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BY CHRISTINE M. GALANTE, DNP, RN, ANP-BC, AE-C

Abstract: Psoriatic arthritis (PsA) is associated with psoriasis, a chronic inflammatory skin disease. About 30% of patients with psoriasis develop PsA, and some of these patients are children and young adults. Because onset can be gradual, PsA signs and symptoms are easily attributed to other causes, especially in younger patients. This article discusses the assessment, pathophysiology, and diagnosis of PsA and informs nurses how best to support patients with PsA.

Keywords: dactylitis, enthesitis, PsA, psoriasis, psoriatic arthritis, psoriatic plaques

PSORIASIS IS A CHRONIC inflam- although they can develop anywhere matory skin disease marked by on the body.8 In the absence of vis- demarcated patchy raised plaques ible plaques, healthcare profession- on extensor surfaces of the body. als may not recognize PsA on initial Approximately 30% of patients with encounter.9,10 Using a case study as psoriasis develop the chronic disease an example, this article discusses as- known as psoriatic arthritis (PsA), an sessment, diagnosis, treatment, and inflammatory autoimmune disorder nursing considerations for patients affecting the joints and surrounding with PsA. tendons and ligaments.1-3 Occur- ring equally in women and men, it A case in point generally manifests in the third to AB, a 22-year-old college student fifth decade of life.4 However, grow- and talented athlete, had been ex- ing evidence suggests that PsA oc- periencing bilateral knee pain since curs earlier in 1% of young girls and he was 15. Initially both knees were boys, starting around age 10.5,6 reddened, swollen, and warm to In some patients, PsA is accom- touch. Over time, he reported to his panied by few if any of the skin coach that the pain and stiffness had plaques associated with psoriasis: progressed to other areas of the body. red, pink, or silvery scaly patches on As he approached his late teens, the skin.7 These plaques typically ap- he began to experience early morn-

PASTUDIO/SHUTTERSTOCK pear on the knees, elbows, and scalp, ing stiffness in his hands, feet, knees, www.Nursing2020.com November l Nursing2020 l 25

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. back, elbows, and neck. After play- is characterized by relapsing swelling a strenuous tournament, he de- ing of peripheral joints in the el- veloped swelling around his ankles bow, wrist, hand, and feet, or of the as well. This was the complaint that axial skeleton, primarily the hips, first brought him to the primary care shoulder, and spine. Enthesitis, provider (PCP). or inflammation of one or more AB reported that over the years, entheses (areas where a tendon or his stiffness and joint pain had been ligament connects with a bone), attributed to the stress of athletic is common in patients with PsA.8 activity and treated with icing and Although not experienced by all over-the-counter (OTC) nonste- patients, changes in fingernails and roidal anti-inflammatory drugs toenails, such as pitting or separa- (NSAIDs). tion from nailbeds, and dactylitis AB’s health history included a ton- (inflammation of fingers or toes) sillectomy at age 8 but was otherwise are also characteristic of PsA.7 unremarkable. He denied smoking, Onset of PsA is slow and insidi- vaping, alcohol consumption, or the ous. Periods of self-limiting inflam- use of recreational drugs. Neither of mation of tendons and joints can his parents had a history of autoim- span up to 5 years before individuals mune or joint disease. seek treatment.1,11,12 The PCP’s initial evaluation re- PsA has been classified into five vealed a 1-cm plaque on the right subtypes (see Five subtypes of PsA). knee; otherwise physical assessment Over the years, the Although PsA cannot be cured, early findings were normal. The PCP or- patient’s stiffness and diagnosis and treatment can slow dered a complete blood cell count, a joint pain had been progression and reduce the risk of Lyme disease titer, erythrocyte sedi- attributed to the stress disability and other complications mentation rate (ESR), and uric acid later in life. and rheumatoid factor (RF) levels. of athletic activity. All were within normal limits except Pathophysiology for the ESR, which was slightly el- PsA is associated with an exces- evated at 30 mm/h (normal for men: Although the prescribed treat- sive inflammatory response, but 0 to 22 mm/h). ment initially eased AB’s signs and the specific cause is unknown. The PCP diagnosed Achilles symptoms, his joint pain and stiffness Genetic and environmental factors tendonitis, instructed AB to stop returned when he resumed playing both play a part in disease devel- playing sports for 6 weeks, and sports. opment.7 prescribed treatment with ice The etiology of PsA is believed packs and NSAIDs for 2 weeks Classic signs and symptoms to be an innate immune biochemi- followed by physical therapy for AB presented with many hallmark cal response that targets skin and 8 weeks. signs and symptoms of PsA, which joint tissues. It is mediated by a cluster of differentiation (CD) 8 Five subtypes of PsA7 and T-cell response that leads to a release of inflammatory cytokines The most common subtypes of PsA are the symmetric polyarthritis and asymmetric oligoarticular forms. and mediators, producing inflam- • symmetrical polyarthritis: symmetrical bilateral joint involvement mation of tendons and joints. This • asymmetric oligoarthritic: unilateral; fewer than four large joints involved abnormal inflammatory response • distal interphalangeal predominant: small joints of fingers and toes; associated produces a lymphocytic proinflam- with spotting, pitting, and separating of nail beds matory response of cytokines, in- • axial arthritis/spondylarthritis: inflammation of neck, spine, and sacroiliac joints; terleukins, interferons, and tumor untreated, it can result in vertebrae fusion necrosis factor (TNF) that attack • arthritis mulilans: bone loss resulting in permanent damage to hands, fingers, the soft tissue of tendons, liga- wrist, and feet (see Arthritis mutilans). Untreated, it leads to loss of mobility and ments, and synovial membranes.10 joint deformities called “opera glass hands” and “telescoping fingers.” This is the The inflammatory state causes most severe but least common form of PsA joint pain, stiffness, and swelling

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. of the tendons and ligaments in extreme emotional stress, increased finger joints and in the lower back, body mass index (BMI), untreated Dactylitis of the neck, hips, and spine. Without streptococcal infections resulting fingers treatment, 40% to 70% of patients in periodontitis and tonsillitis, and This patient with severe psoriatic ar- 20-24 will have joint erosions within 2 remitting Kawasaki disease. thritis has marked finger deformities. years of symptom onset, leading Also called mucocutaneous lymph to irreversible joint damage with node syndrome, Kawasaki disease is functional impairment.13-15 As part characterized by vasculitis. Recent of the inflammatory process, pa- studies also implicate Koebner phe- tients can also experience uveitis, nomenon, in which incidental injury, keratitis, blepharitis, conjunctivi- trauma, and release of endotoxins tis, episcleritis, and scleritis; these from B-hemolytic streptococci infec- complications may threaten eye- tions lead to psoriatic skin lesions sight.9 and deeper tissue involvement, caus- PsA can be triggered by elements ing enthesitis and arthritis.22,25-27 in the environment combined with PsA has been associated with a genetic factors and human leuko- 43% increased risk for cardiovas- cyte antigen immunodeficiency.16 cular disease.27-29 Once believed to Marked by remission and relapses, be limited to the skin and joints, this progressive disease can be trig- PsA has recently been linked to a gered by stress, physical exertion, range of cardiometabolic disorders: environmental elements such as hypertension, dyslipidemia, coro- Source: Stedman’s Medical Dictionary. 28th ed. weather extremes, cutaneous injury, nary artery disease, diabetes, and Philadelphia, PA: Lippincott Williams & Wilkins; 2006. tobacco use, infection, and hypocal- obesity.30 Research has established cemia.10,17 Long-term use of certain an association between PsA and leukin (IL)-1, IL-6, and TNF—sub- medications including corticoste- metabolic syndrome, a systemic stances that trigger systemic inflam- roids, beta-blockers, hydroxychlor- disorder that includes hypertension, mation. This proinflammatory state oquine, tetracyclines, lithium, and dyslipidemia, insulin resistance, and of elevated cytokines, interleukins, NSAIDs has been associated with obesity.31 In addition, researchers interferon-alpha, and TNF promotes triggering PsA.18,19 have linked excessive adipose tis- endothelial vasoconstriction and Factors that may predispose a sue to an increased production of atherosclerosis.32 pediatric patient to PsA include postinflammatory cytokines, inter- Some evidence suggests that the proinflammatory state shares a genetic link, IL12B and IL23R, to an Arthritis mutilans increased incidence of inflamma- The most severe form of psoriatic arthritis, arthritis mutilans is also the most rare. It is tory bowel disease, Crohn disease, characterized by marked deformities of the small bones in the hands and onycholysis. celiac disease, and irritable bowel syndrome (IBS).33,34 Gene mapping to identify familial risk factors is still underway.

Health history PsA diagnosis is primarily based on a comprehensive health history and musculoskeletal exam.35,36 When obtaining a patient’s health history, the nurse should inquire about any personal or family history of psoriasis or other skin disease, as well as any personal or family history of arthritis or other joint disease. Ask Source: Goodheart H, Gonzalez M. Goodheart’s Photoguide to Common Pediatric and Adult Skin Disorders. the patient to describe signs and 4th ed. Philadelphia, PA: Wolters Kluwer Health; 2016. symptoms, including patterns of www.Nursing2020.com November l Nursing2020 l 27

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. pain and what typically exacerbates The value of imaging studies is lim- or relieves the pain; for example: Is ited, but radiographs may reveal bone pain worse in the mornings? Does erosion and resorption. Ultrasound is it improve with activity? used to visualize peripheral joints and Findings that should raise sus- may offer evidence of enthesitis. MRI picions for PsA include a history of is sensitive for detecting structural enthesitis (such as Achilles tendi- damage of soft tissue and inflamma- nopathy or plantar fasciitis), inflam- tion of tendons and ligaments in the matory back pain, dactylitis, eye hip and spinal areas.41-44 disease, gout, nephrolithiasis, or chronic gastrointestinal disorders.35 Management The nurse should also perform medi- Guidelines for managing PsA are cation reconciliation and ask about published by the American College the patient’s use and response to of Rheumatology/National Psoriasis both prescription and OTC medica- Foundation (ACR/NPF), European tions and supplements. League Against Rheumatism (EULAR), American Academy of Dermatology Physical assessment (AAD), British Society of Rheumatol- On physical assessment, inspect ogy (BSR), and Group for Research the patient for edema in the hands, and Assessment of Psoriasis and wrist, elbows, shoulders, knees, and Psoriatic Arthritis (GRAPPA). Recom- ankles. Palpation is likely to reveal mended treatments for PsA include tenderness and edema over tendons. Early, aggressive use of both nonpharmacologic therapies Dactylitis, known colloquially “sau- appropriate medications and topical and systemic medica- sage fingers,” affects toes as well as helps to slow disease tions. Therapies specific to plaque fingers and can impair activities of progression and psoriasis are beyond the scope of daily living requiring fine motor con- this article. trol (see Dactylitis of the fingers).35,37 preserve mobility. Nonpharmacologic therapies and Due to the anatomical relation- treatment approaches for patients ship of nail beds to the distal in- with PsA include the following.35 terphalangeal joint, some patients Enthesitis, which can impact • Complementary and alternative experience pitting of fingernails activity levels and endurance, can therapies. Combined with medica- and toenails and separation of affect Achilles tendons, plantar fas- tions, therapies such as yoga, acu- nails from nail beds (see Nail pitting cia, or tibial tuberosities. Enthesitis puncture, meditation, and therapy and onycholysis). This sign is some- can also be evident in the area of the with topical analgesics such as capsa- times misdiagnosed as a fungal ribs, pelvis, and spine.35 icin, have been found to relieve pain infection. and stiffness and improve the quality Diagnosis of life for those with PsA.45 • Nail pitting and No definitive serum biomarker exists Weight control. Maintaining a for diagnosing PsA, but certain lab healthy weight is important because onycholysis tests and imaging studies can help excess weight, even a few pounds, In this patient, PsA has caused confirm the diagnosis and/or rule out increases joint pressure and exacer- fingernail pitting and lifted the nail other disorders such as gout, rheu- bates joint pain and stiffness. off the nail bed (onycholysis). matoid arthritis, and reactive arthri- • Physical activity. Regular exercise tis.36 In endemic areas, for example, not only helps patients maintain a a Lyme disease titer should be per- healthy weight, but it also protects formed to rule out Lyme disease.35,38 the joints by building joint-protecting Testing may detect autoantibodies muscle, increasing endurance, and such as RF and antinuclear antibod- improving the ability to carry out ies in some patients with PsA.35,38 activities of daily living. During acute C-reactive protein (CRP) and ESR flares, low-impact exercise such as Source: Stedman’s Medical Dictionary. 28th ed. may be normal or elevated in acute walking, swimming, yoga, and even Philadelphia, PA: Lippincott Williams & Wilkins; 2006. flares.35,39,40 stretching are good options. Advise

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. do not alter disease progression. Ex- of life, prevent joint destruction, For more amples include ibuprofen, naproxen, and preserve mobility. Engaging information… meloxicam, and diclofenac.50 in dialogue and shared decision- • Disease-modifying antirheu- making promotes self-management, • American Academy of Dermatology www.aad.org matic drugs (DMARDs). These improves patient outcomes, and immunosuppressive agents interfere promotes adherence to the treat- • American College of Rheumatology 56 www.rheumatology.org with inflammatory pathways in the ment regimen. body. DMARD is an umbrella term While every person with PsA is • Arthritis Foundation www.arthritis.org for a large group of drugs with vary- different, treatment plans typically • British Society for Rheumatology ing mechanisms of action. They are include an individualized medication www.rheumatology.org.uk prescribed to reduce pain and slow regimen, regular checkups, and life- • European League Against the progression of various types of style changes. Guidelines published Rheumatism inflammatory arthritis including PsA, by EULAR, ACR/NPF, AAD, BSR, www.eular.org/index.cfm and may be administered orally, by and GRAPPA vary in approach and 51-53 • National Psoriasis Foundation injection, or by infusion. management of PsA. For example, www.psoriasis.org Biologic DMARDs target specific both GRAPPA and EULAR use step- parts of the immune system to help up approaches, but the GRAPPA rec- ease or stop PsA symptoms and ommendations allow for “skipping patients to avoid strenuous lifting or limit damage to the joints. They ahead” based on the patient’s clinical straining.46 have five different modes of action: condition.51 • Physical and occupational therapy. TNF inhibition, T-cell co-stimulation Because PsA can involve various These two therapies are designed to blockade, IL-6 receptor inhibition, body systems, nursing assessment strengthen muscles around affected B-cell depletion, and IL-1 inhibition. and patient teaching should cover joints, increase flexibility and range Examples include abatacept, adalim- the following points. of motion, and protect joints from umab, etanercept, golimumab, and • Ask the patient about bowel func- further damage. secukinumab.54,55 tion. If the patient reports abnormal • Healthy eating. A nutritious diet Nonbiologic or conventional bowel function, such as alternating that is low in added sugar and so- DMARDs, which affect the im- diarrhea and constipation with mu- dium can ease inflammation. Fruits, mune system more broadly, include cus or blood in the stool, the PCP vegetables, lean protein, fatty fish apremilast, cyclosporine, dimethyl may order more testing, including such as salmon, which is rich in fumarate, fumaric acid esters, leflu- a fecal calprotectin test, fecal occult inflammation-easing omega-3 fatty nomide, methotrexate, and sulfasala- blood testing, and colonoscopy. acids, nuts, olive oil, and whole zine.53 Other medications that may • Assess the patient for vision and grains are all good choices. Work- be prescribed to manage PsA include ocular problems such as dry eye, eye ing with a nutritionist enhances the the phosphodiesterase 4 inhibitor inflammation or pain, or vision loss. treatment plan. The use of probiotics apremilast and acitretin, a systemic As part to the inflammatory process, to reduce inflammation in the GI retinoid. the patient may experience uveitis, tract is also recommended because keratitis, blepharitis, conjunctivitis, many patients with PsA also have Nursing considerations episcleritis, and scleritis, so encour- IBS.47,48 Keeping cardiovascular risks in mind, age regular checkups with an eye Pharmacologic therapy is individ- nurses should monitor patients’ BP, care provider.9 ualized and targeted to relieve signs heart rate and rhythm, and BMI and • Inquire about disturbed sleep pat- and symptoms, reduce systemic assess lab results for elevated fasting terns and fatigue, which have been inflammation, limit structural dam- glucose levels, liver function, total correlated with a higher incidence of age, and achieve remission.49 Early, cholesterol, and both low-density depression and mortality.57,58 aggressive use of appropriate medica- and high-density lipoprotein levels. tions helps to slow disease progres- Patient education should include AB’s case progression sion and preserve mobility. encouraging healthy lifestyle choices, During his period away from sports, • NSAIDs. Utilized for symptom re- including weight control, a nutritious AB’s joint pain and stiffness pro- lief, these are often the first oral med- diet, and regular exercise. gressed rather than improved. He ications recommended for patients Engage patients in dialogue also began to have gastrointestinal with PsA to ease joint pain, stiffness, about their long-term treatment symptoms including frequent bowel and inflammation. However, they goals for PsA to maximize quality movements, abdominal cramping, www.Nursing2020.com November l Nursing2020 l 29

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. and diarrhea alternating with consti- management of psoriasis with systemic nonbiologic 25. Sanchez DP, Sonthalia S. Koebner phenomenon. therapies. J Am Acad Dermatol. 2020;82(6):1445- StatPearls [Internet]. 2020. www.ncbi.nlm.nih.gov/ pation. He noticed larger thick scaly 1486. books/NBK553108. red skin plaques, and his fingers and 7. National Institutes of Health. Genetics Home 26. Hsieh J, Kadavath S, Efthimiou P. Can toes were continuously swollen and Reference. Psoriatic arthritis. 2020. https://ghr.nlm. traumatic injury trigger psoriatic arthritis? nih.gov/condition/psoriatic-arthritis#genes. A review of the literature. Clin Rheumatol. stiff. As his symptoms progressed, he 2014;33(5):601-608. became depressed and began to with- 8. Arthritis Foundation. Psoriatic arthritis. www. arthritis.org/diseases/psoriatic-arthritis. 27. Brezinski EA, Follansbee MR, Armstrong EJ, draw from social activities. 9. 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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. 42. Polachek A, Cook R, Chandran V, Gladman DD, The role of gut microbiome in the pathogenesis of decision making aid for chronic inflammatory Eder L. The association between sonographic psoriasis and the therapeutic effects of probiotics. arthritis patients. J Patient Care. 2016;2(2)1-6. enthesitis and radiographic damage in psoriatic J Family Med Prim Care. 2019;8(11):3496-3503. 57. Mathew AJ, Chandran V. Depression in arthritis. Arthritis Res Ther. 2017;19(1):189. 49. Coates LC, Kavanaugh A, Mease PJ, et psoriatic arthritis: dimensional aspects and link 43. Abrar DB, Schleich C, Brinks R, et al. al. Group for Research and Assessment of with systemic inflammation. Rheumatol Ther. Differentiating rheumatoid and psoriatic arthritis: Psoriasis and Psoriatic Arthritis 2015 treatment 2020;7(2):287-300. a systematic analysis of high-resolution magnetic recommendations for psoriatic arthritis. Arthritis 58. Schieir O, Thombs BD, Hudson M, et al. resonance imaging features—preliminary findings. Rheumatol. 2016;68(5):1060-1071. Symptoms of depression predict the trajectory Skeletal Radiol. [e-pub Aug. 26, 2020] 50. Burchum J, Rosenthal L. First-generation of pain among patients with early inflammatory 44. Felbo SK, Terslev L, Ostergaard M. Imaging NSAIDs. In: Lehne’s Pharmacology for Nursing Care. arthritis: a path analysis approach to assessing in peripheral and axial psoriatic arthritis: 10th ed. St. Louis, MO: Elsevier, Inc.; 2019. change. J Rheumatol. 2009;36(2):231-239. contributions to diagnosis, follow-up, prognosis 51. Ogdie A, Coates LC, Gladman DD. Treatment and knowledge of pathogenesis. Clin Exp guidelines in psoriatic arthritis. Rheumatology Rheumatol. 2018;36 suppl 114(5):24-34. (Oxford). 2020;59(suppl 1):i37-i46. Christine M. Galante is an assistant professor of nursing at New York Institute of Technology in Old 45. Arthritis Foundation. Supplement and herb 52. Benjamin O, Bansal P, Goyal A, et al. Disease- Westbury, N.Y. guide for arthritis symptoms. www.arthritis. modifying anti-rheumatic drugs (DMARD). In: org/health-wellness/treatment/complementary- StatPearls [Internet]. Treasure Island, FL: StatPearls therapies/supplements-and-vitamins/supplement- Publishing; 2020. Copyright © 2020 The Author. Published by Wolters and-herb-guide-for-arthritis-symptoms. Kluwer Health, Inc. This is an open access article 53. Arthritis Foundation. DMARDs. www.arthritis. 46. Ganesan S, Gau GS, Negi VS, Sharma VK, distributed under the terms of the Creative Commons org/drug-guide/dmards/dmards. Attribution Non Commercial-No Derivatives License Pal GK. Effect of yoga therapy on disease activity, 4.0 (CCBY-NC-ND), where it is permissible to down- inflammatory markers, and heart rate variability 54. Brucker MC, King TL. Rheumatoid arthritis. load and share the work provided it is properly cited. in patients with rheumatoid arthritis. J Altern In: Pharmacology for Women’s Health. 2nd ed. The work cannot be changed in any way or used Complement Med. 2020;26(6):501-507. Burlington, MA: Jones & Bartlett Learning; 2017. commercially without permission from the journal. 47. Grinnell M, Ogdie A, Wipfler K, Michaud K. 55. Rein P, Mueller RB. Treatment with biologicals Probiotic use and psoriatic arthritis disease in rheumatoid arthritis: an overview. Rheumatol activity. ACR Open Rheumatol. 2020;2(6): Ther. 2017;4(2):247-261. The author and planners have disclosed no potential conflicts of interest, financial or otherwise. 330-334. 56. El Miedany Y, El Gaafary M, Sayed S, Palmer D, 48. Alesa DI, Alshamrani HM, Alzahrani YA, Ahmed I Implementing shared decision making Alamssi DN, Alzahrani NS, Almohammadi ME. in clinical practice: outcomes of a new shared DOI-10.1097/01.NURSE.0000718032.41238.db

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Earn CE credit online: Go to www.nursingcenter.com/CE/nursing and receive a certiﬁ cate within minutes.

INSTRUCTIONS Supporting young adults with psoriatic arthritis

TEST INSTRUCTIONS PROVIDER ACCREDITATION • Read the article. The test for this CE activity is to be taken online at Lippincott Professional Development will award 1.5 contact www.nursingcenter.com/CE/nursing. hours for this continuing nursing education activity. Lippincott • You’ll need to create (it’s free!) and log in to your personal CE Planner Professional Development is accredited as a provider of account before taking online tests. Your planner will keep track of all your continuing nursing education by the American Nurses Lippincott Professional Development online CE activities for you. Credentialing Center’s Commission on Accreditation. This • There’s only one correct answer for each question. A passing score for activity is also provider approved by the California Board of this test is 14 correct answers. If you pass, you can print your certificate of Registered Nursing, Provider Number CEP 11749 for 1.5 contact earned contact hours and access the answer key. If you fail, you have the hours, and the District of Columbia, Georgia, and Florida CE option of taking the test again at no additional cost. Broker #50-1223. • For questions, contact Lippincott Professional Development: 1-800-787-8985. • Registration deadline is September 2, 2022. Payment: The registration fee for this test is $17.95.