From verywellhealth.com
Psoriatic arthritis (PsA) is an autoimmune disease that occurs because the immune system mistakenly attacks healthy body tissues, namely the joints and entheses (the areas where tendons and ligaments meet bone).
According to the National Psoriasis Foundation (NPF), PsA affects up to 30% of people with the autoimmune skin disease psoriasis. In psoriasis, the immune system mistakenly attacks healthy skin cells leading to the accelerated growth of new cells that build up to form plaques (red patches of flaky, crusty skin).
But PsA is not limited to people with psoriasis, and anyone can develop the condition, including children and teenagers. When children and teens get PsA, the condition is called juvenile PsA.
Juvenile PsA is a type of juvenile idiopathic arthritis (JIA) and is extremely rare. It is called idiopathic because it has no known cause. According to NPF, JIA occurs in around 20 to 45 children per 100,000 children. Of those, about 5% have PsA.
This article will cover the symptoms of juvenile PsA, its causes and risk factors, treatment, and more.
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Juvenile PsA Symptoms
The symptoms of juvenile PsA are the same as those experienced in adult PsA. It is possible to experience juvenile psoriasis before a child has any signs of PsA, but that is not always the case. Some children will develop arthritis symptoms first, and others will never get psoriasis.
Symptoms will vary among children and may include:
- Inflamed, swollen, and painful joints
- Joint stiffness, especially in the morning and after long periods of inactivity
- Redness and warmth of affected joints
- Dactylitis: Sausage-like swelling of fingers and toes
- Enthesitis: Inflammation of the entheses
- Swollen wrists: More common in girls ages 1 to 6
- Deformed joints from ongoing, persistent inflammation
- Low back pain and other spine symptoms
- Sacroiliac joint pain: Felt in the low back and buttocks
- Eye pain and inflammation
- Fatigue
- Nail symptoms: Pitting, ridges, crumbling, discoloration, and nailbed separation
- Skin symptoms: Similar to what is seen in psoriasis
Sometimes, symptoms of juvenile PsA are asymmetric (affecting only one side of the body), but over time, they may become symmetric (affecting both sides).
Causes
The causes of JIA are unknown, and researchers do not know what causes the immune system to turn against its joints and skin. They suspect that genes and environmental factors might be to blame. Children with juvenile PsA often have a first-degree relative (parent or full sibling) with PsA or psoriasis, or a personal history of psoriasis.
Risk Factors
Why some children develop juvenile PsA and others do not is a question that researchers have been trying to answer, and they suspect that genetics might be a risk factor for the condition.
According to the NPF, more than half of children who develop PsA have at least one family member who has psoriasis. Genetic studies have found links with specific genes that might predispose someone to PsA.
Additional risk factors for PsA in children are:
- Being female: PsA affects both boys and girls, but girls have a slightly higher risk
- Older age: The average age for symptom onset of juvenile PsA is 13
- Having psoriasis
Like adult PsA, juvenile PsA tends to be more frequently diagnosed in children who are White and non-Hispanic. One 2018 literature review looked at a cohort of 361 children with PsA, most of whom were later identified to be White (93.9%) and non-Hispanic (91.7%).
Diagnosis
A rheumatologist (a specialist in non-surgical treatment of arthritis and other diseases of the muscles, joints, and bones) can diagnose juvenile PsA with a physical examination, including a complete medical and symptom history, laboratory tests, and imaging.
Physical Examination
During the physical exam, the rheumatologist will ask about the child's symptoms, medical history, and any family history of psoriasis or PsA. During the physical exam, they will look for the following:
- Dactylitis and enthesitis
- Nail symptoms
- Psoriatic rash
- Hand, wrist, and foot tenderness and swelling
- Spinal or sacroiliac joint symptoms
- Contractures of joints: Tightening or shortening leading to a deformity. Contractures can also occur in muscles, tendons, and other body tissues.
- A limping gait (walk)
If your child has eye redness or pain, their doctor will make a referral to a paediatric ophthalmologist (eye doctor). An eye exam can look for uveitis (swelling of the eye's middle layer).
Labs and Tests
There is no single lab test that confirms juvenile PsA. However, some lab tests can rule out other diseases with similar symptoms.
Blood tests might include:
- Complete blood count (CBC): Autoimmune diseases can cause anaemia (low numbers of healthy red blood cells) due to chronic inflammation. The CBC test will also check white blood cell and platelet counts. Both can be elevated from inflammation.
- Erythrocyte sedimentation rate (ESR or sed rate): This test looks at how quickly red blood cells settle to the bottom of a tube. When inflammation is present, the blood proteins will clump together and become heavier, and they will fall and get to the bottom of the test tube much faster. The faster they fall, the more severe the inflammation.
- Anti-nuclear antibody (ANA): This blood test looks for specific proteins (antibodies) the body is making to attack its own cells. This test is positive in people with rheumatic conditions. However, ANA testing is not reliable on its own because it has a high false-positive rate, meaning your child can have high ANA levels and not have PsA or another autoimmune disease.
- Additional testing: Other blood work can rule out other autoimmune or arthritis conditions. For example, rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) testing can rule out another type of JIA called polyarticular RF-positive juvenile arthritis (sometimes called juvenile rheumatoid arthritis), known for attacking the linings of the joints. Joint fluid testing can help to rule out paediatric gout, painful inflammation caused by uric acid crystals in joint fluid.
Imaging
If your child's healthcare provider suspects PsA, they will request imaging studies—X-rays, magnetic resonance imaging (MRI), and ultrasound scans. Imaging for juvenile PsA can reveal the presence and extent of joint inflammation and help your child's healthcare provider distinguish arthritis from other inflammatory conditions.
Imaging is helpful because PsA is known for causing bone and joint destruction very early on. Also, these bone and joint changes are rarely seen with other types of inflammatory arthritis.
Treatment for Juvenile Psoriatic Arthritis
Untreated juvenile PsA can lead to different disease complications. These might include:
- Permanent joint damage
- Bone growth problems
- Chronic arthritis and disability
- Vision problems caused by uveitis
- Heart and lung inflammation that can become severe and life-threatening
Treatment for juvenile PsA will depend on your child's symptoms, disease severity, age, and overall health. Treatment will manage both skin symptoms and joint inflammation. The goals of PsA treatment are to reduce damaging inflammation, maintain mobility and prevent joint deformity and severe disease complications.
Home Remedies and Lifestyle
You can help your child learn how to manage juvenile PsA using different home remedies and lifestyle remedies. These might include:
- Applying heat or cold: Stiffness and pain can affect many children with PsA, especially after periods of activity (pain) and inactivity (stiffness). Heat packs, warm baths, and hot showers can help your child get relief from pain and stiffness. Cold packs can help manage pain and swelling, especially after activity.
- Regular exercise: Exercise can maintain your child's muscle strength and joint flexibility. Swimming or water exercises are the easiest because they put the least stress on the joints.
- Eating a healthy diet: A healthy diet can keep your child at a healthy weight and reduce stress on joints. It can reduce inflammation. Adequate calcium and vitamin D intake, either through diet or taking supplements, is essential for reducing the risk of weak bones related to some of the treatments for the condition and decreased physical activity.
Over-the-Counter (OTC) Pain Relievers
Nonsteroidal anti-inflammatory drugs (NSAIDs) can provide pain relief and reduce swelling. Most are available without a prescription. NSAIDs include Advil (ibuprofen) and Aleve (naproxen).
Injections
Corticosteroids can be given to children as an injection in a single joint. A corticosteroid can be given orally as a pill, but healthcare providers try to avoid this because long-term steroid use can interfere with a child's growth.
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
DMARDs suppress an overactive immune system and reduce inflammation. The goal of these medicines is to prevent bone and joint destruction.
Mexate (methotrexate) is the most commonly prescribed DMARD for juvenile PsA, and is often given as an injection to children. Other DMARDs for juvenile PsA are Arava (leflunomide) and Azulfidine (sulfasalazine).
Biologic Medications
Biologics are medicines that target specific proteins in the immune system responsible for inflammation. They are available as subcutaneous injections or intravenous infusions.
They are prescribed to treat severe PsA or PsA that has not responded to other medications. These medicines can suppress the immune system and increase a child's vulnerability to infections.
Physical and Occupational Therapy
Physical and occupational therapy can help reduce your child's pain and stiffness, maintain muscle strength, improve mobility, and prevent disability. An occupational therapist might be able to prescribe or recommend splints or braces to protect your child's joints as they grow.
Complementary and Alternative Medicine (CAM)
Complementary and alternative medicine is a medical term used to describe medical practices and products that are not part of standard medical care. CAM therapies will not cure or treat your child's PsA, but they can relieve symptoms. CAM options that might be helpful to your child are massage and acupuncture (thin needles applied to specific spots to channel energy).
Treatment for Skin Symptoms
If your child experiences skin symptoms, topical medicines (applied to the skin) and phototherapy (exposing skin to controlled amounts of ultraviolet light) can help manage and reduce these.
Prognosis and Quality of Life
Children who are treated early for PsA can go into remission. Remission means the disease is no longer active and presents few or no symptoms. Your child will still have PsA but they won't experience signs of the condition.
One study reported in 2013 in the journal Paediatric Rheumatology found that 88% of juvenile PsA study participants experienced inactive disease on therapy and 50% off treatment. The study authors noted that these rates were similar to previously reported remission rates.
Even though the potential for remission is higher with early and aggressive treatment, PsA affects children differently. Some may only have involvement in one or two joints and experience a mild disease that is easy to control. Others, however, may have multiple affected joints, have skin and other symptoms, and experience a more severe disease course. But thanks to advances in PsA treatments, most disease complications can be avoided.
Summary
Juvenile psoriatic arthritis is a type of juvenile idiopathic arthritis. JIA conditions, like PsA, involve joint inflammation that appears before age 16.
These conditions are autoimmune diseases where the immune system malfunctions and attacks healthy tissues. In the case of PsA, these attacks are focused on the joints and the entheses. Common symptoms of juvenile PsA are joint pain and stiffness, dactylitis, enthesitis, skin rash, and nail symptoms like pitting and crumbling.
Researchers do not know why some children get juvenile PsA and others don't, but they suspect genetics and environmental factors might play a part. While there is no cure for PsA, it is a treatable and manageable condition. Treatment can prevent joint damage and disease complications and lead to disease remission.
A Word From Verywell
Children and teens with juvenile psoriatic arthritis can live normal and happy lives. They can attend school, play sports, and participate in family and extracurricular activities.
Make sure you treat your child with PsA the same way you treat their siblings. It can also be helpful to educate your child about PsA, what causes it, and how to best manage it.
Children should be allowed to express feelings about PsA, including anger. Help your child understand that they didn't do anything to get sick and that it is possible to feel better and enjoy life despite the condition.
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