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Psoriatic Arthritis

Causes,diagnosis and treatments What Is ? Psoriatic arthritis can damage and other body systems. However, its effects often can be reduced if it’s Psoriatic arthritis is a serious condition that most often affects people who have the chronic diagnosed and treated early. disease . Many people who have psoriasis are not aware of the risk of psoriatic arthritis. People with only also develop psoriatic arthritis, a chronic autoim- mild psoriasis, or even those who simply have mune disease that affects the joints. relatives with psoriasis, can develop psoriatic arthritis. The most common symptoms of psoriatic arthritis are: If you have psoriasis and experience joint or any of the other symptoms discussed in this • Pain and swelling in one or more joints, often booklet, talk to a doctor as soon as possible. the , , and/or joints at the ends of the or About Psoriasis • Joints that are red, warm to the touch, or As many as 7.5 million Americans have psoriasis, tender (painfully sensitive) and stiff a chronic (long-lasting) . • Swollen fingers and/or toes that have a In psoriasis, a person’s immune system sends out sausage-like appearance faulty signals that speed up the growth cycle of • Pain in and around the feet and ankles, especially skin cells. at the back of the heel or the sole of the foot The most common symptom of psoriasis is itchy, • Pain in the lower back, above the tailbone painful red patches on the skin and a silvery white buildup of dead skin cells. • Changes to the fingernails or toenails, such as small pits in the nails, or the nail separating Although psoriasis most commonly appears on from the nail bed the knees, and scalp, it can occur anywhere on the body, including the fingernails and Symptoms of psoriatic arthritis can be similar to toenails. other kinds of arthritis. For an accurate diagnosis, it’s important to see a medical provider who Psoriasis is not contagious. However it’s more than specializes in . just a skin disease. People with psoriasis are more likely to develop other serious health conditions, such as arthritis, , heart disease and Who Gets Psoriatic Arthritis? depression. Most people who develop psoriatic arthritis already have symptoms of psoriasis on their About Psoriatic Arthritis skin. Sometimes, however, psoriatic arthritis develops before the skin condition or appears Approximately 30 percent of people with psoriasis at the same time.

2 3 Psoriasis and psoriatic arthritis both run in What Are the Effects families. People who have relatives with psoriasis Of Psoriatic Arthritis? should watch for signs of psoriatic arthritis, even Persistent warmth and swelling of the if they don’t have psoriasis themselves. membrane lining the joint, called the synovium, • Psoriatic arthritis affects men and women can to joint damage and deformities. equally. Proper treatment can help prevent or reduce these effects. Most people with psoriatic • It usually develops between the ages of 30 arthritis lead normal lives. and 55. Psoriatic arthritis can affect any joint, but some • Both psoriasis and psoriatic arthritis are more joints are affected more than others. Knees, common among whites than among people wrists, fingers and toes are the most commonly of African or Asian descent. affected joints. • People whose psoriasis symptoms include Early on, arthritis is more likely to occur changes in fingernails and toenails appear to unevenly in joints on both sides of the body, be more likely to develop psoriatic arthritis. such as in your right and your left . As the disease progresses, symptoms are more What Causes Psoriatic Arthritis? likely to occur symmetrically; for example, both The cause of psoriatic arthritis is not fully knees may be affected. known. However, scientists continue to study three key areas: Some people have swelling at the end joints of the fingers or toes; in others the entire or • Immune system problems. In psoriatic may develop painful, sausage-like swelling. arthritis and other types of , the immune system mistakenly Psoriatic arthritis can also cause pain at the attacks the lining of the joints, causing pain points where and ligaments attach to and . your bones – especially at the back of the heel (the Achilles ) or in the sole of the foot. • Hereditary factors. Scientists have found certain genes that may indicate if a person is Approximately five percent of people with more likely to develop psoriasis or psoriatic psoriatic arthritis have arthritis only in the arthritis. spine. This form of psoriatic arthritis, called , can lead to pain, stiffness and • Environmental factors. Scientists think that restricted movement in the lower back, buttock elements in the environment, or an event and neck regions. such as a trauma or virus, may trigger psoriasis and/or psoriatic arthritis in people Some people with psoriatic arthritis have who have a genetic predisposition; however, symptoms both in the spine and in other joints. more study is needed to determine if this is true.

4 5 Psoriatic Arthritis Treatments Early and accurate diagnosis is important. The sooner psoriatic How Is Psoriatic arthritis is diagnosed and treated, Arthritis Diagnosed? the less likely it is to cause permanent If you have symptoms of psoriatic arthritis, your primary care provider should refer you to a rheu- damage or . Once joint matologist – a doctor specializing in diseases of the damage is done, it can’t be reversed. joints, muscles and bones. The rheumatologist will ask about your symptoms and perform a physical examination to see if you have: works for someone else with psoriasis and/or pso- • , swelling, painful movement or riatic arthritis. Take all as directed by inability to move joints fully your doctor and pharmacist. • Evidence of psoriasis on the skin or changes You may experience a bad reaction when you take in your fingernails and toenails two or more medications together. Tell all your providers about any prescription and over-the- Your doctor also may perform some or all of the counter (OTC) medications and/or herbal or following tests: dietary supplements you are taking for these or • X-ray, MRI or ultrasound to look for changes any other conditions. in your bones, joint tissue and Treating Psoriasis • Blood tests to rule out other diseases, such as There are many OTC and prescription treatments for skin psoriasis. If you have psoriasis, talk to a • Joint fluid tests to rule out or infectious dermatologist about the following treatment op- arthritis tions: • Topical medications applied directly to the skin Treating Two Diseases Since most people with psoriatic arthritis also have • Treatments using sunlight or specialized ultra- psoriasis, care needs to be coordinated among violet light your primary care doctor, dermatologist and • Medications taken internally that target the skin rheumatologist. • Medications taken internally that target the im- Some treatments work on symptoms of both mune system psoriasis and psoriatic arthritis; others work only on skin psoriasis or only on arthritis. The National Psoriasis Foundation maintains up-to-date psoriasis treatment guides as well as a What works for you may be different from what database of dermatologists at www.psoriasis.org.

6 7 Goals for Treating • Follow up on your lab work. Just because Psoriatic Arthritis you haven’t heard from your doctor doesn’t If left untreated, the inflammation that mean that you shouldn’t know what’s in your accompanies psoriatic arthritis can lead lab results. Your first evaluation will establish to joint damage. Controlling inflammation a baseline – levels against which future tests may slow down or prevent joint damage. will be measured. It’s important for you to Treatment of psoriatic arthritis focuses on monitor your levels. multiple goals: • Follow directions. Take your medicine as • Reducing inflammation prescribed. Skipping doses – even just one – • Relieving pain can cause your disease to flare. • Retaining joint function • Ask first. Before you start a new exercise routine, drug or vitamin regimen, talk to your doctor. Certain drugs and supplements Developing Your Psoriatic can interact in unhealthy ways. Arthritis Treatment Plan The first issues you will face after your psoriatic Drugs That Control Psoriatic Arthritis arthritis diagnosis are treatment decisions. To help Early, aggressive treatment of psoriatic arthritis is make these choices, you need to understand the achieved with a category of drugs called disease- goals of treatment and how drugs are used to meet modifying antirheumatic drugs (DMARDs). This these goals. category includes: Why Is It Important to See • Nonbiologic or “traditional” DMARDs that Your Doctor Regularly? have broad immune-suppressing effects You and your doctor each play a role in making sure your treatment is as safe as possible. Once • Biologic response modifiers or biologics that treatment starts, it’s monitored with regular office target specific – proteins in the visits and blood tests. If disease activity is high, blood that cause inflammation – or block monitoring may occur monthly. Someone with blood cells that help release cytokines mild psoriatic arthritis might be monitored every • Targeted DMARDs that affect different three months. inflammatory pathways than biologics Tips for Talking to Your Doctor • Keep all appointments. Even if you’re feeling DMARDs, biologics and targeted DMARDs all well, it’s important to continue to see your reduce disease activity, slow the progression of pso- doctor. riatic arthritis and prevent or slow joint damage. However, biologics and targeted DMARDs work • Side effects matter. Always mention medi- faster than traditional DMARDs . cation side effects you are experiencing to your doctor. If the side effects outweigh the Before taking any DMARD, you should receive ’s benefits, it might be time to talk blood tests to rule out liver problems – some to your doctor about changing your regimen. medications can adversely affect the liver. A flu vaccine may be recommended as well. Before

8 9 taking biologics, you may have a skin test and chest Cyclosporine has been used to treat skin pso- X-ray to rule out . riasis and psoriatic arthritis. Side effects may include nausea, vomiting, , gum inflam- Nonbiologic DMARDs mation, high blood pressure, itching, excessive was originally developed as a cancer hair growth, liver function abnormalities and treatmant. It has long been a first-line treatment for abnormalities. Cyclosporine may cause many types of arthritis, including psoriatic arthritis. birth defects, so women of childbearing age However, clinical trial data regarding its effective- should use an effective means of birth control ness for psoriatic arthritis has been inconclusive. It while on this medication. The pill or liquid is has been shown to improve psoriasis skin symp- taken twice a day. toms. Methotrexate is given weekly, either orally as a liquid or pill, or by injection. suppresses the immune system and may relieve joint pain, stiffness and swelling Side effects may include nausea, vomiting, mouth in psoriatic arthritis. Side effects may include sores, diarrhea, low count, liver stomach irritation, inflammation of the pan- function abnormalities and pneumonia. Metho- creas, and low blood count. Azathioprine trexate can cause birth defects or miscarriage if may cause birth defects, so women of childbear- taken during pregnancy, so women of childbearing ing age should use an effective means of birth age should use an effective means of birth control control while on this medication. The tablet is while taking the drug. You should not drink alco- taken once or twice a day. hol if you take methotrexate. has been shown in studies to be comparable to methotrexate for relieving symptoms of psoriatic arthritis. Biologics and Your Side effects may include nausea, diarrhea, skin rash, Immune System liver toxicity, high blood pressure, headache and . Leflunomide can cause birth defects. Men These medications suppress the immune and women should use effective birth control while system and may make you more vulnerable on lefluonomide and for three months after discon- to infections. tinuing it. The pill is taken once a day. • Contact your doctor if you develop signs of infection (, sore throat, chills, may relieve the joint pain and swell- cough) while on a biologic. ing associated with psoriatic arthritis according to clinical studies. However, people who are allergic • You should also be tested for tuberculosis to medications containing sulfa should not take (TB) infection before starting a biologic, sulfasalazine. Side effects may include gastrointes- and you should not receive any live virus tinal problems, loss of appetite, skin rash, sunlight vaccines while taking one. sensitivity, dizziness, headache, liver abnormalities, • Tell your doctor if you are pregnant, lowered blood count and low sperm count. The pill nursing or plan to become pregnant is taken twice a day. before taking a biologic.

10 11 substances secreted by specific cells of the immune system that carry signals locally between cells and have an effect on other cells. Six biologics are currently approved by the Food and Drug Administration (FDA) to treat psoriatic arthritis – , , etan- ercept, , and . Five are delivered by injection. One is delivered by infusion in a doctor’s office. Targeted DMARDs is approved for the treatment of plaque psoriasis and psoriatic arthritis. This drug blocks selective phosphodiesterase 4 (PDE4), an enzyme involved in inflammation. Common side effects Biologics include diarrhea, headache and nausea. Apremilast Biologics are used if moderate to severe disease also may cause unintentional and in- activity can’t be controlled with non-biologic crease the risk of new or worsening depression and DMARDs. Emerging evidence suggests that bio- other mood changes. The pill is taken twice a day. logics may be appropriate as a first-line treatment for some patients with psoriatic arthritis. They may be used alone but more often are used with Drugs That Treat Psoriatic methotrexate and other DMARDs. Two biologics Arthritis Symptoms shouldn’t be used together. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) can help reduce joint pain and swell- Because biologics suppress the immune system, ing. They work by blocking the production of they may raise the risk of infection. If the drug is substances called prostaglandins at the site of injected, you may also experience pain and swell- inflammation. ing at the injection site. If it’s infused, you may have an infusion reaction (difficulty breathing, • NSAIDs are available over the counter rapid or weak pulse, nausea, vomiting). Another (OTC) and by prescription. OTC NSAIDs side effect is headache. include , and sodium and are available in lower strengths What Biologics Treat Psoriatic Arthritis? than prescription versions. The OTC doses Biologics target specific parts of the immune sys- may control pain but typically are not strong tem to help block or slow inflammation. enough to reduce inflammation. Each biologic plays a different role in stopping • NSAIDs may interact with other medica- the inflammatory process. Two categories used to tions; talk with your doctor about whether it treat psoriatic arthritis include tumor necrosis fac- is safe to take OTC medications in addition tor (TNF) and interleukin (IL) inhibitors. These to those prescribed for you. drugs work by reducing signals sent by TNF or IL-12 and IL-23 cytokines. Cytokines are

12 13 • Long-term use of NSAIDs can cause stomach When Is Surgery Considered? problems, a decline in kidney function and increase the risk of heart attack or . The Most people with psoriatic arthritis will never prescription medication celecoxib, a type of need surgery. However, NSAID called a COX-2 selective inhibitor, was if your joints are severely damaged by the designed to be safer for the stomach but may disease, or if other treatments don’t lessen the pose an increased risk of heart attack and stroke. pain, your doctor may recommend surgery to reduce pain and improve function. Talk to your doctor about the risks and to decide what medications are right for you. – drugs such as and – are man-made versions of Doctors use them in a few different ways: hormones that occur in the body. These drugs can quickly reduce high levels of inflammation and • Short-term oral therapy. At high doses, may be used as a cream, taken as pills or injected pills can help reduce inflamma- into a joint or vein. They work to reduce swell- tion and relieve symptoms in a person with ing, stiffness, tenderness and pain related to joint new-onset, severe psoriatic arthritis. A moder- inflammation. However, they have less potential ate dose of corticosteroids may be prescribed to impact the course of psoriatic arthritis. at the start of DMARD therapy to control symptoms. Once DMARD therapy begins working, the corticosteroid dose is gradually lowered, then the drug eventually is stopped. • Injection during a flare. If a single joint is flaring, the injection may be administered directly into the joint. In these cases, the existing psoriatic arthritis treatment regimen isn’t usually changed. • Low-dose, ongoing oral therapy. A tiny daily dose of corticosteroid in pill form may be combined with one or more DMARDs. How- ever, most rheumatologists try to avoid ongoing treatment with corticosteroids if possible. Corticosteroids have many side effects, some potentially serious. For example, they can cause thinning of the bones (osteoporosis) and can increase the risk of serious infection. Other side effects include weight gain, facial swelling known as “moon face” and thin skin/easy bruising, among others. To reduce the risk of side effects, the lowest possible dose of corticosteroid should be used for the shortest period of time. 14 15 Living with be centered on plant-based foods. Approximately Psoriatic Arthritis two-thirds of your diet should come from fruits, vegetables and whole grains. The other third should The Benefits of Self-management include fat-free or low-fat dairy products and lean One of the best ways to cope with a chronic disease proteins. Get details at www.choosemyplate.gov. is to take a proactive role in your own treatment Stress management. Stress has been shown to have and, by extension, your own life – a process called a major impact on psoriasis and is linked to inflam- self-management. mation. Some ways to relieve stress include: First, make a conscious decision to maintain a • Regular exercise positive attitude and lead an overall healthy lifestyle • Practices like yoga, and meditation by eating well, engaging in physical activity and finding a way to work through any emotional is- • Spending time with family and friends sues surrounding your diagnosis. Learn all you can about your condition from your doctor or health Other Ways to Manage care professional – and from trusted sources such as Psoriatic Arthritis the Arthritis Foundation (www.arthritis.org). Tackling the pain that comes with psoriatic arthritis Maintain an open line of communication with your may seem impossible when you’re first diagnosed. and keep track of symptoms, medication Your doctor will likely prescribe medication, but regimens, side effects, pain levels, etc. Consider there are other ways to control pain – and improve seeing an occupational therapist, who can teach you your daily life. Try one or more of these: how to reduce strain on your joints and provide • Hot and cold treatments. Heat improves blood assistive devices such as braces, splints and canes to circulation, helping to reduce and give your joints a rest. Finally, develop a network of muscle spasms. Cold helps reduce swelling by friends, family members and even co-workers you constricting blood vessels. can count on for emotional support. • Relaxation techniques. Train your muscles to Lifestyle Changes That Can Help Manage relax and slow down your thoughts with tech- Psoriatic Arthritis niques such as deep breathing, guided imagery Rest and physical activity. Rest is important when and visualization. psoriatic arthritis is active and your joints feel pain- ful, swollen or stiff. Rest helps reduce inflammation • Massage. Research shows massage can help ease and fights that can come with a flare. When arthritis pain, improve joint function and ease disease activity is low, physical activity becomes stress and anxiety. important. Your exercise program should emphasize • Topical treatments. Applied directly to the low-impact aerobic conditioning, muscle strength- skin over the painful muscle or joint, these may ening and flexibility. A physical therapist can help contain salicylates or , which decrease you design – and stick to – an exercise program that sensitivity to pain. works for you. • Acupuncture. Acupuncture is the practice of Nutrition. Eat a balanced diet, which, according inserting fine needles into the body along special to the U.S. Food and Drug Administration, should points called “meridians” to relieve pain. 16 17 Our goal is to help you: Learn, be inspired and connect. Subscribe to Arthritis Today magazine to get information on everyday life with arthritis, the latest health news, tools to help you chart a winning course and much more. Go to arthritistoday.org/subscribe.

Contact your local office about resources and events going on where you live. Go to arthritis.org, click the Local Offices tab at the The Arthritis Foundation is the top and enter your ZIP code. Raise funds to conquer arthritis in our annual Champion of Yes. events, Walk to Cure Arthritis and Jingle Bell Run. Visit We lead the fight for the arthritis community and arthritis.org/events. help you conquer your everyday battles through Talk about your condition. You’re not alone life-changing information and resources, access when you connect with our community. Visit to optimal care, advancements in science and arthritis.org/community. community connections. Go to www.arthritis.org Make your voice be heard. Go to arthritis.org/advocate and become an Arthritis or call 800-283-7800. Foundation Advocate for better access to .

Acknowledgements

The Arthritis Foundation appreciates the contributions of and reviews by the following: Eric Matteson, MD, MPH, professor of medicine and chair, Division of Rheumatology, Mayo Clinic

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