Psoriatic arthritis

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Psoriatic arthritis
Classification and external resources
Psoriatic arthritis2010.JPG
Severe psoriatic arthritis of both feet and ankles. Note the changes to the nails.
ICD-10 L40.5, M07
ICD-9 696.0
MedlinePlus 000413
eMedicine radio/578
Patient UK Psoriatic arthritis
MeSH D015535
Magnetic resonance images of the fingers in psoriatic arthritis. Shown are T1-weighted (a) pre-contrast and (b) post-contrast coronal images. Enhancement of the synovial membrane at the third and fourth proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints is seen, indicating active synovitis (inflammation of the synovial membrane; large arrows). There is joint space narrowing with bone proliferation at the third PIP joint and erosions are present at the fourth DIP joint (white circle). Extracapsular enhancement (small arrows) is seen medial to the third and fourth PIP joints, indicating probable enthesitis (inflammation of a tendon insertion).
Sagittal magnetic resonance images of the ankle region in psoriatic arthritis. (a) Short tau inversion recovery (STIR) image, showing high signal intensity at the Achilles tendon insertion (enthesitis, thick arrow) and in the synovium of the ankle joint (synovitis, long thin arrow). Bone marrow oedema is seen at the tendon insertion (short thin arrow). (b,c) T1 weighted images of a different section of the same patient, before (panel b) and after (panel c) intravenous contrast injection, confirm inflammation (large arrow) at the enthesis and reveal bone erosion at tendon insertion (short thin arrows).

Psoriatic arthritis (also arthritis psoriatica, arthropathic psoriasis or psoriatic arthropathy) is a type of inflammatory arthritis[1][2] that will develop in up to 30 percent of people who have the chronic skin condition psoriasis.[3] Psoriatic arthritis is said to be a seronegative spondyloarthropathy and therefore occurs more commonly in patients with tissue type HLA-B27.

Signs and symptoms[edit]

  • Pain, swelling, or stiffness in one or more joints is commonly present.[4]
    • Asymmetrical oligoarthritis (70%) (DIP involvement is a characteristic feature).
    • Sacroiliitis/spondylitis (40%)
    • Symmetrical seronegative arthritis (15%)
    • Distal interphalangeal (DIP) joint arthritis (15%)
  • Hand joints involved in psoriasis are proximal interphalangeal (PIP) + distal interphalangeal (DIP) + metacarpophalangeal (MCP) + wrist
  • Joints that are red or warm to the touch.[4]
  • Sausage-like swelling in the fingers or toes, known as dactylitis.[4]
  • Pain in and around the feet and ankles, especially tendinitis in the Achilles tendon or plantar fasciitis in the sole of the foot.[4]
  • Changes to the nails, such as pitting or separation from the nail bed.[4]
  • Pain in the area of the sacrum (the lower back, above the tailbone).[4]
  • Along with the above noted pain and inflammation, there is extreme exhaustion that does not go away with adequate rest. The exhaustion may last for days or weeks without abatement. Psoriatic arthritis may remain mild, or may progress to more destructive joint disease. Periods of active disease, or flares, will typically alternate with periods of remission. In severe forms, psoriatic arthritis may progress to arthritis mutilans[5] which on X-ray gives pencil in cup appearance.
  • Because prolonged inflammation can lead to joint damage, early diagnosis and treatment to slow or prevent joint damage is recommended.[6]
  • Scaly skin lesions are seen over extensor surfaces (scalp, natal cleft and umbilicus).
  • The nail changes are pitting, onycholysis, sub–ungual hyperkeratosis and horizontal ridging.

Causes[edit]

The exact causes are not yet known, but a number of genetic associations have been identified in a genome-wide association study of psoriasis and psoriatic arthritis including HLA-B27.[7][8]

Diagnosis[edit]

There is no definitive test to diagnose psoriatic arthritis. Symptoms of psoriatic arthritis may closely resemble other diseases, including rheumatoid arthritis. A rheumatologist (a doctor specializing in diseases affecting the joints) may use physical examinations, health history, blood tests and x-rays to accurately diagnose psoriatic arthritis.

Factors that contribute to a diagnosis of psoriatic arthritis include:

  • Psoriasis in the patient, or a family history of psoriasis or psoriatic arthritis.
  • A negative test result for Rheumatoid factor, a blood factor associated with rheumatoid arthritis.
  • Arthritis symptoms in the distal Interphalangeal articulations of hand (the joints closest to the tips of the fingers). This is not typical of rheumatoid arthritis.
  • Ridging or pitting of fingernails or toenails (onycholysis), which is associated with psoriasis and psoriatic arthritis.
  • Radiologic images indicating joint change.

Other symptoms that are more typical of psoriatic arthritis than other forms of arthritis include inflammation in the Achilles tendon (at the back of the heel) or the Plantar fascia (bottom of the feet), and dactylitis (sausage-like swelling of the fingers or toes).[9]

Classification[edit]

There are five main types of psoriatic arthritis:

  • Asymmetric: This type affects around 70% of patients and is generally mild. This type does not occur in the same joints on both sides of the body and usually only involves fewer than 3 joints.
  • Symmetric: This type accounts for around 25% of cases, and affects joints on both sides of the body simultaneously. This type is most similar to rheumatoid arthritis and is disabling in around 50% of all cases.
  • Arthritis mutilans (M07.1): Affects less than 5% of patients and is a severe, deforming and destructive arthritis. This condition can progress over months or years causing severe joint damage. Arthritis mutilans has also been called chronic absorptive arthritis, and may be seen in rheumatoid arthritis as well.
  • Spondylitis (M07.2): This type is characterised by stiffness of the spine or neck, but can also affect the hands and feet, in a similar fashion to symmetric arthritis.
  • Distal interphalangeal predominant (M07.0): This type of psoriatic arthritis is found in about 5% of patients, and is characterised by inflammation and stiffness in the joints nearest to the ends of the fingers and toes. Nail changes are often marked.

Treatments[edit]

The underlying process in psoriatic arthritis is inflammation; therefore treatments are directed at reducing and controlling inflammation. Milder cases of psoriatic arthitis may be treated with NSAIDS alone; however, there is a trend toward earlier use of disease-modifying antirheumatic drugs or biological response modifiers to prevent irreversible joint destruction.

Nonsteroidal anti-inflammatory drugs[edit]

Typically the medications first prescribed for psoriatic arthritis are NSAIDs such as ibuprofen and naproxen followed by more potent NSAIDs like diclofenac, indomethacin, and etodolac. NSAIDs can irritate the stomach and intestine, and long-term use can lead to gastrointestinal bleeding.[10][11] Other potential adverse effects include damage to the kidneys and cardiovascular system.

Disease-modifying antirheumatic drugs[edit]

These are used in persistent symptomatic cases without exacerbation. Rather than just reducing pain and inflammation, this class of drugs helps limit the amount of joint damage that occurs in psoriatic arthritis. Most DMARDs act slowly and may take weeks or even months to take full effect. Drugs such as methotrexate or leflunomide are commonly prescribed; other DMARDS used to treat psoriatic arthritis include cyclosporin, azathioprine and sulfasalazine. These immunosuppressant drugs can also reduce psoriasis skin symptoms but can lead to liver and kidney problems and an increased risk of serious infection.

Biological response modifiers[edit]

Recently, a new class of therapeutics called biological response modifiers or biologics has been developed using recombinant DNA technology. Biologic medications are derived from living cells cultured in a laboratory. Different from the traditional DMARDS that affect the entire immune system, biologics target specific parts of the immune system. They are given by injection or intravenous (IV) infusion.

Biologics prescribed for psoriatic arthritis are TNF-α inhibitors, including infliximab, etanercept, golimumab, certolizumab pegol and adalimumab.

Biologics may increase the risk of minor and serious infections. More rarely, they may be associated with nervous system disorders, blood disorders or certain types of cancer.

Other treatments[edit]

Retinoid etretinate 30mg/day is effective for both arthritis and skin lesions.Photochemotherapy with methoxy psoralen and long wave ultraviolet light (PUVA) are used for severe skin lesions. Doctors may use joint injections with corticosteroids in cases where one joint is severely affected. In psoriatic arthritis patients with severe joint damage orthopedic surgery may be implemented to correct joint destruction, usually with use of a joint replacement. Surgery is effective for pain alleviation, correcting joint disfigurement, and reinforcing joint usefulness and strength.

Self care[edit]

People with psoriatic arthritis and other forms of arthritis may find day-to-day tasks difficult. Adjustments include using gadgets such as jar openers, lifting heavy objects with both hands, etc.

Maintaining a healthy weight places less strain on the joints, leading to reduced pain and increased energy and mobility.

Regular exercise is recommended for people with arthritis to help maintain flexibility and strength. Yoga, biking (gentle), swimming and walking are commonly recommended.

Hot and cold packs can relieve inflamed joints. Cold has a numbing effect and can dull the sensation of pain. Heat can help relax tense muscles and relieve pain.

Epidemiology[edit]

Seventy percent of people who develop psoriatic arthritis first show signs of psoriasis on the skin, 15 percent develop skin psoriasis and arthritis at the same time, and 15 percent develop skin psoriasis following the onset of psoriatic arthritis.[12]

Psoriatic arthritis can develop in people who have any level severity of psoriatic skin disease from mild to very severe.[13]

Psoriatic arthritis tends to appear about 10 years after the first signs of psoriasis. For the majority of people this is between the ages of 30 and 55, but the disease can also affect children. The onset of psoriatic arthritis symptoms before symptoms of skin psoriasis is more common in children than adults.[14]

More than 80% of patients with psoriatic arthritis will have psoriatic nail lesions characterized by nail pitting, separation of the nail from the underlying nail bed, ridging and cracking, or more extremely, loss of the nail itself (onycholysis).[14]

Men and women are equally affected by this condition. Like psoriasis, psoriatic arthritis is more common among Caucasians than Africans or Asians.[15]

Additional images[edit]

References[edit]

  1. ^ Freedberg, Irwin M.; Fitzpatrick, Thomas B. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York: McGraw-Hill. pp. 427–436. ISBN 0-07-138076-0. 
  2. ^ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology (10th ed.). Saunders. p. 194. ISBN 0-7216-2921-0. 
  3. ^ About psoriatic arthritis. National Psoriasis Foundation. Retrieved 2008-08-31. 
  4. ^ a b c d e f Amherd-Hoekstra A, Näher H, Lorenz HM, Enk AH (May 2010). "Psoriatic arthritis: a review.". Journal of the German Society of Dermatology 8 (5): 332–9. doi:10.1111/j.1610-0387.2009.07334.x. PMID 20015187. 
  5. ^ Davidson's principles and practice of medicine. (21st ed.). Edinburgh: Churchill Livingstone/Elsevier. 2010. p. 1096. ISBN 978-0-7020-3084-0. 
  6. ^ Farragher TM, Lunt M, Plant D, Bunn DK, Barton A, Symmons DP (May 2010). "Benefit of early treatment in inflammatory polyarthritis patients with anti-cyclic citrullinated peptide antibodies versus those without antibodies.". Ann. Rheum. Dis. 62 (5): 664–75. doi:10.1002/acr.20207. PMC 2962800. PMID 20461787. 
  7. ^ Liu Y, Helms C, Liao W, et al. (March 2008). "A genome-wide association study of psoriasis and psoriatic arthritis identifies new disease loci". In Leal, Suzanne M. PLoS Genet. 4 (3): e1000041. doi:10.1371/journal.pgen.1000041. PMC 2274885. PMID 18369459. 
  8. ^ Rahman P, Elder JT (March 2005). "Genetic epidemiology of psoriasis and psoriatic arthritis". Ann. Rheum. Dis. 64 (Suppl 2): ii37–9; discussion ii40–1. doi:10.1136/ard.2004.030775. PMC 1766868. PMID 15708933. 
  9. ^ Psoriatic Arthritis. The Johns Hopkins University School of Medicine and the Johns Hopkins Arthritis Center. Retrieved 2011-05-04. 
  10. ^ Warner TD, Giuliano F, Vojnovic I, Bukasa A, Mitchell JA, Vane JR (1999). "Nonsteroid drug selectivities for cyclo-oxygenase-1 rather than cyclo-oxygenase-2 are associated with human gastrointestinal toxicity: a full in vitro analysis". Proc Natl Acad Sci U S A 96 (13): 7563–8. doi:10.1073/pnas.96.13.7563. PMC 22126. PMID 10377455. 
  11. ^ Scholer DW, Ku EC, Boettcher I, Schweizer A (April 1986). "Pharmacology of diclofenac sodium". Am. J. Med. 80 (4B): 34–8. doi:10.1016/0002-9343(86)90077-X. PMID 3085490. 
  12. ^ Psoriatic Arthritis. The Johns Hopkins University School of Medicine and the Johns Hopkins Arthritis Center. Retrieved 2011-05-04. 
  13. ^ Who's At Risk. National Psoriasis Foundation and Arthritis Foundation. Retrieved 2011-05-04. 
  14. ^ a b Psoriatic Arthritis. WebMD LLC. Retrieved 2011-05-04. 
  15. ^ Epidemiology of Psoriatic Arthritis. WebMD LLC. Retrieved 2011-05-04. 

External links[edit]