Psoriatic arthritis in hips

Contents

How Does Psoriatic Arthritis Affect the Hips?

The chronic, inflammatory disease process of psoriatic arthritis (PsA) can affect any joint in the body. When one or both hips are involved in PsA, individuals can experience pain, stiffness, and difficulty walking. PsA can be either asymmetrical (affecting only one hip) or symmetrical (affecting both hips). In addition to its effects on the joints, PsA can cause inflammation, known as enthesitis, in the tendons and ligaments that attach muscle to the bones. The synovial tissue, the fluid-filled capsule between the bones, can become inflamed. PsA can appear as sacroiliitis, which refers to inflammation in the joints between the spine and the pelvis.1-4

Diagnosis is often made through clinical evaluation and imaging, particularly using ultrasound or MRI (magnetic resonance imaging), which are more sensitive than x-ray to detect inflammatory changes in individuals with PsA. Ultrasound is useful for detecting structural changes and abnormal blood flow. MRI allows for visualization of soft tissue as well as bony changes.1

The hips and psoriatic arthritis

The hips are rarely involved in those with PsA, and it is estimated that the hips become inflamed due to PsA in less than 10% of cases.5,6 Individuals with the onset of PsA before age 30 seem to be at the greatest risk for hip involvement, especially if they have axial (spinal) involvement.5

Typical symptoms for hips & psoriatic arthritis

Symptoms of PsA in the hips include:

  • Pain in the hip joint, which may include pain in the groin, outer thigh, or buttocks
  • Pain or stiffness, especially first thing in the morning or after a period of rest
  • Difficulty walking, or walking with a limp
  • Stiffness or reduced range of motion2,3
  • Sexual intercourse may be painful, especially for women with PsA that affects the hips.7

What can be done to alleviate pain or disability of the hips?

Minor pain and stiffness of mild PsA can be alleviated with non-steroidal anti-inflammatory drugs (NSAIDs). In addition, injections of corticosteroids may be used.4

For moderate to severe disease, treatments that target joint disease in PsA can reduce symptoms and prevent disease progression. Recommended treatments include disease-modifying anti-rheumatic drugs (known as DMARDs). The first step for treatments is usually DMARDs such as methotrexate, leflunomide, or sulfasalazine. Other treatments include medicines that target tumor necrosis factor (TNF), a chemical that produces a wide range of inflammation in PsA. Examples of TNF blockers include etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), golimumab (Simponi), and certolizumab pegol (Cimzia). Other DMARDs that have proven effective in clinical trials include ustekinumab (Stelara), brodalumab (which is awaiting FDA approval), and secukinumab (Cosentyx). 1 The FDA has also recently approved Inflectra (infliximab-dyyb), a biosimilar to infliximab, for the treatment of psoriatic arthritis.8

Physical and occupational therapy can be critical treatment approaches to both protect the involved joints and maintain function. A physical therapy program generally includes various exercises and stretches, applied heat and/or cold, orthotics, assistive devices for gait, and possible vocational readjustments.2

Surgical care may be indicated for severe disease. Arthroscopic surgery to the synovial capsule has shown to be effective, and joint replacement or reconstructive surgery are occasionally necessary.2

The Effects of Psoriatic Arthritis on the Body

Overview

You may know a bit about the skin symptoms associated with psoriasis, and you may also know about the joint pain of classic arthritis. Psoriatic arthritis is a combination of both skin and arthritic symptoms, but the inflammation that drives the condition makes symptom management difficult. Learn more about the effects of psoriatic arthritis on the body, as well as symptoms to watch for.

The effects of psoriatic arthritis on the body

Psoriatic arthritis (PsA) is a form of arthritis that can develop within 10 years of developing psoriasis. Skin psoriasis causes flare-ups of red, patchy skin that can occur anywhere on the body.

According to the National Psoriasis Foundation, about 30 percent of people with psoriasis eventually develop PsA. In some cases, it’s diagnosed before you have skin psoriasis because the symptoms might be more noticeable. It’s also possible to develop PsA without psoriasis, especially if you have a family history of psoriasis. Both skin psoriasis and inflammatory types of arthritis are considered autoimmune disorders.

PsA is a chronic, or long-term, condition. Anyone can get it, but it’s most common in middle-age adults. Since there’s no cure, treatment aims at symptom management and preventing permanent joint damage.

PsA affects many parts of the body and targets larger joints, including those of your lower extremities and the distal joints of your fingers and toes. Symptoms range from mild flare-ups to some that can be chronic.

Skeletal system

PsA causes inflammation in your joints. It can affect a single joint or many. Stiff, swollen, and painful joints are classic symptoms.

Inflammation in your knees or shoulders can limit range of motion, making it hard to move freely. It can even cause severe neck and back pain and make it difficult for your spine to bend.

Your fingers and toes may swell, causing a sausage-like appearance. One of the more common symptoms of PsA is soreness where your tendons and ligaments connect to your bones. This causes pain in your heel, the sole of your foot, and around your elbows.

Low-impact exercise, especially water exercise, can help keep your joints become more flexible. Physical and occupational therapy may be useful to help strengthen muscles and improve flexibility. Walking is one of the best exercises and shoe inserts can help lessen the impact on your joints.

About 5 percent of people with PsA can develop arthritis mutilans. This is a less common but more severe form of arthritis that can destroy the joints of your hands and feet, leading to permanent disfigurement and disability. Medications such as biologics can prevent this damage.

Skin, hair, and nails

Psoriasis is a chronic skin condition that causes rough, red patches to form on your skin. It sometimes looks like silvery scales. Symptoms include tenderness and itching. Patches can form anywhere but tend to show up around your elbows, knees, hands, and feet. The skin around your joints can appear cracked. In some cases, skin lesions or blisters may form.

Patches on your scalp can range from what resembles a mild case of dandruff to severe shedding. The big difference is that scalp psoriasis causes larger scales that are also red and extremely itchy. Scratching may cause flakes in your hair and on your shoulders.

Your fingernails and toenails may become thick, ridged, or discolored. They can grow abnormally, develop pits, or even separate from the nail bed.

Eyes and vision

Studies have found that psoriasis can also lead to vision problems. Inflammatory lesions such as conjunctivitis are the most likely side effect. In very rare cases, psoriasis might cause a loss of vision.

Uveitis, a condition in which the middle layer of your eye swells, can be the result of PsA.

Musculoskeletal system

Chronic inflammation can damage the cartilage that covers the ends of your bones. As the condition progresses, damaged cartilage then causes the bones to rub against each other. Besides weakening your bones, this process weakens surrounding ligaments, tendons, and muscles, which leads to inadequate joint support. This can make you lose the desire to stay active, which can inadvertently make your symptoms worse.

It’s important to engage in regular moderate exercise so you keep your muscles strong. Ask your doctor to recommend an exercise program or a physical therapist who can teach you how to exercise without stressing your joints.

Immune system

Sometimes in autoimmune conditions, your body mistakenly attacks healthy tissues. With PsA, your immune system attacks your joints, tendons, and ligaments. PsA is a lifelong condition but you may experience periodic attacks followed by remission.

Mental health

Physical pain and discomfort, along with the chronic nature of the disease, can have an impact on your emotional health. PsA may increase your risk for anxiety and depression. You might feel embarrassment, low self-esteem, and sadness. You might also feel extremely worried and uncertain about the future of your condition.

Mental health risks are especially high in cases where PsA isn’t managed. If you start to notice symptoms of depression or anxiety, get in touch with a healthcare professional who can help you with treatment options.

Other effects

Other effects of PsA include extreme fatigue and restlessness. You may also have a slightly raised risk for developing high blood pressure, high cholesterol, or diabetes. A healthy diet, regular moderate exercise, and a good night’s sleep go a long way towards helping you manage your overall condition. Ask your doctor for complementary health techniques that can help.

Your most pressing psoriatic arthritis questions answered

Q: Is there a way to tell the difference between pain from psoriatic arthritis and just plain getting old?

A: Psoriatic arthritis is an inflammatory form of joint disease, unlike osteoarthritis, which is noninflammatory. Generally, osteoarthritis pain tends to occur later in the day. It’s not associated with morning stiffness, joint swelling is generally not severe and we don’t see redness or swelling like we do in psoriatic arthritis. Psoriatic arthritis tends to be worse in the morning. It’s associated with joint swelling and decreased range of motion, and tends to improve as the day goes on, in contrast to osteoarthritis, which tends to get worse as the day goes on.

Q: Is it possible that psoriatic arthritis, or other arthritis, would start in my shoulders and knees, for example, major joints rather than smaller joints?

A: Absolutely. We tend to emphasize the small joints of the hands and the feet because those are the most common joints we see involved, but shoulders, knees, cervical spine, lumbar spine, thoracic spine and sacroiliac joints certainly are also sites that can be the early joints involved by psoriatic arthritis. Moreover, patients with psoriatic arthritis can develop something we call dactylitis, where a digit such as a toe or a finger becomes diffusely swollen and looks like a little sausage. Or they can develop something called enthesitis, a type of pain caused by inflammation at the places where tendons, ligaments and joint capsules attach to the bone.

Q: Does the course of psoriatic arthritis symptoms wax and wane, relapse and remiss, or is it strictly a progressive condition?

A: In about 5 percent of patients, we can see true remission even without therapy, but that’s very unusual. As to whether it’s strictly a progressive condition, it really depends on how you define progression. As a rheumatologist, I define progression as progressive joint damage. In other words, we call this damage to the bone that can take the form of erosion, so little divots are appearing in the bone or there is a narrowing of the joint space.

If you look at that way of defining psoriatic arthritis, about 50 percent of patients from the time of diagnosis to two years will have damage in their joints on X-ray. If you follow them longer out, to eight or 10 years, that number is about 85 percent. But you have to remember that the patients who are seen by rheumatologists, especially at big academic centers, tend to be more severely involved. So our observations regarding progression on X-ray may be more severe than what is seen in a nonacademic population, meaning population out in the community.

Q: I have yellowing and thickening of my toenails. How can I tell if it is psoriatic disease or a combination of psoriatic disease and toenail fungus?

A: These can be distinguished in a dermatologist’s office. They will take a swab, and take a component underneath the nail with the swab, and put it in a liquid and look under the slide of a microscope. If you see little linear kinds of branching structures, these are hyphae that are associated with fungus. If you see that, it means that the nail problem in that particular joint is at least in part contributed to by a fungal infection. That doesn’t mean that there can’t be both psoriasis and fungus going on together. If that wet mount analysis on microscope is negative, though, it is likely that the nail problem is due to psoriasis.

Christopher Ritchlin, M.D., MPH is a rheumatologist at the Psoriasis Center at University of Rochester and a member of the National Psoriasis Foundation Psoriatic Arthritis Design Committee.

Click the two videos below for more information about psoriatic arthritis with Dr. Ritchlin, and check out our other free health webcasts.

Psoriatic Arthritis Symptoms

Most people who have psoriatic arthritis experience both psoriasis and joint pain. Other symptoms are also common. Recognizing and reporting symptoms to a health care provider can help lead to a faster diagnosis, so treatment can begin.

Psoriasis

Psoriasis can affect the skin anywhere, though it is most commonly seen in patches on the elbows, knees, and scalp. It typically appears as patches of raised red skin covered by white scales. It can also have a pimple-like or burned appearance. A psoriasis rash is often accompanied by severe itching and burning.

About 85% of people who develop psoriatic arthritis experience psoriasis first.1 People who have psoriasis are encouraged report aches, pains, and other symptoms to their primary health care providers or dermatologists.

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Joint Pain

Experts estimate 96% of people who have psoriatic arthritis have joint pain in their fingers, toes, or joints in the limbs, such as the knees.1 When pain is in a toe or finger, the last knuckle tends to be affected. Pain is usually worse in the morning, lasting about an hour. The affected joints are inflamed and may be swollen and warm to the touch.

See Understanding Joint Pain

About 50% of people experience joint pain in their neck, back and/or hips.1 The most common area of the back to be affected is the sacroiliac (SI) joints of the lower back. When psoriatic arthritis causes back, neck, or hip pain it is called axial arthritis or spondyloarthritis.

For more in-depth information, see Sacroiliac Joint Dysfunction on Spine-health.com

Back and neck pain can help distinguish psoriatic arthritis from rheumatoid arthritis, which does not typically cause pain in the spine’s joints.

In This Article:

  • What Is Psoriatic Arthritis?
  • Psoriatic Arthritis Symptoms
  • Psoriatic Arthritis Causes
  • Psoriatic Arthritis Diagnosis
  • Psoriatic Arthritis Treatment

Other Symptoms of Psoriatic Arthritis

In addition to joint pain, a person with psoriatic arthritis may experience:

Dactylitis
About 40% to 50% of people how have psoriatic arthritis notice significant swelling in toes or fingers.1 The skin over the joints may appear purple. This condition is called dactylitis, and may also be referred to as “sausage digits.” (Dactylitis can also be a sign of other conditions, such as certain infections and sickle cell disease.)

Joint stiffness
Inflammatory joint pain is often accompanied by stiffness. Like joint pain, joint stiffness is typically worse in the morning and improves during the day.

Enthesitis
Tendons connect muscles to bones, and ligaments attach bones to other bones. The point where a tendon or ligament attaches to a bone is called an enthesis. If an enthesis becomes inflamed, it is called enthesitis. About 30% to 50% of the people who have psoriatic arthritis also have enthesitis in one or more places.2

The most common tissues affected by enthesitis are the Achilles tendon, located on the back of the leg near the ankle, and the plantar fascia, located on the sole of the foot.

See What Is Enthesopathy and Enthesitis?

Fingernail and toenail problems
Up to 87% of people experience changes in their fingernails and toenails.1 They may notice small holes in their nail surfaces, called pitting. They may also notice ridges that travel horizontally across the nail, cracking, and/or discoloration. Sometimes nails may crack or separate from the nail bed.

Fatigue
A person with psoriatic arthritis may feel exhausted, even when he or she gets enough sleep. Fatigue may cause a person to feel overwhelmed and cut back on daily activities.

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Diseases Associated with Psoriatic Arthritis

People who have psoriatic arthritis are more likely to get certain other medical conditions, which can produce their own set of symptoms. These conditions include:

  • Inflammatory bowel disease, which causes gastrointestinal pain/diarrhea
  • Chronic kidney disease, which may cause joint swelling in its later stages
  • Diabetes, which can cause frequent urination, thirst, hunger, weight changes, and other symptoms
  • Cardiovascular disease, which may result in high blood pressure, chest pain, heart fluttering, shortness of breath and other symptoms
  • Inflammatory bowel disease, which can cause diarrhea, stomach pain and blood in the stool
  • Conjunctivitis and uveitis, which are inflammatory eye conditions that can cause eye redness and pain and changes or loss of vision

About 8% of people with psoriatic arthritis have uveitis.1

What are the symptoms of psoriatic arthritis?

The most common symptoms of PsA are:

Swollen and painful joints

Share on PinterestSwollen, painful joints and fatigue are common symptoms of psoriatic arthritis.

PsA can lead to pain and swelling in any joint in the body. The joints may also be red and warm to the touch.

PsA often affects the hands, fingers, feet, toes, knees, ankles, and spine. It can also affect the neck and wrists. A person may also experience pain in the lower back.

PsA in the finger usually affects the joint closest to the nail.

Swelling in arthritis happens when either the lining of the joint or the fluid that surrounds the joint increases in volume. When this happens, more blood enters the area around the joint, which increases pressure and causes redness and swelling.

Symptoms can vary in severity between people. In some people, arthritis may affect one or two joints, but others might experience severe changes throughout the body.

Stiffness and reduced movement

Many people experience stiffness, particularly in the morning or after rest. It can occur with or without pain and in any joint and can limit movement.

Although stiffness is a widespread problem, stiffness that continues for longer than an hour could be a sign of inflammatory arthritis, such as PsA.

Fatigue

PsA, like other types of inflammatory arthritis, can lead to fatigue.

Around 29% of people with PsA report experiencing severe fatigue and 50% have moderate to severe fatigue, according to an article published by the National Psoriasis Foundation.

People with PsA may be more prone to other conditions, including anemia, obesity, diabetes, sleep problems, depression, and anxiety. These, too, can lead to fatigue.

Nail changes

PsA can trigger changes in the finger and toenails, signs of nail psoriasis.

These include:

  • pits, or small depressions
  • detachment from the nail bed

If the nail detaches, a person may develop onycholysis, an infection that resembles a fungal infection.

A person with psoriasis who notices changes in their nails should speak to their doctor, who may suggest screening for PsA.

Swollen fingers and toes

One symptom that is specific to PsA is dactylitis, which causes swollen, “sausage-like” fingers and toes.

However, many other symptoms of PsA can resemble those of three other arthritic diseases: rheumatoid arthritis, gout, and reactive arthritis.

Early symptoms with psoriatic arthritis are important. People will complain of pain and swelling in their joints – hands, feet, wrists, etc. They may have a small patch of psoriasis or have psoriasis covering many areas of the body. There may be complaints of stiffness and fatigue. For example, studies in Toronto showed the year before they were diagnosed, people had reported joint pain, fatigue, and stiffness. Early in the disease, people will often have episodes of worsening of the psoriatic arthritis and then episodes of improvement.

Age

Age 30 to 40 years is the peak where people develop psoriatic arthritis, which is about a decade later than the peak age for psoriasis. It usually takes 10 to 20 years to develop psoriatic arthritis in those with psoriasis, but there are certainly exceptions to this rule as well. About 7.5 million Americans have Psoriasis and up to a third may have psoriatic arthritis. It is equally common in both men and women.

About Psoriasis

Psoriasis is a relatively common skin disease. It affects about 2-4% of Americans. The area of skin that is most associated with psoriatic arthritis is psoriasis that is located on the scalp, behind or inside the ear or around the anus.

  • Plaque psoriasis – The most classic form is plaque psoriasis, where people will develop raised lesions. This is often seen on the knees and elbows and can be quite bothersome.
  • Guttate psoriasis – Guttate psoriasis looks like a rash in the shape of drops of rain. It spreads over almost the entire body, so if you add these patches together, it’s a lot. Patches are flat and pink to dark red and are covered with very fine scale if any. People tend to get this form of psoriasis more often after strep throat. It’s most common in young people.
  • Inverse psoriasis – This form of psoriasis affects moist skin such as areas under the breast, in the groin and under arms. It tends to look different and it can be very uncomfortable.
  • Pustular psoriasis– About two to four percent of people with psoriasis will have this type of psoriasis. It looks like little pimples on the hands or on the soles of the feet. These are itchy and tender and the skin may become dry and flaky.
  • Erythroderma – This is rare but severe and most of the skin is affected with red, warm, sometimes painful rash. This type of psoriasis may require hospitalization and treatment with medications to rapidly get the skin inflammation under control. This form of psoriasis can be life-threatening.
  • Nail psoriasis – Nail psoriasis can look in many ways. The most common form is nail pitting. Psoriasis nail pits are small dents on the surface of the nail. This can range from just a few pits on several nails to the entire nail surface being changed. The extreme form of pitting would be nail plate crumbling. Another form is what we call onycholysis, when the nail lifts off the nail bed. The nails grow slowly, so even with treatment, it takes months for the nail to fully recover.

About Enthesitis

Tendons are the bands of tissue that attach your muscles to your bones. Ligaments are bands of tissue that connect bones to bones. The places where the tendons and ligaments connect to your bones are called entheses. In psoriatic arthritis, these areas can become inflamed and painful. This is called enthesitis. For example, when the Achilles tendon or plantar fascia become inflamed, you can have a great deal of heel pain and it may be difficult to walk.

About Dactylitis

Dactylitis is the swelling of the entire finger or toe. This is also called a sausage digit. People with psoriatic arthritis may have one or more sausage digits if their disease is not under control. These fingers or toes can be quite painful. Dactylitis is a sign of severe psoriatic arthritis as it tends to be associated with permanent damage to the joints of the affected digit if left untreated.

What is psoriatic arthritis?

Arthritis means inflammation of the joints. Psoriasis is a common skin condition which typically causes patches (plaques) of red, scaly skin to develop. Psoriatic arthritis is a particular type of arthritis that develops in some people who also have psoriasis.

Understanding joints

Normal joint

The place where two bones meet is called a joint. Joints allow movement and flexibility of various parts of the body. The movement of the bones is caused by muscles which pull on tendons that are attached to bone.

Cartilage covers the end of bones. Between the cartilage of two bones which form a joint there is a small amount of thick fluid called synovial fluid. This fluid ‘lubricates’ the joint, which allows smooth movement between the bones.

The synovial fluid is made by the synovium. This is the tissue that surrounds the joint. The outer part of the synovium is called the capsule. This is tough, gives the joint stability, and stops the bones from moving ‘out of joint’. Surrounding ligaments and muscles also help to give support and stability to joints.

Who develops psoriatic arthritis?

About 1 person in 10 with psoriasis develops psoriatic arthritis. About 2 in 100 people develop psoriasis at some stage in their lives.

In most cases, the arthritis develops after the psoriasis – most commonly within 10 years after the psoriasis first develops. However, in some cases the arthritis develops much later. In a small number of cases the arthritis develops first, sometimes months or even years before the psoriasis develops. Men and women are equally affected.

Psoriasis most commonly first occurs between the ages of 15 and 25 and psoriatic arthritis most commonly develops between the ages of 25 and 50. However, both psoriasis and psoriatic arthritis can occur at any age, including in childhood.

Note: people with psoriasis also have the same chance as everyone else of developing other types of arthritis such as rheumatoid arthritis and osteoarthritis. Psoriatic arthritis is different, and is a particular type of arthritis that occurs only in some people with psoriasis.

What causes psoriatic arthritis?

The exact cause is not known. Inflammation develops in the synovium of affected joints (the tissue that surrounds each joint) and sometimes in other parts of the body such as tendons and ligaments. It is not clear what triggers the inflammation. It seems that the immune system is affected in some way which leads to inflammation. Genetic factors seem to be important, as psoriatic arthritis occurs more commonly in relatives of affected people. However, it is not a straightforward hereditary condition. It is thought that a virus or other factor in the environment may trigger the immune system to cause the inflammation in people who are genetically prone to it.

Which joints are affected in psoriatic arthritis?

Any joint can be affected. However, there are five main patterns of this disease. Affected people tend to fall into one of these patterns, although many people overlap between two or more patterns. The patterns are:

Asymmetrical oligoarticular arthritis

This is a common pattern and tends to be the least severe. ‘Oligo’ means ‘a few’. In this pattern usually fewer than five joints are affected at any time. A common situation is for one large joint to be affected (for example, a knee) plus a few small joints in the fingers or toes.

Symmetrical polyarthritis

This pattern is also quite common. Symmetrical means that, if a joint is affected on the right side of the body (such as a right elbow), the same joint on the left side is also often affected. Polyarthritis means that several joints become inflamed, usually including several of the smaller joints in the wrists and fingers.

Spondylitis with or without sacroiliitis

This pattern occurs in about 1 in 20 cases. ‘Spondylitis’ means inflammation of the joints and discs of the spine. ‘Sacroiliitis’ means inflammation of the joint between the lower spine (sacrum) and the pelvis. Back pain is the main symptom.

Distal interphalangeal joint predominant

This is a rare pattern where the small joints closest to the nails (distal interphalangeal joints) in the fingers and toes are mainly affected.

Arthritis mutilans

This is a rare pattern where a severe arthritis causes marked deformity to the fingers and toes.

Joint symptoms

The common main symptoms are pain and stiffness of affected joints. The stiffness is usually worse first thing in the morning, or after you have been resting. The inflammation causes swelling and redness around the affected joints. Over time, in some cases, the inflammation can damage the joint. The extent of joint damage can vary from case to case. On average, the joint damage tends not to be as bad or as disabling as occurs with rheumatoid arthritis. However, joint damage can cause significant deformity and disability in some cases.

Inflammation around tendons

This is quite common. It probably occurs because the tissue which covers tendons is similar to the synovium around the joints. A common site is inflammation of the tendons of the fingers. Affected fingers may become swollen and ‘sausage-shaped’ if there is inflammation in the finger joints and overlying tendons at the same time. The Achilles tendon is another common site, especially where the tendon attaches to the bone. Various other tendons around the body are sometimes affected.

The skin rash of psoriasis

See separate leaflet called Psoriasis for more details.

Other symptoms that may occur include:

  • Inflammation of ligaments.
  • Pitting of the nails (tiny depressions in the nail), and separation of the nail from the nail bed. See separate leaflet called Psoriatic Nail Disease for more details.
  • Anaemia and tiredness.
  • Inflammation in other parts of the body. Inflammation of the front of the eyes (conjunctivitis) and/or of the iris around the pupil (uveitis) are the most common examples. Rarely, inflammation can develop in other places such as the aorta (a main blood vessel) or lungs.

How is psoriatic arthritis diagnosed?

There is no test which clearly diagnoses early psoriatic arthritis. When you first develop symptoms of arthritis it can be difficult for a doctor definitely to confirm that you have psoriatic arthritis. This is because there are many other causes of arthritis. However, if you have developed psoriasis within the previous few years and then an arthritis develops, there is a good chance that the diagnosis is psoriatic arthritis.

In time, the pattern and course of the disease tends to become typical and a doctor may then be able to give a firm diagnosis.

Some tests may be done, such as blood tests and X-rays. These can help to rule out other types of arthritis. For example, most people with rheumatoid arthritis have an antibody in their blood called rheumatoid factor. This does not usually occur in psoriatic arthritis. (This is why psoriatic arthritis is described in medical textbooks as a ‘seronegative’ type of arthritis – that is, ‘antibody-negative’.) Also, the X-ray appearance of joints affected by psoriatic arthritis tends to be different to that seen in rheumatoid arthritis and osteoarthritis.

How does psoriatic arthritis progress?

Once the disease is triggered, psoriatic arthritis is usually a chronic relapsing condition. Chronic means that it is persistent. Relapsing means that, at times, the disease flares up (relapses) and, at other times, it settles down. There is usually no apparent reason why the inflammation may flare up for a while and then settle down.

The amount of joint damage that may eventually develop can range from mild to severe. At the outset of the disease, it is difficult to predict for an individual how badly the disease will progress. However, modern medicines that are commonly used these days aim to suppress the inflammation in the joints and prevent joint damage.

What are the treatments for psoriatic arthritis?

The main aims of treatment are:

  • To reduce pain and stiffness in affected joints and tendons as much as possible.
  • To prevent joint damage and deformity as much as possible.
  • To minimise any disability caused by pain or joint damage.

Treatment aim 1 – to reduce pain and stiffness

During a flare-up of inflammation, if you rest the affected joint(s) it helps to ease pain. Special wrist splints, footwear, gentle massage, or applying heat may also help. Medication is also helpful. Medicines which may be advised by your doctor to ease pain and stiffness include the following:

Non-steroidal anti-inflammatory medicines

These are known as ‘non-steroidal anti-inflammatory drugs (NSAIDs)’ and are sometimes just called ‘anti-inflammatories’. They are good at easing pain and stiffness. There are many types and brands. Each is slightly different to the others, and side-effects may vary between brands. To decide on the right brand to use, a doctor has to balance how powerful the effect is against possible side-effects and other factors. Usually one can be found to suit. However, it is not unusual to try two or more brands before finding one that suits you best.

The leaflet that comes with the tablets gives a full list of possible side-effects. The most common side-effect is stomach pain (dyspepsia). An uncommon but serious side-effect is bleeding from the stomach (abdomen). Your doctor may prescribe another medicine to ‘protect the stomach’ from these possible problems. If you develop any of the following symptoms whilst taking anti-inflammatories, stop taking the tablets and see a doctor urgently:

  • Stomach (abdominal) pains.
  • Passing blood or black stools (faeces).
  • Bringing up (vomiting) blood.

Note: it is thought that some anti-inflammatories may make the rash of psoriasis worse in some people. Tell your doctor if you think that your psoriasis has become worse since starting an anti-inflammatory. An alternative anti-inflammatory or a different type of painkiller may be an option.

Painkillers

Paracetamol often helps. This does not have any anti-inflammatory action but is useful for pain relief in addition to, or instead of, an anti-inflammatory. Codeine is another painkiller that is sometimes used.

Steroids

An injection of steroid directly into a joint or inflamed tendon is sometimes used to treat a bad flare-up in one particular joint or tendon. Steroids are good at reducing inflammation.

Note: anti-inflammatories, ordinary painkillers, and steroids ease the symptoms. However, they do not alter the progression of the disease or prevent joint damage. You do not need to take them if symptoms settle between flare-ups.

Treatment aim 2 – to prevent joint damage as much as possible

Disease-modifying medicines

There are a number of medicines called disease-modifying anti-rheumatic drugs (DMARDs). DMARDs are commonly used as early as possible after a diagnosis of psoriatic arthritis is made. They aim to suppress inflammation and reduce the damaging effect of the disease on the joints. They work by blocking the effects of chemicals involved in causing joint inflammation. Sulfasalazine and methotrexate are the most commonly used DMARDs for psoriatic arthritis; however, there are others.

DMARDs have no immediate effect on pains or inflammation. It can take up to 4-6 months before you notice any effect. Therefore, it is important to keep taking a DMARD as prescribed, even if it does not seem to be working at first. After starting a DMARD, many people continue to take an anti-inflammatory for several weeks until the DMARD starts to work. Once a DMARD is found to help, the dose of the anti-inflammatory can be reduced or even stopped. It is then usual to take a DMARD indefinitely.

Each DMARD has different possible side-effects. If one does not suit, a different one may be fine. Some people try two or three DMARDs before one is found to suit. (Some side-effects can be serious. These are rare and include damage to the liver and blood-producing cells. Therefore, it is usual to have regular tests – usually blood tests – whilst you take a DMARD. The tests look for some possible side-effects before they become serious.)

Some DMARDs also have a beneficial effect on reducing the rash of psoriasis.

Newer disease-modifying medicines

A new class of recently developed medicines modify the effect of TNF alpha. The chemical TNF alpha plays an important role in causing inflammation in joints and skin. Blocking the effect of TNF alpha has been shown to reduce damage to joints and to reduce symptoms. Medicines which modify or block the effect of TNF alpha include etanercept, infliximab, adalimumab, and golimumab. They show promise but their long-term benefits are still being evaluated. One problem with these medicines is that they need to be given by injection. They are also expensive.

Recent guidelines advise that etanercept, infliximab, adalimumab or golimumab should be offered as an option for treating adults with psoriatic arthritis when:

  • The person has arthritis with three or more tender joints and three or more swollen joints; and
  • When at least two other DMARDs, given on their own or together, haven’t worked.

A different medicine called ustekinumab can be used if a tumour necrosis factor (TNF) alpha inhibitor can’t be used or hasn’t been effective.

Treatment aim 3 – to minimise disability as much as possible

  • As far as possible, try to keep active. The muscles around the joints will become weak if they are not used. Regular exercise may also help to reduce pain and improve joint function. Swimming is a good way to exercise many muscles without straining joints too much. A physiotherapist can advise on exercises to keep muscles around joints as mobile and strong as possible. They may also advise on splints to help rest a joint if needed.
  • If such things as your grip or mobility become poor, an occupational therapist may advise on adaptations to the home to make daily tasks easier.
  • If severe damage occurs to a joint, joint replacement surgery may be an option.
  • Sometimes an operation is needed to fix a damaged tendon.

Other treatments

See the separate leaflet called Psoriasis for details of treatments for the psoriasis skin rash.

Some people try complementary therapies such as special diets, bracelets, acupuncture, etc, to help ease arthritis. There is little research evidence to say how effective such treatments are for psoriatic arthritis. In particular, beware of paying a lot of money to people who make extravagant claims of success. For advice on the value of any treatment it is best to consult a doctor, or contact one of the groups below.

What is the outlook (prognosis) for people with psoriatic arthritis?

The severity of psoriatic arthritis is variable and can be mild or severe. In about half of cases there is a progressive disease, eventually leading to loss of function in affected joints. However, symptoms can often be well controlled with medication. Because of the newer medicines, in particular the newer disease-modifying medicines, the outlook for a person who is diagnosed with psoriatic arthritis now is likely to be much better than it used to be.

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