Psoriatic arthritis

What is psoriatic arthritis?

Psoriatic arthritis can cause painful inflammation in any of your joints and it’s often associated with a scaly skin condition called psoriasis.

Psoriatic arthritis causes painful inflammation in and around your joints. It usually affects people who already have psoriasis, a skin condition that causes a red, scaly rash, especially on your elbows, knees, back, buttocks and scalp. However, some people develop the arthritic symptoms before the psoriasis, while others will never develop the skin condition.

Psoriasis can affect people of any age, both male and female, but psoriatic arthritis usually only affects adults.

What are the symptoms of psoriatic arthritis?

You may notice some of the following symptoms:
• red, scaly skin rash (psoriasis)
• stiff, painful joints
• sausage-like swelling (daktylitis) of fingers or toes
• thickening, discoloration and pitting of your nails
• pain and swelling at the back of your heel
• eye inflammation (less frequent)
Symptoms of psoriatic arthritis can include:
• pain and stiffness in and around your joints
• swelling of your fingers or toes (dactylitis), caused by inflammation occurring simultaneously in joints and tendons
• buttock pain, a stiff back or a stiff neck, which is caused by inflammation in your spine (spondylitis)
• pain and swelling in your heels, caused by inflammation where your Achilles tendon attaches to the bone
• pain in other areas where tendons attach to bone (enthesitis), such as your knee, hip bones and chest
Psoriatic arthritis can affect any of the joints on your body, although some joints are more likely to be affected than others.
About 1 in 3 people who have psoriatic arthritis will have pain and stiffness in their neck or back.

Does psoriatic arthritis affect other parts of the body?

You may develop itchiness and redness in your eyes (which is caused by inflammation of the membrane that covers the front of your eye), the inside of your eyelids (conjunctivitis) or around your pupils (iritis/uveitis).
People with psoriasis or psoriatic arthritis may also have a slightly greater risk of developing heart disease, so it’s important to tackle anything that could add to this risk, such as:
• smoking
• drinking a lot of alcohol
• being overweight
• blood pressure problems
Psoriatic arthritis doesn’t usually affect other major organs, such as your kidneys, liver or lungs.

What causes psoriatic arthritis?

The arthritis and the skin condition are both caused by inflammation. The processes of inflammation are very similar in your skin and your joints. We don’t yet know exactly what triggers the inflammation, although a particular combination of genes makes some people more likely to develop psoriasis and psoriatic arthritis.
Research suggests that something – perhaps an infection – acts as a trigger in people who are already susceptible to this type of arthritis because of the genes they’ve inherited from their parents. No specific infection has yet been found – it may be that a variety of infections can trigger the condition, for example bacteria that live in patches of psoriasis.
Sometimes the arthritis can follow an accident or injury, particularly if it affects a single joint.

How is psoriatic arthritis diagnosed?

Your doctor will examine you and ask if you have a family history of psoriasis. You may also have blood tests to rule out other conditions, and X-rays can sometimes help to confirm the diagnosis.
It’s important that psoriatic arthritis is diagnosed early so you can start treatment as soon as possible. There’s no specific test for psoriatic arthritis, but the diagnosis will be based on your symptoms, a physical examination or the existence of psoriasis.
It can be difficult to distinguish between psoriatic arthritis and rheumatoid arthritis. Your doctor will consider which of your joints are affected and may want to take a blood test for rheumatoid factor, while X-rays of your back, hands and feet can also be helpful, as psoriatic arthritis can affect the bones and joints in these areas in a distinctive way.

What treatments are there for psoriatic arthritis?

• non-steroidal anti-inflammatory drugs (NSAIDs)
• disease-modifying anti-rheumatic drugs (DMARDs)
• steroid injections, tablets or ointments
• ointments or light therapy for skin symptoms
• exercise and physiotherapy to keep your joints mobile
• surgery to repair damaged tendons or replace badly damaged joints – this is rarely needed
A team of healthcare professionals are likely to be involved in your treatment. You may also see:
• a physiotherapist, who can give you advice on exercises to help maintain your mobility
• an occupational therapist, who can give you advice on protecting your joints from further damage, for example, by using splints or altering the way you perform tasks to reduce the strain on your joints
• a podiatrist, who can assess your foot-care needs and offer advice on special footwear.

Drugs

Non-steroidal anti-inflammatory drugs (NSAIDs)
Anti-inflammatory drugs can be very effective in controlling pain and stiffness. Usually you’ll find your symptoms improve within hours of taking these drugs, but the effect will only last for a few hours, so you have to take the tablets regularly.
Some people find that NSAIDs work well at first, but become less effective after a few weeks. In this situation, it sometimes helps to try a different NSAID. There are about 20 available, including ibuprofen, diclofenac, indometacin, nimesulide and naproxen.

Like all drugs, NSAIDs can sometimes have side-effects, but your doctor will take precautions to reduce the risk of these, for example, by prescribing the lowest effective dose for the shortest possible period of time, e.g. they may prescribe the lowest possible dose or shorter treatment.

NSAIDs can cause digestive problems (stomach upsets, indigestion or damage to the lining of the stomach), so in most cases NSAIDs will be prescribed along with another drug which will help to protect the stomach.

NSAIDs also carry an increased risk of heart attack or stroke. Although the increased risk is small, your doctor will be cautious about prescribing NSAIDs if there are other factors that may increase your overall risk, for example, smoking, circulation problems, high blood pressure, high cholesterol or diabetes.

Disease-modifying anti-rheumatic drugs (DMARDs)

Disease-modifying drugs help by tackling the causes of inflammation. They change the way the condition progresses and hopefully will stop your arthritis from getting worse. It may be several weeks before DMARDs start to have an effect on your joints, so you should keep taking them even if they don’t seem to be working. Sometimes these drugs are given by injection.

DMARDs aren’t usually used as a first-choice treatment, and the decision to use them will depend on a number of factors, including how much effect NSAIDs have had, how active your arthritis is and how likely it is that you’ll have further joint damage.

Examples of DMARDs include:
• methotrexate
• sulfasalazine
• cyclosporine
• leflunomide

Biological therapies are a newer group of disease-modifying drugs that may be used if other DMARDs aren’t working well enough. These are given either by injection or through a drip into a vein. Biological therapies used for treating psoriatic arthritis include:
• adalimumab
• etanercept
• infliximab
• golimumab

When taking almost all DMARDs, you’ll need to have regular blood tests and in some cases a urine test. The tests allow your doctor to monitor the effects the drug has had on your condition, but also to check for possible side-effects, including problems with your liver, kidneys or blood count.

You can take NSAIDs along with DMARDs, and sometimes you might need to take more than one DMARD.
Steroid injections (cortisone)

Your doctor might recommend steroid injections if your joints are particularly painful or your ligaments and tendons have become inflamed.

Surgery

You probably won’t need surgery, although very occasionally a damaged tendon may need surgical repair. Sometimes, after many years of disease, a joint that has been damaged by inflammation is best treated with joint replacement surgery.

If your psoriasis is bad in the skin around the affected joint, your surgeon may recommend a course of antibiotic tablets to help prevent infection. Sometimes psoriasis can appear along the scar left by the operation, but this can be treated in the usual way.

Treatments for the skin

Your skin will usually be treated with ointments. There are 5 main types:
• tar-based ointments
• dithranol-based ointments (it’s very important not to let these come into contact with normal skin)
• steroid-based creams and lotions
• vitamin D-like ointments, such as calcipotriol and tacalcitol
• vitamin A-like (retinoid) gels, such as tazarotene

If the creams and ointments don’t help your psoriasis, your doctor may suggest:

• light therapy, involving short spells of exposure to high-intensity ultraviolet light carried out in hospital
• retinoid tablets

Many of the DMARDs used for psoriatic arthritis will also help your skin condition. Similarly, some of the treatments for your skin may help your arthritis.

Treatments for nail psoriasis are usually less effective than the skin treatments. Many people use nail varnish to make the marks less noticeable.

Self-help and daily living
Keeping to a healthy weight reduces the strain on your joints. Exercising will help, but you’ll need to find the right balance between rest and activity so you don’t overdo it.

Exercise

Inflammation can lead to muscle weakness and stiffness in your joints. Exercise is important to prevent this and to keep your joints working properly. However, inflammation can also make you feel unusually tired so you may find you need to take more rests than usual. You’ll need to find out for yourself the right balance between rest and exercise.
Your doctor or a physiotherapist will be able to give you advice on suitable forms of exercise, depending on which of your joints are most affected.

Diet and nutrition

No specific diets have been found to be very effective for psoriatic arthritis, although some people find that fish body oils (not fish liver oils) from salt-water fish reduce their need to take NSAIDs.
Being overweight will put extra strain on your joints, particularly your leg and back joints. It’s also important to control your weight because of the increased risk of heart disease. We recommend a healthy, balanced diet with plenty of fresh vegetables and fruit.

Complementary medicine

There’s no scientific evidence that suggests any form of complementary medicine helps to ease the symptoms of psoriatic arthritis. Generally speaking, complementary and alternative therapies are relatively well tolerated, but you should always discuss it with your doctor if you want to try them. There are some risks associated with specific therapies, but in many cases the risks associated with them are more to do with the therapist than the therapy. This is why it’s important to go to a legally registered therapist, or one who has a set ethical code.
If you decide to try therapies or supplements you should be critical of what they’re doing for you, and base your decision to continue on whether you notice any improvement.

Sex and pregnancy

Sex can sometimes be painful, particularly for a woman whose hips are affected. Try experimenting with different positions to find one that’s suitable.

Psoriatic arthritis won’t affect your chances of having children or a successful pregnancy. You may find that your arthritis improves during your pregnancy, although your symptoms may return after your baby is born.

Some of the drug treatments given for psoriatic arthritis should be avoided when you’re trying to start a family. For instance, sulfasalazine can temporarily cause a low sperm count, and you shouldn’t try for a baby if you or your partner are on methotrexate or have been using it recently (some doctors say within the last 6 months).

If you’re thinking about starting a family, you should discuss your drug treatment with your doctor well in advance so that your medications can be changed if necessary.
Both psoriasis and psoriatic arthritis do tend to run in families to some extent. If there’s a history of psoriasis or psoriatic arthritis in your family, then your children may be more likely than most to get psoriatic arthritis, but the risk of passing it on directly is still low.

Living with psoriatic arthritis

Any long-term condition can affect your moods, emotions and confidence, and it can have an impact on your work, social life and relationships. Talk things over with a friend, relative or your doctor if you find your condition is getting you down. You can also contact support groups if you want to meet other people with psoriatic arthritis.