Psoriatic arthritis
Arthritis - psoriatic; Psoriasis - psoriatic arthritis; Spondyloarthritis - psoriatic arthritis; PsA
Psoriatic arthritis is a joint problem (arthritis) that often occurs with a skin condition called psoriasis.
This is a picture of guttate (drop-shaped) psoriasis on the arms and chest. Guttate psoriasis is a rare form of psoriasis. It frequently follows a streptococcal infection, appears rapidly and affects the face, chest, and nearest limbs. The patches are small and round or oval and have the typical appearance of psoriasis. This photograph shows the diffuse and widespread coverage on the arm and chest.
This is a picture of guttate (drop-shaped) psoriasis on face and neck. Guttate psoriasis is a rare form of psoriasis. It frequently follows a streptococcal infection, appears rapidly and affects the face, chest, and nearest limbs. The patches are small and round or oval and have the typical appearance of psoriasis. This photograph shows the diffuse and widespread coverage on the face and neck.
Causes
Psoriasis is a common skin problem that causes red patches on the skin. It is an ongoing (chronic) inflammatory condition. Psoriatic arthritis occurs in 7% to 42% of people with psoriasis. Nail psoriasis is linked to psoriatic arthritis.
In most cases, psoriasis comes before the arthritis. In a few people, the arthritis comes before the skin disease. However, having severe, wide-spread psoriasis appears to increase the chance of getting psoriatic arthritis.
The cause of psoriatic arthritis is not known. Genes, immune system, and environmental factors may play a role. It is likely that the skin and joint diseases have similar causes. However, they may not occur together.
Psoriasis is a common skin condition that causes skin redness and irritation. Most people with psoriasis have thick, red skin with flaky, silver-white patches called scales. Psoriasis may affect you at any age, but it usually begins between the ages of 15 and 35. You can't spread this disorder to others, but it does seem to be passed down through families. We think it probably occurs when your immune system mistakes healthy cells for dangerous substances. Skin cells grow deep in your skin, normally rising to the surface about once a month. But, in people with psoriasis, this process occurs too fast, usually happening in only about 2 weeks, and dead skin cells build up on your skin's surface. Many factors can trigger psoriasis, or make it more difficult to treat, including bacterial or viral infections, dry air or skin, injuries to your skin, some medications, stress, too much or too little sunlight, and even too much alcohol. In general, psoriasis may be very bad in people who have a weakened immune system. Psoriasis can appear suddenly or it can appear slowly. Often, it goes away and then flares up again, time after time. If you have psoriasis, you'll probably have irritated patches of skin on your body, often on your elbows and knees. But it can show up anywhere on your body, even your scalp. The skin patches may be itchy, dry and covered with silver, flaky scales. They may be pink in color and raised and thick. So, what do you do about psoriasis? Well, your doctor will need to look at your skin to make a diagnosis. Sometimes the doctor will take a skin sample, or a biopsy, to rule out other possible problems. Your treatment will focus on controlling your symptoms and preventing infections. In general, you have three options topical medications like lotions or creams, pills or injections that affect your whole body, and therapy that uses light to treat psoriasis. But most people tend to use creams or ointments they place directly on their skin. Psoriasis is a life-long condition you can control with treatment. It may go away for a long time and then suddenly return. Fortunately, with the right treatment, it usually does not affect your general physical health.
Symptoms
The arthritis may be mild and involve only a few joints. The joints at the end of the fingers or toes may be more affected. Psoriatic arthritis most often causes arthritis only on one side of the body.
In some people, the disease may be severe and affect many joints, including the spine. Symptoms in the spine include stiffness and pain. They most often occur in the lower spine and sacrum.
Some people with psoriatic arthritis may have inflammation of the eyes.
Most of the time, people with psoriatic arthritis have the skin and nail changes of psoriasis. Often, the skin gets worse at the same time as the arthritis.
Tendons may become inflamed with psoriatic arthritis. Examples include the Achilles tendon, the plantar fascia, and the tendon sheath in the hand.
Exams and Tests
During a physical exam, the health care provider will look for:
- Joint swelling
- Skin patches, usually red and scaly (psoriasis)
- Pitting in the nails
- Joint tenderness
- Inflammation in the eyes
Joint x-rays may be done.
There are no specific blood tests for psoriatic arthritis or for psoriasis. Tests to rule out other types of arthritis may be done:
- Rheumatoid factor
- Anti-CCP antibodies
The provider may test for a gene called HLA-B27. People with involvement of the spine are more likely to have HLA-B27.
Treatment
Your provider may suggest nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and swelling of the joints.
Arthritis that does not improve with NSAIDs may need to be treated with medicines called disease-modifying antirheumatic drugs (DMARDs). These include:
- Methotrexate
- Leflunomide
- Sulfasalazine
Apremilast is another medicine used for the treatment of psoriatic arthritis.
Multiple injectable biologic medicines are effective for progressive psoriatic arthritis that is not controlled with DMARDs. These medicines block a protein called tumor necrosis factor (TNF) or other proteins involved in the inflammation process. They are often helpful for both the skin disease and the joint disease of psoriatic arthritis.
Additionally, there is an oral synthetic agent, tofacitinib, that is available to treat psoriatic arthritis that is progressing even with the use of DMARDs or anti-TNF agents.
Very painful joints may be treated with steroid injections. These are used when only one or a few joints are involved. Most experts do not recommend oral corticosteroids for psoriatic arthritis. Their use may worsen psoriasis and interfere with the effect of other drugs.
In rare cases, surgery may be needed to repair or replace damaged joints.
People with inflammation of the eye should see an ophthalmologist.
Your provider may suggest a mix of rest and exercise. Physical therapy may help increase joint movement. You may also use heat and cold therapy.
Outlook (Prognosis)
The disease is sometimes mild and affects only a few joints. However, in many people with psoriatic arthritis damage to joints occurs within the first several years. In some people, very bad arthritis may cause deformities in the hands, feet, and spine.
Most people with psoriatic arthritis who do not improve with NSAIDs should see a rheumatologist, a specialist in arthritis, along with a dermatologist for the psoriasis.
Early treatment can ease pain and prevent joint damage, even in very bad cases.
When to Contact a Medical Professional
Contact your provider if you develop symptoms of arthritis along with psoriasis.
References
Fitzgerald O, Magee C. Psoriatic arthritis. In: Firestein GS, Budd RC, Gabriel SE, Koretzky GA, McInnes IB, O'Dell JR, eds. Firestein & Kelley's Textbook of Rheumatology. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 82.
Gossec L. Clinical features of psoriatic arthritis. In: Hochberg MC, Gravallese EM, Smolen JS, van der Heijde D, Weinblatt ME, Weisman MH, eds. Rheumatology. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 127.
Smolen JS, Schöls M, Braun J, et al. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann Rheum Dis. 2018;77(1):3-17. PMID: 28684559
Veale DJ, Orr C. Management of psoriatic arthritis. In: Hochberg MC, Gravallese EM, Smolen JS, van der Hejjde D, Weinblatt ME, Weisman MH, eds. Rheumatology. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 131.
Version Info
Last reviewed on: 1/25/2023
Reviewed by: Neil J. Gonter, MD, Assistant Professor of Medicine, Columbia University, NY and private practice specializing in Rheumatology at Rheumatology Associates of North Jersey, Teaneck, NJ. Review provided by VeriMed Healthcare Network. Internal review and update on 01/25/2024 by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
