Psoriatic Arthritis: Types, Causes, Symptoms, Treatment- Analgesics, DMARDs, Surgery
Psoriatic arthritis is a type of inflammatory arthritis. Psoriatic arthritis is a condition which affects few of the individuals suffering from psoriasis, a disease of the skin in which silver color scales on red colored patches are formed on the skin. This problem usually occurs over the ankles, feet, elbows, hands, knees, and sometimes also on the other areas of the body. Many of the psoriasis patients often develop this condition of psoriatic arthritis. It is psoriasis that first appears and later progresses to psoriatic arthritis though there may be cases where the joint problems may begin even before the appearance of skin lesions.
Psoriatic arthritis often affects any part of the body which may even include the spine and fingertips. Psoriatic arthritis is a condition which develops gradually from mild to severe. Once the condition is severe treatment becomes more difficult. As seen in few other forms of arthritis, in this disease also periods of flare-ups alternating with periods of remission may be observed.
The main symptoms of psoriatic arthritis may include swelling, joint pain and stiffness. The more the symptoms increase the more it makes difficult to treat the condition. Therefore the treatment must be initiated as soon as possible.
There is no direct treatment for psoriatic arthritis. The treatment concentrates only on controlling the symptoms in order to prevent the joints from getting affected. Psoriatic arthritis can be disabling if left untreated or not treated promptly.
Types of Psoriatic Arthritis
Psoriatic Arthritis Can Be Classified Into Five Types-
- Symmetric Psoriatic Arthritis: In this type of psoriatic arthritis, same joints on both sides of the body are affected like for example the knee joints or the elbow joints on both sides of the body. Psoriatic arthritis basically resembles rheumatoid arthritis, but is mild and not as severe as rheumatoid arthritis though this form of psoriatic arthritis can be disabling due to progressive destruction of the tissues.
- Asymmetric Psoriatic Arthritis: Asymmetric psoriatic arthritis often affects single or three joints. There is no particular joint involvement in this type. Asymmetric psoriatic arthritis not only affects the smaller joints but sometimes the larger joints may also get affected like hip, knee and single or many digits. Matching pairs on both sides of the body are not seen to be affected in this form of arthritis.
- Distal Interphalangeal Predominant: Distal interphalangeal predominant primarily affects the smaller joints in the toes and fingers that are around the nails. Distal interphalangeal predominant can sometimes be confused with Heberden's nodes due to their similarities, which again is caused due to osteoarthritis.
- Spondylitis: Spondylitis is a condition in which spinal column specifically gets affected. Spondylitis often causes stiffness and inflammation in the spinal vertebrae, sacroiliac region, neck or lower back which may result in difficulties with movements. Spondylitis may also affect the connective tissues like ligaments which often leads to arthritic problems in the joints of the legs, feet, arms, or hips.
- Arthritis Mutilans: Arthritis mutilans is a very rare category of psoriatic arthritis. Arthritis mutilans is very severe in nature. Arthritis mutilans often affects the smaller joints in the toes and fingers near the nails leaving them destructed and deformed. Arthritis mutilans can also affect the neck and low back.
Epidemiology of Psoriatic Arthritis
Psoriatic arthritis is an inflammatory type of arthritis which mostly affects the individuals suffering with psoriasis. Millions of Americans suffering with psoriasis are found to develop the condition of psoriatic arthritis. More than one million of US adult population suffers with psoriatic arthritis. Psoriatic arthritis most commonly occurs in individuals between 30 to 50 years of age.
Causes and Risk Factors of Psoriatic Arthritis
Psoriatic arthritis is caused when the immune system begins to attack bodies own tissues and cells. This often results in the joint inflammation and also overproduction of the cells of the skin. The clear reason for this behavior of immune system is still not known. However, environmental and genetic factors are suspected reasons. Most of the individuals suffering with psoriatic arthritis often carry a family history of diseases like psoriasis or psoriatic arthritis. Given below are few of the most common risk factors of psoriatic arthritis.
- Physical trauma.
- Viral or bacterial infection.
- Family history.
Signs and Symptoms of Psoriatic Arthritis
Signs and symptoms of psoriatic arthritis differ from person to person. The onset may be sudden in some cases whereas other cases may show a subtle gradual onset. Given below are the most common symptoms of psoriatic arthritis.
- Throbbing and discomfort is often experienced in single or many joints.
- Feeling of pain and stiffness in the affected joint.
- Development of swelling.
- Decreased range of motion may also be experienced in the joints.
- Fatigue and stiffness may also be experienced in the mornings.
- Gray or silver scaly spots on the knees, lower spine, scalp, or the elbows could also be noticed.
- Feeling of stiffness and inflammation in the knees, ankles, lower back, or wrists.
- Sausage-like appearance due to swelling of the little joints around the nails that is the fingers and toes.
- Pitting of the nails.
- Toenails or fingernails may get detached.
- Pain and tenderness where tendons and ligaments attach to the bone.
- Eye inflammation.
Treatment for Psoriatic Arthritis
Treatment for psoriatic arthritis aims at relieving the symptoms and improving function of the affected joints. Different treatments are trialed to check out which treatment works best for a particular patient. Treatment consists of medications, physical therapy and surgery depending upon the patient's condition.
- Medications: Given below are few of the commonly used medications.
- Analgesics: Analgesics help in decreasing the pain, but they do not have any anti-inflammatory effects. Few of the analgesics include tramadol, narcotics containing hydrocodone such as Vicodin and Lortab or oxycodone such as Percocet and Oxycontin, and acetaminophen drugs such as Tylenol.
- Nonsteroidal Anti-inflammatory Drugs (NSAIDs): NSAIDs help in reducing both inflammation and pain. Generally, NSAIDs include naproxen and ibuprofen such as in Motrin and Advil. Oral NSAIDs often lead to irritation of the stomach, and may sometimes increase the risk of stroke and heart attack. NSAIDs may also be found in the form of gels and creams to gently rub on the joints.
- Disease-modifying Antirheumatic Drugs (DMARDs): These drugs are frequently used for the treatment of psoriatic arthritis. DMARDs often help in slowing down the immune system from damaging the joints of the body. DMARDs may include hydroxychloroquine and methotrexate. Methotrexate is very commonly taken DMARD for psoriatic arthritis. These drugs must be taken with special care due to their severe side effects. Regular blood tests may be required for continuous monitoring and watching out for side effects.
- Immunosuppressant Medications: Immunosuppressant medications help in suppressing the immune system of the body. Commonly used medications are leflunomide and azathioprine. Immunosuppressant medications may carry serious side effects and therefore they are only used in very severe cases. The side effects may include increased risk of serious infection and anemia. Sometimes also leads to problems of kidney and liver.
- TNF-alpha Inhibitors: TNF-alpha inhibitors work by blocking the protein responsible for causing inflammation in arthritis. TNF-alpha inhibitors help in treating signs and symptoms of psoriasis. Adalimumab, etanercept, golimumab, and infliximab are few of the commonly used TNF-alpha inhibitors. TNF-alpha inhibitors also carry along with them the risk of severe side effects, which can sometimes be life-threatening.
Surgery for Psoriatic Arthritis
Surgery is performed only in severe cases when conservative measures fail. Age plays an important role in deciding whether the patient can be approved for surgery. Surgery helps in relieving the pain, increasing the movement and improving the physical look of the affected region.
Given below are few surgical methods that can be considered for treatment of psoriatic arthritis based upon the patient's condition.
- Joint fusion
- Joint replacement
Synovectomy: Synovectomy is performed for restoring the joint functioning or removing the diseased region of the joints. Synovectomy is often performed by using arthroscopy.
Arthroscopy: Arthroscopy is done by using pencil-sized, flexible, fiberoptic instrument called arthroscope. Two or three small incisions are made for inserting the arthroscope and removing loose fragments in the joint, bone spurs, damaged lining, or cysts.
Osteotomy: Osteotomy is performed for realigning the long bones of the leg or arm in order to release the pressure off of the affected joint.
Joint Fusion: As the name itself suggests, this procedure is performed by fusing or combining the bone ends with the help of screws, pins, rods, or plates which hold the bones in their place during the healing process. Joint flexibility will get eliminated with joint fusion.
Joint Replacement: This procedure is performed by removing an affected joint in order to replace it with an artificial joint made up of plastic or metal components. Joint replacement can either be partial or total depending on the condition of the affected joint.
Physical Therapy (PT) for Psoriatic Arthritis
Physical therapy is really helpful in treating psoriatic arthritis. Performing exercises often improves range of motion, reduces pain, and improves joint flexibility. This also strengthens cartilage tissues, bones and joints surrounded by the muscles. Assistive and supportive devices like splints, braces, cane, walker, crutches and elastic bandages may also be used. Heat or ice is also applied to the affected joints periodically during daytime.
Additional modalities such as ultrasound and electrical stimulation are also used to alleviate the pain.
Investigations for Psoriatic Arthritis
Psoriatic arthritis is really difficult to diagnose as there is no single test available to verify the diagnosis, however, some of the tests, which may help in diagnosing psoriatic arthritis are given below.
The Lab Tests Which Often Assist in Diagnosing Psoriatic Arthritis May Include:
- Erythrocyte sedimentation rate.
- Synovial fluid analysis.
- Complete blood count.
- C-reactive protein.
Other Tests May Include:
- Joint x-rays.
- Joint ultrasound or MRI.