Accordingly, there are five types of psoriatic arthritis:
- symmetrical (both sides of the body),
- asymmetric and few joints,
- distal interphalangeal joints, and.
- Arthritis mutilans
Psoriatic arthritis is a chronic disease characterized by a form of inflammation of the skin (psoriasis) and joints (inflammatory arthritis). Psoriasis is a common skin condition affecting 3% of the population in the United States. An estimated 30% of people in the U.S. who have psoriasis will develop PsA in their lifetime. They understand your confusion. They hear it all the time. Signs and symptoms include patchy, raised, red areas of skin inflammation with scaling. Psoriasis often affects the tips of the elbows and knees, the scalp and ears, the navel, and around the genital areas or anus. Approximately 15%-25% of patients who have psoriasis also develop an associated inflammation of their joints. Patients who have inflammatory arthritis and psoriasis are diagnosed as having psoriatic arthritis.
The onset of psoriatic arthritis generally occurs in the fourth and fifth decades of life. Males and females are affected equally. The skin disease (psoriasis) and the joint disease (arthritis) often appear separately. The skin disease precedes arthritis in nearly 80% of people. However, arthritis may precede psoriasis in up to 15% of patients. In some patients, the diagnosis of psoriatic arthritis can be difficult if arthritis precedes psoriasis by many years. Some patients have had arthritis for over 20 years before psoriasis eventually appears! Conversely, patients can have psoriasis for over 20 years before the development of arthritis, leading to the ultimate diagnosis of psoriatic arthritis.
Psoriatic arthritis is a systemic rheumatic disease that also can cause inflammation in body tissues away from the joints other than the skin, such as in the eyes, heart, lungs, and kidneys. Psoriatic arthritis shares many symptoms with several other arthritic conditions, such as ankylosing spondylitis, reactive arthritis, and arthritis associated with Crohn’s disease and ulcerative colitis. All of these health conditions can cause inflammation in the spine and other joints, and the eyes, skin, mouth, and various organs. Given their similarities and tendency to cause inflammation of the spine, these health conditions are collectively referred to as “spondyloarthropathies.”
- Asymmetric arthritis. This is the most common type of psoriatic arthritis. Asymmetric arthritis can occur in any joint, and it can affect a few or many of them, but it won’t affect the same joints on both sides of your body. With asymmetric arthritis, joints are swollen and may be tender and warm to the touch. People who have asymmetric arthritis in their hands and feet may notice that their fingers and toes look like small sausages. This condition tends to be milder than other forms of psoriatic arthritis, but it can become disabling.
- Symmetric arthritis. This form is very similar to rheumatoid arthritis (RA); there is less deformity than with RA, but symmetric arthritis can still be disabling. Typically, you will experience pain in the joints – knee, hips, ankles, wrists – on both sides of your body. It is likely that at least five joints will be swollen and stiff. Women are more likely to have symmetric arthritis than men, and the amount of psoriasis associated with this condition is likely to be severe. This is the second most common type of psoriatic arthritis.
- Spondylitis. This type of psoriatic arthritis causes inflammation in your spine. You will feel stiffness in your neck, lower back, and sacroiliac joints (the joints where the base of the spine meets the pelvis). As it progresses the disease can make movement rather painful. The inflammation can cause some spinal vertebrae to fuse; the fusion may at some point require surgery. “A lot of times spondylitis goes unrecognized,” Samuels says.
- Distal interphalangeal predominant. This type of psoriatic arthritis is most commonly found in males but is somewhat rare. It affects the distal joints, which are the small joints closest to the nails on your hands and feet. Your fingernails and toenails are likely to show symptoms of psoriatic arthritis such as ridges, pits, and a yellowish-orange color.
- Arthritis mutilans. This is the most debilitating and disabling type of psoriatic arthritis. It is the least common – only about 1 to 5 percent of people with psoriatic arthritis have arthritis mutilans. The small bones in your hands, especially the fingers, the feet, and possibly the neck and back break down, causing permanent deformity. It can be quite painful.
What causes psoriatic arthritis?
The cause of psoriatic arthritis is currently unknown. A combination of genetic, immune, and environmental factors is likely involved. In patients with psoriatic arthritis who have arthritis of the spine, a blood test gene marker called HLA-B27 is found in about 50%. Several other genes have also been found to be more common in patients with psoriatic arthritis. Certain changes in the immune system may also be important in the development of psoriatic arthritis. The importance of infectious agents and other environmental factors in the cause of psoriatic arthritis is being investigated by researchers.
Nail changes due to psoriatic arthritis are very common.
Researchers have found that 80 to 90 percent of people with plaque psoriasis experience changes in their nails, and that nail changes are even more widespread in those with psoriatic arthritis.
Many people may notice changes in their nails as an early warning sign of psoriatic arthritis or damage to the joints.
Changes may appear in any part of the nail structure or surrounding finger or thumb, including:
- the visible part of the nail that doctor call the nail plate
- the nail bed, which is the skin beneath the nail
- the nail matrix, which is the tissue at the bottom of the nail
- the area where the nail meets the fingertip (hyponychium)
- the small, pale semi-circle at the base of the nail (lunula)
What are the risk factors for developing psoriatic arthritis?
The major risk factor for developing psoriatic arthritis is having a family member with psoriasis. This relationship has been recognized as so significant that it is used as a helpful part of the health history for the doctor to aid in the diagnosis of psoriatic arthritis. It might be that stressful life situations could affect the immune system, allowing for the expression and/or exacerbation of psoriatic arthritis. However, precisely how these emotional issues are related to psoriatic arthritis has not been established.
Get to know your psoriatic arthritis and make note of your experiences. You can help your doctor monitor your psoriatic arthritis by sharing your experience of symptoms and life impact for you. While lifestyle changes alone are not enough, there are things you can do to help control your psoriatic arthritis. Living with psoriatic arthritis can be difficult, but there are certain things you can do to make the condition’s symptoms a lot easier to manage.
People with psoriatic arthritis tend to have fatigue and there are now studies that show that staying active improves fatigue. Work with your doctor to find an appropriate exercise program. However, it may not be appropriate to start a new exercise program if you are in the middle of a psoriatic arthritis flare. If tendons and/or joints are inflamed, high impact exercise is best avoided until you recover.
From getting enough rest and dressing comfortably to tips on handling shopping trips, here are some suggestions.
Fatigue is often a problem for people with psoriatic arthritis. To combat exhaustion, take a quick nap, suggests Martin Bergman, MD, a clinical associate professor of medicine at the Drexel University College of Medicine in Philadelphia and the chief of the rheumatology division at Taylor Hospital in Ridley Park, Pennsylvania. “Don’t be afraid to take naps, or just close your eyes for 10 or 15 minutes. It’s an amazingly good way to refresh yourself,” he says.
Foot and ankle problems are common among people with psoriatic arthritis, and sometimes swollen toes won’t fit into standard-size shoes. Look for a shoe with a high toe box, or consider a wider version of your normal size. Shoe inserts or heel cups can also help relieve foot pain. If you’re experiencing a lot of pain and none of these solutions work for you, consider visiting a podiatrist.
Exercise can help relieve some of the symptoms of psoriatic arthritis, including pain and fatigue. It can also lift your mood. Bergman says it’s good to start with gentle stretching. “Once you’re moving and feeling good, there’s nothing wrong with some mild strength building,” he adds. “I have patients with psoriatic arthritis who are very active, but you don’t want to just jump into it. You have to give your body a chance to build up to where you have to be.”
Don’t let a little achiness keep you from moving around with psoriatic arthritis, but respect your limitations. “Joints are truly something where it’s using it or lose it. If you don’t move them, they become weaker and the cartilage itself can become damaged,” Bergman explains. “That said when things are really ‘angry’ — tender and swollen — it’s best to rest the joint. When things are just stiff and achy, that’s when you should move it.”
When you lose excess weight, you significantly lighten the load on your joints. According to the Arthritis Foundation, every pound of extra weight translates into four pounds of pressure on your knees.
By maintaining a healthy weight, you’ll avoid extra pressure that can aggravate sensitive joints.
Stress isn’t good for anyone, and research has shown that it can worsen pain associated with psoriatic arthritis. Stress-reducing activities you can try include meditation, yoga, and relaxation techniques. Physical activity can help you manage stress but talk to your doctor before starting any exercise program.
Posture is critical for anybody who has a musculoskeletal issue, including psoriatic arthritis. And it’s especially important in the age of computers, laptops, and iPhones, which cause many of us to slouch forward with rounded shoulders. Some people with arthritis may also slope forward to protect themselves. Don’t do it. “You want to keep as erect an upper quadrant as you can,” says Frost. “Shoulders back, head tucked back.” Much like the piano posture you may have been taught as a child. Posture is just as important when you’re asleep. If you sleep on your side, put a pillow between your knees to even out your hips, advises Frost. (If you have a flare on one side, though, don’t sleep on it.) Find a pillow that doesn’t cause too much forward flection or extension of the neck. “It’s all about keeping the as good alignment of the skeletal system as you can,” says Frost.
Uveitis, a painful inflammation of the eye, is more common in people with psoriatic arthritis. So check in on your eye health by making regular visits to a healthcare professional. Early diagnosis and treatment can help prevent vision loss and tissue damage.
Having psoriatic arthritis doesn’t mean having to forego a trendy bag or briefcase. But you should choose a bag that’s on the smaller side, so the extra weight doesn’t strain your joints, says Frost. Consider carrying your bag on your forearm instead of using the fragile joints of your hand. And try to use a cross-body bag rather than getting one that has to hang off a single shoulder.
The right medications are important, not just for relieving pain from psoriatic arthritis, but also for preventing long-term joint destruction. Today, there are many classes of medications available, from over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs) like aspirin or ibuprofen to highly sophisticated DMARDs (disease-modifying antirheumatic drugs) that slow the progression of the disease. Talk to your doctor about the right drug or drugs for you. “Most people (with psoriatic arthritis) are controlled by medication,” says Dr. McKown. The flip side of having a lot of different medications available is that you may need to try a few before finding the one that works for you. “We don’t have a good predictor of who’s going to respond better to which medication,” says Apostolos Kontzias, MD, staff rheumatologist with the Cleveland Clinic in Ohio. Specialists generally have a sequence of first-line, second and third-line drugs they try. The good news is that most people will eventually find the right fit. “We keep trying until we find the right one,” he says.
Having psoriatic arthritis—or any chronic disease—can be an isolating experience. Pain and discomfort may make you not want to go out or seek social contact, but having a supportive community will make life much more enjoyable. Thanks to the Internet, it’s easy to find one-on-one help and groups of people who understand. The National Psoriasis Foundation, the Arthritis Foundation, and Inspire can help you connect.
According to one recent study, people with psoriatic arthritis had a 30% higher incidence of hypertension when compared with people who had severe psoriasis. And people with psoriasis are already at a higher risk for cardiovascular problems. Make sure you have your blood pressure and cholesterol levels checked regularly. Detect problems early and get them treated pronto, avoiding more serious issues later on.
Just as people with psoriatic arthritis are at a higher risk for cardiovascular disease, they’re also more likely to develop type 2 diabetes. In addition to careful blood pressure and cholesterol monitoring, pay close attention to your blood sugar. (This is a blood test that can be done at the doctor’s office). If it’s elevated, you may be able to ward off a type 2 diabetes diagnosis with diet, exercise, and lifestyle changes, which can prevent serious complications.
s many as 60% of people with psoriasis experience depression. That means people with psoriatic arthritis—most of whom developed psoriasis first—are at risk as well. Some medications used to treat psoriatic arthritis may also alleviate symptoms of depression. Either way, talk to your doctor about the best ways to get help.
Mornings are especially hard if you have psoriatic arthritis, as you may wake up stiff and in pain, says Dr. McKown. Taking a hot shower soon after you wake up can help dissipate those symptoms and help ensure your day starts off on the right tone. If your hands are particularly sore, putting them under hot water often will help.
Consulting with a rheumatologist is critical to long-term management of psoriatic arthritis. Not only will this type of specialist be able to accurately diagnose your condition, but he or she will also have a good handle on the multiple medications available and will know about new medications as they become available. “We want our patients seeing rheumatologists,” says Siegel.
This may seem like a no-brainer given that smoking cigarettes cause lung cancer, throat cancer, pancreatic cancer, emphysema, heart disease, and more. But it can also complicate matters even more for people who have psoriatic arthritis. In a recent study of almost 1,500 psoriatic arthritis sufferers, smokers didn’t respond to medication as well as non-smokers and they didn’t stick with treatment very long. Not surprisingly, smokers also did not improve as much as non-smokers.
The inflammation that is a hallmark of psoriatic arthritis can damage blood vessels and increase cardiovascular risk. Eating fresh fruits and veggies and whole grains while staying away from saturated fat and refined products can reduce this risk. “We recommend that people think about a heart-healthy diet,” says Dr. McKown. That means lots of fruits, veggies and whole grains, less fat, red meat, and refined products.
If you’re taking fish-oil supplements or just eating a lot of fatty fish like salmon and mackerel for your heart, you may already be seeing benefits to your joints as well. “There is evidence that fish oil can help with inflammation,” says Dr. McKown. The American Heart Association recommends eating two servings (3.5 ounces cooked each) of salmon or other fish, especially fatty fish, weekly. Or talk to your doctor about a good fish-oil supplement.
Researchers have noted vitamin D deficiencies are more common in people with psoriatic arthritis than the rest of the population. There’s limited evidence that more vitamin D will actually improve the condition, but vitamin D is necessary for many other aspects of health, including bone health. Most people get their vitamin D through sun exposure. Ask your doctor about how much time you should spend in the sun or whether it’s a good idea to eat more vitamin D-fortified foods or add a supplement to your diet.
ags that hang off your body can put undue stress on joints and on your spine. This includes backpacks and briefcases. Choose a roller bag instead and a roller bag that you can push rather than pull in particular. “Cases with four-wheel rollers are fabulous because they just roll right with you as you’re walking,” says Frost. “That’s ideal [although] if you can’t get the push, pull is better than not.” If you have to carry something, make sure you distribute the load. That means one grocery bag on each arm, not two on one arm and nothing on the other. “With any kind of aggressive activity with the body, you try to distribute the load however you can and distribute on the larger joints if possible,” says Frost. “Instead of holding it in your hand, hold it in your arms.”
Too much alcohol can damage your liver even if you’re healthy. Some people with psoriatic arthritis are at added risk either because of the medications they’re taking or because they are overweight. Check with your doctor on how much it’s safe to drink or whether you should be drinking at all.
Turmeric, a spice used liberally in Indian cuisine, has both anti-inflammatory and antioxidant effects that may help control flares in both psoriasis and psoriatic arthritis, according to the National Psoriasis Foundation. You can flavor up your diet with turmeric-containing curries or take it in pill or supplement form. Check with a healthcare professional to see if a supplement is right for you. Just for you Anna.
Shop for spatulas and other utensils with larger handles and grips. This will make life easier in the kitchen, especially if you have arthritis in your hands and wrist, says Frost. Other gadgets are available to help in the car (attachable seat-belt handles), the den (large-size remote controls), the dressing room (long-handled shoe horns), and the yard (ergonomic gardening tools).
Small adjustments at home can make a big difference in your quality of life. For instance, if you happen to be in the market for a washing machine, choose a front-loader rather than a top-loader, advises Frost. Also, levers are more user-friendly than doorknobs. “All you have to do is push it down and open the door,” she says.
If you also have psoriasis (and most people with psoriatic arthritis do), keeping the skin condition under control will help ensure the arthritis is under control also. The good news is that many psoriasis medications are also prescribed for psoriatic arthritis. And some of the triggers are the same too, for example, stress, skin infections, and strep infections.
If you were an avid gardener before your diagnosis, you can still dig in the dirt: You just may need to do it while sitting on a stool rather than kneeling on the ground. “The bottom line . . . is to keep moving and engaging in activities and occupations that are meaningful. There is usually a solution,” says Frost. You “may not be able to perform it in exactly the same way but (you) can still be active. All it takes is a conversation and problem-solving.”
Be aware of your psoriatic arthritis and know what may trigger symptoms of flare to you personally. Look for resources; the National Psoriasis Foundation offers several support programs that may be of help: https://www.psoriasis.org/about-psoriatic-arthritis. Consider enlisting family, friends, work colleagues, to help make your psoriatic arthritis manageable, leading to a productive and enjoyable life overall.
Lots of information but great stuff!