimzia), Etanercept (Enbrel), Infliximab (Remicade), Ixekizumab (Taltz), Tofacitinib (Xeljanz), Ustekinumab (Stelara), and Secukinumab (Cosentyx).
    These medications target particular parts of the immune system that trigger swelling and lead to joint damage. These drugs can increase the risk of infections.
    A higher dosage of Tofacitinib can increase the risk of blood clots in the lungs.
    Biologic agents can be used alone or can be combined with DMARDs, such as Methotrexate.
  • Newer Oral Medication: The new oral drug is Apremilast (Otezla) that is an Enzyme Inhibitor that reduces the activity of an enzyme in the body that controls the movement of inflammation within cells. Potential side effects include nausea, diarrhoea, and headaches.

Other Procedures:

Other procedures may include:

Steroid Injections: Steroid injections helps to reduce inflammation quickly and is sometimes injected into an affected joint.

Surgery:

Most people with Psoriatic Arthritis (PsA) will never need surgery. But when no medication or other treatment method has worked, surgery can relieve pain, help an affected joint work, and allow the patient to move more.

Surgical Procedures may include:

  • Synovectomy: Synovectomy is a surgical procedure that helps to remove the diseased lining of a joint. 
  • Arthroplasty: Arthroplasty is the surgical procedure performed if the damage is terrible. In the procedure, the patient may need to replace the joint. 
  • Joint Fusion: When a joint can’t easily be replaced, then joint fusion might make it stronger, more stable, and less painful for patients.
  • Joint Replacement Surgery: Joint replacement surgeries help treat the joints severely damaged by Psoriatic Arthritis (PsA) and replace artificial prostheses made of metal and plastic.

Light Therapy:

Exposing the skin to ultraviolet (UV) light can help to get rid of Psoriasis skin plaques. But due to UV light can damage skin and possibly lead to skin cancer, and it is essential to get light therapy only with a doctor’s advice. 

Different types of Light Therapies are:

  • Narrowband UVB Phototherapy
  • Excimer Laser
  • PURVA

Topical Treatments:

Topical treatments include Creams, Gels, Ointments, and Lotions to relieve the itchy Psoriatic Arthritis (PsA) rash. These treatments are available over the counter and with a prescription.

Options for Tropical Treatments are:

  • Anthralin
  • Calcitriol or Calcipotriene (forms of vitamin D-3)
  • Salicylic Acid
  • Steroid Creams
  • Tazarotene (a derivative of vitamin A)

Psoriatic Arthritis - Post-Procedure

Psoriatic Arthritis - Risk & Complications

Complications of Psoriatic Arthritis (PsA) differs in patients and may include:

Arthritis Mutilans: A small percentage of people with Psoriatic Arthritis (PsA) develop Arthritis Mutilans. It is a painful, severe, and disabling form of the disease. Over a period, Arthritis Mutilans destroys the small bones in the hands, especially the fingers and can lead to permanent deformity and disability.

Pinkeye (Conjunctivitis) or Uveitis: People suffering from Psoriatic Arthritis (PsA) sometimes also catch eye problems like pinkeye (conjunctivitis) or Uveitis which can cause reddened eyes, pain, and blurred vision. Patients with these problems are also at higher risk of cardiovascular disease.

Having Psoriatic Arthritis (PsA) can make the patient more likely to develop other conditions over time. 

Some of the most common are:

  • Cancer: People with Psoriatic Arthritis (PsA) may be more likely to get Lymphoma and Non-Melanoma skin cancer. The treatment plan should include regular Cancer screenings.
  • Cardiovascular Disease: Psoriatic Arthritis (PsA) can boost the risk for cardiovascular diseases like a Heart Attack or Stroke. Talk to the doctor about the risk and treatments that can help.
  • Crohn’s Disease: People with Psoriatic Arthritis (PsA) and Crohn’s share similar changes to their genes, called Mutations. That is why there’s a link between Psoriasis, Psoriatic Arthritis (PsA), and Inflammatory Bowel Disease (IBD) like Crohn’s Disease or Ulcerative Colitis. The odds are even higher if the patient suffers from both Psoriasis and Psoriatic Arthritis (PsA).
  • Depression: Psoriasis and Psoriatic Arthritis (PsA) can make the patient more likely to have low self-esteem and mood disorders like depression. Depression is even more likely if the patient has both Psoriatic Arthritis (PsA) and Psoriasis. But treating Psoriasis can help with depression.
  • Diabetes:Patient with Psoriasis and Psoriatic Arthritis raises the risk of type 2 diabetes. Having severe Psoriasis boosts it even higher. Tell the doctor if the patient has symptoms of type 2 diabetes, such as hunger, heavy thirst, blurry vision, or fatigue.
  • Gout: A patient gets this form of Inflammatory Arthritis when uric acid crystals form in the joints. Though the patient can get uric acid from food, doctors also think it’s a by-product of Psoriasis and Psoriatic Arthritis.
  • Joint Damage: Arthritis Mutilans is a rare but destructive condition that sometimes happens with Psoriatic Arthritis, rapidly damages joints at the ends of the fingers and toes. Severe damage can conflict with activities of daily living, such as dressing or walking.
  • Metabolic Syndrome:  Some researchers have found a link between Psoriasis, Psoriatic Arthritis, and Metabolic Syndrome (a cluster of conditions that include obesity, heart disease, and high blood pressure). Women with Psoriasis and anyone with severe Psoriatic Arthritis may be almost twice as likely to get it as others.
  • Eye Inflammation and Vision Problems: Inflammation in the coloured part of the eye, the iris, can cause pain that worsens in bright light and can cause vision problems. The patient will probably need to see an eye doctor to treat this condition known as Uveitis.

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