Let's Talk About Psoriatic Arthritis

From healthcentral.com

We've got the doctor-approved details on causes, symptoms, treatments, and a jillion other facts and tips that can make life with psoriatic arthritis easier.

Whether you’ve just been diagnosed or worry you could have psoriatic arthritis, you’re probably nervous, confused, and maybe even a little scared. That’s normal, and everyone featured on HealthCentral with a chronic illness felt like you do now. But we—and they—are here for you. On this page alone, you’ll discover the realities and challenges of the condition, but also the best treatments, helpful lifestyle changes, where to find your psoriatic arthritis (PsA) community, and all the crucial information to help you not just manage—but thrive. We’re sure you’ve got a lot of questions...and we’ve got the answers you need.

What Is Psoriatic Arthritis, Anyway?

Given that its name references psoriasis, it’s easy to think that psoriatic arthritis (PsA) is a complication or even form of the condition that causes red, scaly plaques on the skin. But let’s get this straight from the get-go: These are two related—but separate—autoimmune conditions, both of which are driven by an out-of-whack inflammatory response. In psoriasis, your immune system targets the skin, causing rapid growth that leads to those uncomfortable, itchy rashes. In PsA, the joints, ligaments, and tendons are the target, leading to joint pain, swelling, and stiffness that, if left untreated, can lead to irreversible joint damage that can seriously interfere with your ability to move or function normally. Both conditions are systemic diseases and can cause symptoms body-wide.

                                                                                   Nikki Cagle

About 30% of people with psoriasis will develop PsA (though doctors can’t predict who), most commonly in their 30s and 40s. Right now, 7 million people are living with psoriatic arthritis.
Usually, skin problems show up first, but in some people the first signs are joint-related, which can make diagnosis trickier (which we’ll get to). Also confounding: The severity and location of skin lesions have very little impact on the severity and location of PsA joint symptoms and vice versa. Case in point: You could have skin lesions only on your legs and knees but have swelling only in your fingers on one hand. It’s annoying like that.

What Causes Psoriatic Arthritis in the First Place?

We don’t know the exact causes of psoriasis or PsA. The best guess is that a combination of genetics, an overactive immune system, and the stuff you’re exposed to (aka “environmental factors”) all play a role in causing that chronic inflammation that targets the skin and joints. Let’s take a look:
Genetics. There’s clear evidence that PsA tends to run in families—about 40% of people with PsA have a family history— and it's more common in identical twins compared to fraternal twins, according to a study in the Annals of Rheumatic Diseases. There seem to be at least 25 genes that are involved in the development of both psoriasis and PsA.

Immune system. PsA is an autoimmune disease, which means that the body mistakenly attacks healthy tissue (in this case joints, ligaments, and tendons), often thanks to getting faulty instructions from the genes. There’s also some early research that suggests that natural bacteria patterns of people with PsA may differ from those without it. Those unique biomes could potentially be misdirecting the immune system as well. 

Environmental factors. Your risk of getting PsA may also be influenced by things that happen to you as you go through life. Some think that the disease can lay dormant in the body until something triggers it. Though more research is needed, some potential PsA triggers include:

• drug use
• emotional (even low-grade) stress
• HIV infection
• joint or skin trauma
• streptococcus infections

Do I Have PsA Symptoms?

Recognizing the symptoms of PsA early is critical so you can get the right treatment to slow or even prevent long-term damage. The symptoms of PsA can come on slowly (maybe you feel like you have less strength in your hands than usual) or you can wake up with a toe so swollen it is difficult to walk – each case of PsA is unique. Overall, though, there are some common symptoms:

• Psoriasis. Most people with psoriatic arthritis first have psoriasis and the associated skin symptoms. Psoriatic arthritis usually starts about 10 years after psoriasis begins. However, it is possible to develop psoriatic arthritis without having psoriasis.
• Joint pain and stiffness. One of the tricky parts of PsA is that the symptoms, including joint pain, can come and go. When things are at their worst, it’s called a flare up, or flare. Without the right treatment, a flare can last for months. A PsA flare can cause one or more joints to feel very stiff and sore. You may also notice swelling, especially around joints you can easily see like the knee or elbow. One tell-tale sign that it might be PsA is that by the time you make a doctor’s appointment for one sore joint, the pain seems to have moved to a different joint.
• Tenderness over tendons. It is not only our bones that feel the impact of PsA. Tendons that attach to bones can also be impacted. You may develop tendonitis of the elbow or in the heel of the foot. Pain in these joints can make diagnosis more difficult because it can also occur from sports activity or plain old overuse. A clearer sign of PsA is a sudden swelling or tenderness in the fingers or toes, a condition called dactylitis. The affected digit will look like a little sausage.
• Reduced range of motion. The inflammation that is the hallmark of PsA can impact how joints move. Stiffness may be especially noticeable after sitting or sleeping. You may feel like the joint is stuck, or just isn’t working correctly. Walking up and down the stairs or getting in and out of car may become suddenly or increasingly difficult. Sometimes the pain gets better once you move around, but, depending on the level of inflammation, at other times it can stay sore throughout the day.
• Fatigue. A wiped-out feeling can be one of the most troublesome symptoms of PsA, and it impacts about half of those living with the disease. While there may be multiple causes for the fatigue, the inflammation associated with PsA can be at least partly to blame. The proteins that are released during an inflammatory response can quite literally drain your energy. Living with the stress of chronic pain can also cause sleep problems and depression, both of which can make you feel more tired. Fatigue by itself can be a difficult symptom to pin on psoriatic arthritis, but if you are feeling more tired than usual, and experiencing some of the other symptoms, telling your doctor about your exhaustion may help put some of the puzzle pieces together.
• Nail problems. PsA frequently affects fingernails and toenails. You may notice small pits on the surface of your nail, your nail separating from your nail bed, or your nails turning a different color than what is natural for you.
• Eye problems. The swelling that PsA creates throughout your body can impact your eyes. You may find that your eyes are redder or more irritated than usual or that your vision has suddenly worsened.

                                                                                    Nikki Cagle

Psoriatic Arthritis vs Rheumatoid Arthritis

Both psoriatic arthritis and rheumatoid arthritis (RA) are types of inflammatory arthritis so they do have some similarities. But there are also major differences:

• Most people with PsA will also have psoriasis.
• RA doesn’t affect your skin.
• RA often shows up as swelling in both joints, like two knees, whereas PsA will present in a more asymmetrical pattern, like a right hip and left knee being sore.
• Dactylitis, the swelling of a finger or toe, is also more common in PsA than in RA.
• Bloodwork can indicate RA, but there is not yet a blood test for PsA.

Also, we don’t know as much about what causes PsA flare-ups as we do with RA. With PsA, flares can be sudden and make things significantly worse, or PsA can also be present with low-grade symptoms all the time. For example, you may go for a walk and need to ice a joint afterwards. With a flare up, it might suddenly be difficult to walk, period.

How Do Doctors Diagnose PsA?

Unfortunately, there’s no single test that can diagnose PsA. Your doctor will perform a physical exam, which will include a medical history to determine if psoriasis or PsA runs in your family. He or she will also check your skin for signs of psoriasis, which may appear as red or dry scaly patches, examine your joints for symptoms like swelling or tenderness, and check your fingernails for telltale pitting and flaking. He or she will press or probe the soles of your feet and around your heels checking for tenderness (if you wince or yell ouch, that may be a sign).
Your doctor may also run lab tests to rule out other causes of joint pain like rheumatoid arthritis or gout. These include:

• Blood tests. While there is not a simple blood test to detect PsA, there is other information that helps doctors pinpoint the cause of your symptoms. If you test positive for rheumatoid factor (RF), for instance, you probably do not have PsA; most people with PsA are nearly always RF negative. Your doctor will also pay close attention to your levels of C-reactive protein (CRP), which is a protein made by the liver that increases with inflammation.
• Joint fluid tests. Drawing fluid from an inflamed joint can help your doctor rule out another condition that may look similar: gout. If the analysis indicates that you have a high level of uric acid, gout could be why. When there’s too much uric acid in the body, crystals can form in the joints, particularly the big toe, causing severe pain.
• X-rays. These images may be helpful in diagnosing PsA if the disease has been present for a while but undiagnosed. An x-ray can reveal what type of damage has occurred and if the bones are changing shape. Aging and other types of arthritis can also cause bone changes, so this information is just one piece of the puzzle. The images are less helpful early on when the disease hasn’t had a chance to cause damage.
• Magnetic resonance imaging (MRI). An MRI scan can provide a detailed image of both hard and soft tissue, which makes it particularly effective for spotting inflammation around tendons as well as identifying earlier signs of PsA that an x-ray can’t pick up.

What Are the Top Treatments for PsA?

The goal of treatment is simple: reduce the inflammatory response caused by PsA.
In the same way that different causes may be to blame for the disease, treatment may also require a multidimensional approach. This means that medication, surgery, and lifestyle factors may all play a role in managing your PsA. Your rheumatologist can help you decide which treatment options may be most appropriate, depending on the severity of your symptoms and what has worked for you in the past.

Because there may be both skin and joint issues with PsA, treatment may require a coordinated effort and trial and error. Some treatments may help joints more than skin and vice versa. It may take time to find the right combination that works for you.

Uncontrolled inflammation is the underlying cause of most of the discomfort associated with psoriatic arthritis. The severity of your inflammation and how you feel will often determine which treatment your doctor will choose. Fortunately, there are many effective medications available.

Medications for Psoriatic Arthritis

There’s a pretty wide range of drugs that can treat your PsA, everything from drugstore aspirin to advanced biologics.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are usually the first step if your pain and inflammation are very mild. It may take several weeks for these drugs to kick in though, and they are not recommended for long-term use since they carry side effects like stomach irritation, heart problems, and kidney damage. The most common NSAIDs include:

• Bayer, Bufferin among others (aspirin)
• Advil, Motrin (ibuprofen)
• Aleve (naproxen)
• Relafen (nabumetone)
• COX-2 inhibitors, a subclass of NSAIDs with less of a risk of internal bleeding or stomach ulcers, a common side effect of other NSAIDs that are used in large doses for a long time. Brand names include Bextra and Celebrex.

Biologics

Also known as biologic-response modifiers, these medications are protein-based drugs that are derived from living cells cultured in a laboratory. They are made to control certain parts of the immune system, which may sound creepy but stay with us: Biologics can zero in on the proteins that fuel inflammation and shut those bad boys down at the source. They’re highly effective too: Up to 60% of those with PsA achieve minimal disease activity after one year of treatment with biologics, according to a study in Arthritis Research & Therapy.

They’re typically delivered either by self-injection or via an IV infusion (usually at an infusion centre), and you may need monitoring with blood tests. Generally, biologics are intended to be taken long-term. They’re categorized by the cells they target:

• Tumour-necrosis factor (TNF) inhibitors
• Interleukin-17 (IL-17) or Interleukin-12 and -23 (IL-12/23) inhibitors
• T-cell inhibitors

DMARDs

These “disease-modifying anti-rheumatic drugs” used to be the mainstay for treating PsA. They work by “down-regulating”—or suppressing—the body’s overactive immune system. They can all be taken orally (methotrexate is also available as an injection). Due to the immune-suppressing nature of these drugs, they can come with side effects, like mouth sores, hair loss, stomach upset, infection, fatigue, or liver damage. As a result, patients must be closely monitored with regular (weekly to every few months) lab tests.

                                                                                    Nikki Cagle

PDE4 Inhibitors

Currently there is only one PDE4 inhibitor—Otezla (apremilast)—approved for PsA. This drug can be taken orally and routine blood tests are not required.

Corticosteroids

Corticosteroids are a short-term option—a couple of months, max—you can use while waiting for other longer-term medications to take effect; they’re also helpful for getting flares under control. (Long-term use can lead to side effects like high blood sugar, high blood pressure, bone loss, and glaucoma.) They can be taken orally, intravenously, or injected right into the joint. The most common is prednisone.

Surgery

Surgery is not a standard treatment for those with PsA. However, if you’ve lived with psoriatic disease without diagnosis or treatment, it is possible that it has caused permanent joint damage and arthroplasty might be recommended. This is surgery that reconstructs or replaces the damaged joint. Bones can be reshaped, or replaced with metal, ceramic, or plastic parts.
More than a million joint replacement surgeries are performed each year, mostly of the hip or knee, but the shoulders, elbows, and joints in the hands and feet can be replaced as well. As with all surgery, you will need to weigh the risks against the potential benefits of the procedure.

How Do I Manage PsA Flares?

When PsA symptoms suddenly get worse, it’s known as a flare up—and they’re different for each person. For some, it may be a joint or two hurting more than usual, while others may feel uncomfortable from head to toe and tired on top of that. There is no one trigger or cause for flare ups, but some factors have been reported to precede a PsA flare, such as stress, injury, infection, or skipping medication.

Experience with flares is the best possible way to manage them. The longer you live with the disease, the sooner you can tell when one is coming. You will begin to avoid triggers and get the rest you need. Still, some flares come out of nowhere and require more than self-management. During these times, you’ll need to be in touch with your rheumatologist and, depending on your situation, he or she will recommend strategies and additional treatment to get you through.

Complementary Approaches to Treatment

Beyond medications and surgery, there are other measures you can take on a daily basis to help you live your best life with PsA. The symptoms of psoriatic disease can worsen with stress, so it’s wise to take relaxation as seriously as any other lifestyle changes you can make (along with taking the meds your doctor has prescribed).

Exercise. When you’re stiff and sore, exercise may be the last thing you want to do. But movement is known to loosen joints impacted by PsA. According to the National Psoriasis Foundation, exercise is key to overcoming psoriatic arthritis symptoms. Training with weights can keep the muscles surrounding joints strong so they can better support movements. Stretching can keep your joints moving through their range of motion to combat stiffness. Cardiovascular exercise can help you drop unwanted pounds and may make you feel better overall. Your doctor or a physical therapist can help you get moving safely.

Eat a healthy diet. Because everyone is different and PsA is a complex disease, there is no one diet that is recommended. However, certain foods do have the power to help you feel better—or worse. Fruits and vegetables, which contain compounds that can reduce inflammation, should be consumed as often as possible. They are also known to have antioxidant properties that can make us feel better overall (think of a rust-removal system for your car). Foods that contain good bacteria such as yogurt and anything fermented also show promise in reducing levels of that internal fire. On the flip side, a diet that contains high fat, sugar, and salt does the opposite.

Get your sleep. Sleep impacts every system in our body in a positive way. It can make us feel less depressed and anxious, improve our physical functioning, and accelerate healing. The Centres for Disease Control recommends that adults shoot for seven to nine hours of sleep a day. If you are battling a flare, chronic pain, or adjusting to a new treatment, you may need more rest than usual. If your pain is keeping you up at night, it is important that you let your doctor know so changes can be made to your treatment plan.

Make Time to Decompress. Emotional stress has been shown to be the most common trigger for psoriasis flare-ups, and research shows that a period of angst precedes the onset of PsA in at least 44% of patients. And once that stress loops starts, it can be harder to rein in: An upside-down life can make your symptoms worse, which only stresses you out even more. You’re the best judge of what helps you relax most—a walk outside, knitting, reading, whatever. Just try to work that downtime into your schedule every day.

Does PsA Have Serious Complications?

It can, mostly because the inflammation that affects your joints can affect other parts of your body, too. But you have some control! Treating your PsA and getting the disease under control reduces your risk of developing related conditions. Here are areas that PsA can influence:

Your eyes. About 7% of people with PsA will go on to develop uveitis, or eye inflammation, according to the National Psoriasis Society. This causes pain, irritation, redness, and blurred vision. If it’s left untreated, it can lead to vision loss. Like many aspects of PsA, it can come on suddenly and get worse quickly. If your eye is bothering you for more than a couple of days, it is time to call your eye doctor. Be sure to tell them that you have PsA as this can make a difference in how quickly they will see you.

Your gut. People with psoriasis have an increased risk of developing Crohn’s disease later in life. That’s not surprising in that in both diseases cause healthy tissue to be mistaken for a foreign invader Symptoms of Crohn's include frequent diarrhoea, abdominal pain, cramping, bloody stools and weight loss. If you are experiencing any of these symptoms unrelated to any other medical condition (or bad takeout), it may be time to meet with your doctor.

Your heart. The leading cause of death for people with PsA is cardiovascular disease, according to the National Psoriasis Foundation. Researchers believe this is because the chronic inflammation that goes along with PsA can also go hand in hand with high blood pressure, abdominal obesity, and insulin resistance. If you have PsA, be sure to talk to your doctor about your overall cardiovascular risks and how you can lower them. The good news is that treating your psoriatic disease could also decrease your chances of experiencing a heart attack, stroke, or other cardiovascular event.

Your bones. The prevalence of osteoporosis in those with psoriatic disease is just as high if not higher than those without the disease. It is not completely understood if the bone disease is related to inflammation from psoriatic arthritis, decreased movement, or other factors. You can talk to your doctor about whether a bone density test should be included in your next check-up.

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