What Is Psoriatic Arthritis?

"Just Because You Suffer With Psorisis And Arthritis, Doesn't Mean You Have Psoriatic Arthritis"

By Definition –

Psoriatic arthritis is a type of joint inflammation that happens in individuals with psoriasis (joint inflammation being the literal meaning of arthritis and psoriasis being an auto-immune disease typically charactised by red scaly patches).

It is an autoimmune disease and behaves much like rheumatoid arthritis, with the additional symptoms of psoriasis.

As with many forms of arthritis, successful treatment of psoriatic arthritis relies on early diagnosis. Psoriatic arthritis is not simply a combination of psorisis and arthritis – it is an autoimmune disease and a variant of arthritis, similar in some ways to rheumatoid arthritis – but one which needs its own unique treatment plan for maximum effectiveness.

What Is Psoriatic Arthritis?

Immune cells are normally the bodies best friend – existing with the simple purpose of spotting and destroying any foreign or potentially dangerous molecules entering your body.

In the case of an auto-immune disease, these protective cells turn against the body, failing to recognise your own antigens and assuming them to be foreign invaders.

With psoriatic arthritis, typical sufferers will start out with a specific variant of the gene HLA-B27, this will then normally need to be combined with some form of environmental trigger such as an infection or physical trauma.

Once this trigger has occurred, your immune antibodies will cease to recognise your self-antigens and release what are known as ‘cytokines’ with the specific goal of destroying them. The end outcome is inflammation on a grand scale.

Ultimately, your immune system while fighting against your own antigens will create osteoblasts and osteoclasts that leads to a combination of ossification (bone remodelling) and joint erosion.
This bone remodelling then leads to the deformities that you often see in sufferers with a whole variety of different forms of arthritis.

According to the Psoriasis Association,

“Psoriatic arthritis (PsA) affects joints (such as the knees or those in the hands and feet), as well as areas where tendons join to bone (such as the heel and lower back). Most people who have psoriatic arthritis find it occurs after developing skin psoriasis, but some do develop the arthritis before they notice any psoriasis on their skin.”

As touched on in the definition above, psoriatic arthritis can also affect connective tissue called ‘entheses’. These are what attaches tendons and ligaments to your bones.

When your psoriatic arthritis affects these, it is known as ‘enthesitis’ and the pain is likely to be far wider than just tightly constrained to the joint.

The chest is one area that is a particularly common site to be affected by enthesitis, although the heel is another frequently affected site, causing a problem with walking or even standing.

Unfortunately, psoriatic arthritis has no obvious cure and is likely to just worsen over time. As with all forms of arthritis treatment is possible to arrest it’s development and control it’s symptoms, but the effectiveness of these really depends on just how fast you can get it diagnosed and start treatment. Time is crucial.

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Types Of Psoriatic Arthritis

Psoriatic Arthritis can loosely be broken down in to 5 categories, depending on which areas of your body it affects –

  1. Oligoarticular. Normally pretty mild symptoms, affecting less than 5 joints
  2. Polyarticular (or ‘Rheumatoid Pattern’). So-named because it resembles rheumatoid arthritis. It usually affects the same joint on both sides and typically affects 5 or more joints. This is especially likely to affect the feet, ankles, hand and wrists.
  3. Spondyloarthritis. This generally affects the spine and sacroiliac joint. It is asymmetric, meaning it does not affect both sides of the body equally. Spondyloarthritis tends to lead to fusion between the bones (vertebrae) in the neck and the sacroiliac joint, leading to considerable pain and stiffness.
  4. Distal Interphalangeal Predominant. This affects mostly the joints at the ends of your toes or your fingers. It is likely to cause nail abnormalities such as pitting/ ridging and could even cause dactylitis (also known as ‘sausage fingers’ due to the swelling). Over time, Distal Interphalangeal Predominant Psoriatic Arthritis (say that after a night out!), can lead to severely distorted hands/ feet and bone erosion.
  5. Arthritis Mutilans. The severe bone erosion causes such extreme deformities as to look like the ‘opera glass’ hand, where fingers shrink back in to hand leaving short, stumpy, badly deformed digits.

Symptoms Of Psoriatic Arthritis

Typical symptoms of psoriatic arthritis include –

1) Painful swelling in the joints

2) Stiff Joints, worse in the morning but loosening with exercise

3) Inflamed tendons also known as Enthesitis. Sometimes the tendons can become inflamed without the joints following suit and this can lead to a misdiagnosis of tennis elbow or tendonitis.

4) Nail psoriasis is also common in people with psoriatic arthritis and can often be an early indicator of the disease.

5) The tendency of psoriatic arthritis to affect the end joints of finger and toes is so strong, that ‘sausage fingers’ (when the fingers swell to painful proportions) is another frequent symptom. The effect of fingers and toes getting swollen is also referred to as ‘Dactylitis’ and is very common with up to 4 in 10 people that have psoriatic arthritis suffering with it

6) Back/ Neck Pain. 40% of people with psoriatic arthritis suffer with back or neck pain.

7) Tiredness and fatigue. Partly as a result of the sheer pain and your battle with it, you are likely to feel exhausted from time to time. As the disease progresses you are likely to find it increasingly hard to perform relatively simple tasks like taking out the rubbish.
This is, regrettably, a tiredness that can not be cured simply with a good nights rest.

8) Psoriasis. This is obvious isn’t it? Not necessarily, because as we mentioned earlier, the mere presence of psoriasis and arthritis does not indicate a definite diagnosis of ‘psoriatic arthritis’ since it could still be psoriasis alongside a different arthritis. However, psoriasis is still always present in those cases that are ‘psoriatic arthritis’

9) The Existence Of ‘Flares’. One of the characteristics of psoriatic arthritis is that it’s symptoms tend to rise and fall, sometimes suddenly in what are termed as ‘flares’. These are not dissimilar to those experienced by gout sufferers where they can suddenly be faced with two days of excruciating pain before the symptoms settle down again for a period before ‘flaring’ again.

10) Changes In Mood

11) Eye Problems/ Loss Of Vision

12) Flaky Scalp

13) Anxiety or Depression

14) Inflammation In The Lungs (or Interstitial lung disease)

15) Damaged Blood Vessels. With genuine risk of heart attack or stroke

16) Crohn’s Disease (or Inflammatory Bowel Disease)

What Causes Psoriatic Arthritis?

It is difficult to pinpoint exactly what is likely to cause psoriatic arthritis. To some extent, the cause can be put down to just sheer bad luck.

However, genes inherited from your family can leave you statistically much more likely to develop psoriatic arthritis. Then it is the common triggers of an infection, an injury, smoking or obesity that are most likely to trigger the disease into presenting itself.

These triggers are true for many types of arthritis however, and simply having psoriasis at the same time as arthritis is absolutely no guarantee that you have psoriatic arthritis.

Why you???

It is difficult to pinpoint exactly what is likely to cause psoriatic arthritis. To some extent, the cause can be put down to just sheer bad luck.

However, genes inherited from your family can leave you statistically much more likely to develop psoriatic arthritis. Then it is the common triggers of an infection, an injury, smoking or obesity that are most likely to trigger the disease into presenting itself.

These triggers are true for many types of arthritis however, and simply having psoriasis at the same time as arthritis is absolutely no guarantee that you have psoriatic arthritis.

Typical Effects Of Psoriatic Arthritis On Your Body

Muscoskeletal Effects

Similar in many respects to that of rheumatoid arthritis, this auto-immune disease occurs because your immune system essentially gets confused and starts mistaking your own body for foreign antibodies. The result is your own immune system turns on you causing inflammation, pain and swelling all over your body.

Your joints are particularly vulnerable because cartilage is directly damaged by the inflammation, although this is also very likely to affect surrounding tendons and ligaments as well.

This can often lead to bones eventually wearing away the increasingly thinned cartilage until bone grinds on bone.

Beside bone erosion at this point, psoriatic arthritis can also lead to bone ‘spurs’ forming – extra shards of bone growing outwards in uncomfortable positions.

It is quite common for it even to affect your spine and neck, whereupon it is known as ‘spondylitis’ or your fingers where their sausage-like appearance is referred to as ‘dactylitis’

Effects On Your Skin.

The psoriasis itself is likely to cause patches of raised, red scaly skin with flakey patches that are silver or white in colour.

Effects On Your Eyes And Vision

‘Uveitis’ is a condition defined by inflammation that affects the eyes. For more on this condition please see ‘psoriatic arthritis in the eyes’.

While uveitis is much more common in women than in men, if ignored or not treated correctly it can cause blindness.

However, it is also not uncommon for psoriatic arthritis sufferers to experience cloudy or blurred vision, a loss of peripheral vision (not being able to see things at the side of your eye line) and even experience a heightened sensitivity to bright lights.

Effects On The Digestive System

Unfortunately, for sufferers of psoriatic arthritis, there is a strong connection with both inflammatory bowel disease and colitis.

Psoriatic arthritis can also lead to a build up of fat in the liver. When this is not caused by directly by excess alcohol consumption (the most common reason), it is known as ‘non alcoholic fatty liver disease’ (logically, I guess).

If you develop non alcoholic fatty liver disease, you are unlikely to be aware in the early stages, until you start to develop cirrhosis (si-roh-sis), which is when the liver gets scarred and this scarring starts preventing your liver from working properly.

Typical symptoms include aching pain in the top right of your stomach, unexplained weight loss, itchy skin, swollen ankles/ feet or jaundice (yellowing of the skin and eyes)

Effects On Your Heart

Statistically, having psoriatic arthritis will put you at a higher risk of developing heart complications including inflammation of the heart and suffering a heart attack.

The increased risk is however not as big as with some other diseases and can be mitigated to some extent by living an otherwise healthy life.

Areas Most Likely To Be Affected By Psoriatic Arthritis

Almost any area within the human body can be affected by psoriatic arthritis.

Like many forms of arthritis, it relies on inflammation and almost every area from your lungs to your heart to your eyes can suffer with psoriatic arthritis.

Typically however, inflammation affects your joints first, and so the following areas are the most likely areas to be affected –

  • Toes
  • Ankles
  • Knees
  • Elbows
  • Wrists
  • Fingers
  • Back
  • Shoulders
  • Neck

Diagnosis Of Psoriatic Arthritis

It normally falls to a Rheumatologist to assign the required tests and make a definitive diagnosis, although it is likely a whole team of specialists will treat you for various aspects of your psoriatic arthritis.

Diagnosis of Psoriatic Arthritis isn’t necessarily straightforward (this is often the case with arthritis – not least because there are over 50 different types of arthritis, many of which can behave quite similarly).

Psoriatic arthritis can behave in a very similar manner to rheumatoid arthritis and as mentioned above, it is further complicated by the fact that just suffering with psoriasis and arthritis does not mean you actually have psoriatic arthritis.

Just to complicate the diagnosis even further it is even possible for someone to have psoriasis and osteoarthritis or rheumatoid arthritis, but still not psoriatic arthritis!

Blood tests can reveal the existence of the antibody known as rheumatoid factor and also anti-citrullinated protein antibodies. Both are found in rheumatoid arthritis, but not in psoriatic arthritis. Once again, we are left trying to diagnose a disease first by ruling out the other possible alternatives.

An X-Ray or an MRI scan can then be used to show joint erosion what is known as ‘pencil-in-cup’ radiographic sign. An MRI in particular may be show new bone growth with badly-defined edges that indicated the possible existence of psoriatic arthritis.

Psoriatic Arthritis Medication

A family doctor can normally offer treatment for the pain with a series of mild painkillers or NSAIDs that can be given to reduce both pain and inflammation, providing the pain is not too severe.

As soon as psoriatic arthritis is suspected, your doctor should then refer you straight away to a Rheumatologist for confirmation of the diagnosis and active treatment. You may then be referred to a pain specialist and a physio for respective advice on pain relief and exercise.

Depending on the severity, you may then also be referred to an occupational therapist who can look at mobility equipment to help protect your knees/ hips etc, as well as analysing the way you undertake certain tasks.

Finally, a podiatrist may also be of use in your ‘team’ to assess your footware needs.
In cases of psoriatic arthritis, it is normal for the rheumatologist to take the lead.

A typical treatment route would be to treat both the psoriasis and the arthritis separately.

Your Likely Treatment Journey For Your Arthritis…

Start on NSAIDs (non-steroidal anti-inflammatory drugs) such as Ibuprofen or Naproxen. Due to the potential side effects associated with NSAIDs, it is likely you will also be prescribed a Proton Pump Inhibitor (PPI) such as Lansoprazole or Esomeprazole for the heartburn and potential damage to your stomach from the acidity of the anti-inflammatories.

Your doctor is also likely to consider your risk factors for heart attacks or a stroke – both of which are increased by taking NSAIDs. This doesn’t mean you wont be prescribed them, but if you suffer with other ‘high risk’ factors such as diabetes, high cholesterol or are a smoker, then they may think twice as the risks will be substantial.

If this is unsuccessful or not considered on balance a good route, then it is likely they may try steroid injections in the affected joints.

This would mean trying injections containing steroids such as hydrocortisone or methylprednisolone.

These should relieve pain within just a few hours, but they will wear off within a week or two and other treatments may need to be investigated.

The next option for your Rheumatologist may well be to decide whether there is a likely benefit in Immunomodulatory drugs (DMARDs also known as Disease Modifying Anti Rheumatic Drugs, such as Sulfasalazine and Methotrexate.

If both the basic NSAIDs and stronger Immunomodulatory drugs fail, then it is often left to newer biological response modifiers known as ‘TNF Inhibitors’. These are more commonly known now as ‘Biologic DMARDs’ (Disease Modifying Anti Rheumatic Drugs).

These include names such as Infliximab, Etanercept and Adalimumab, all designed to block the actions of ‘TNF-Alpha’. Alternatively you may be prescribed ‘Ustekinumab’ to impact the behaviour of the interleukins.

Again however, it should always be a rheumatologist that starts you on these disease-modifying drugs and only after a full assessment.

You should also already be seeing a dermatologist for individual treatment of your psoriasis. If you’re not, then you should add one to your ‘team’ of doctors helping you manage with psoriatic arthritis.

Surgery –

Replacement or revision surgery can be performed on hip and knee joints, although rarely on the spine.

Your Likely Treatment Journey For The Psoriasis –

It is likely that your psoriasis will also be causing you discomfort in itself. You will most probably be referred to a dermatologist who will consider using a variety of creams and gels to control your psoriatic symptoms.

These may include –

  • Vitamin A gels (Tazarotene)
  • Vitamin D ointments
  • Steroid-based creams (Quite a large number of options)
  • ‘Dithranol-based’ ointments
  • ‘Tar-based’ ointments
  • Salicylic Acid

If these are unsuccessful, then there is the option for your doctor to consider referring you for ‘Light therapy’. This is where ultraviolet light is used to stop skin cells growing too quickly as well as reducing inflammation.

This will help with the aesthetic of the scaling and possibly the redness on your skin.

If your psoriasis continues to be a massive issue, then your rheumatoloigst may look again at prescribing DMARDs or biologics as they also have the benefit of treating the psoriasis.

Natural Treatments For Psoriatic Arthritis

1) Occupational Therapy.

Visiting an occupational therapist can give you valuable advice and tips around making changes in your home to reduce the amount of strain on your arthritis-affected hands and legs.

2) Get Some Sunshine.

This can be short-term and sunburn will make it infinitely worse, but getting a tan can often make your psoriasis feel a lot better.

3) Glucosamine.

This is said to be an essential building block of cartilage. It is generally considered that taking a supplement of glucosamine sulfate may slow down the loss of cartilage around joints caused by arthritis

4) Fish Body Oils.

Containing omega 3 fatty acids, they are heavily linked with reducing inflammation. However, as always, the natural sources such as mackeral or salmon are far better sources than tablets.

5. Utensils.

As covered elsewhere, there are a range of arthritis-ready items to help you with your daily life around the house if you suffer with arthritis.

6) Keep a journal

7) Join a support group

8) Counselling.

Try and come to terms with the mental side of your illness

9) Socialise Regularly.

Make sure you don’t suffer in silence. The benefits of friendship and going out are well documented for your mental health in particular.

10) Exercise.

Exercise is really good for keeping your stiffening joints relatively agile and maintaining as full a range of motion as possible. There are 3 key types of exercise – Stretching, Strengthening and Cardiovascular.

  • Stretching is really useful to maintain your normal range of motion. Classes such as Tai Chi or Yoga can be particularly good for this.
  • Strength Training. This is perfect for stabilising your joints and, in the case of lifting weights, can be great for increasing bone density as well. Another advantage is that by improving your bone density you are also much more likely to prevent issues such as osteoporosis.
  • Activities such as pilates or using resistance bands are great for stabilisation. Dumbbell lifting and weight-operated gym equipment is useful for increasing bone density.
  • Cardiovascular or aerobic exercise is really good for increasing your physical stamina, mental wellbeing and the health of your heart. Walking, swimming or cycling are great examples and can be undertaken to some extent, even if you are suffering with a more developed version of the disease.

11. Rest and Relaxation.

If you are not feeling 100% or when you can feel your symptoms start to flare, make sure you take plenty of rest. This may need to be planned in your diary, so you know you wont forget or find yourself too committed to other people to be able to take a break when you need to.

12. Meditation.

You could even go one step further and learn home meditation. This will help you get the most out of your ‘relaxing time’

13. Hypnosis.

This is slightly different to mediation in that it aims to alter your bodies perception of pain and therefore reduce it. We’ve written an article all about self hypnosis for pain relief here – it’s something again that is both natural and can be learnt at home with some surprising results!

14. Healthy Eating.

As medical knowledge about the body continues to develop, the role of diet in everything from disease prevention to pain relief is growing in importance.

And whether it be following an anti-inflammatory diet (covered Here) or just the ‘mere’ importance of eating healthy, it’s benefits can be truly amazing. In the case of psoriatic arthritis, general healthy eating will help greatly with your energy levels and hopefully prevent much of the exhaustion that comes as a symptom.

If you then chose to take this to the ‘next level’, then a full anti-inflammatory diet might not be a bad thing either as inflammation always contributes to pain levels in any form of arthritis.

15. Sleep.

Sleep is essential to slowing down the development of any auto-immune disease. Good, undisturbed sleep does this for two reasons – a) firstly it helps the body to heal during the ‘phase 3’ or ‘deep restorative sleep’ and b) Not getting enough sleep is widely proven to make your body more receptive to pain messages, thus making your pain feel a lot worse and your life that much harder.

16. Acupuncture. Needles are used to penetrate the skin, in some cases to numb certain nerve endings, while in other cases it is designed to stimulate blood flow to the nerves and produce endorphins (natural pain-relieving substances)

17. Mind Over Matter

The Alexander Technique, Self-Hypnosis or The Feldenkrais Method are good examples. All of these are based on achieving pain relief through better understanding of how your body works and how to move better with less tension.

18. Stop Drinking and Smoking

This will not only aggravate your pain, but it speed the progression of your arthritis.

The Final Word –

Psoriatic arthritis shares many similarities with rheumatoid arthritis and, as is the case with both, time is all important. The faster you get diagnosed, the faster you can get treatment and the better your chances are of slowing it’s development.

There are many methods of both natural and painkiller-led pain control that can be effective, while there are also drugs that can be used to slow down it’s progression.

Psoriatic arthritis is rarely fatal, but can be if it is completed ignored as it can eventually spread to your heart, causing an inflamed lining that ultimately leads to a heart attack.

Much more likely though is you’ll be given a plan to counter the arthritis and a plan to counter the psoriasis.

Hopefully the information above will give you some idea at to the other treatments you could consider.

Frequently Asked Questions

Yes – it is not completely hereditary as there is no guarantee that your children will develop either psoriasis or arthritis from you. However, if you suffer with psoriatic arthritis, it is MORE LIKELY that your children will develop it at one point in their lives. 

It is however, just one factor in many that may contribute to the chances of one of your developing psoriatic arthritis.

It is impossible to say for certain if psoriatic arthritis is more painful than rheumatoid arthritis. It really depends on which stage of the disease you are at and which type of psoriatic arthritis you have. 

Theoretically, rheumatoid and psoriatic arthritis at exactly the same level of development, will see psoriatic arthritis with a greater range of symptoms/ pains due to the psoriasis element. Pain is however highly subjective and therefore will mean different things to different people.

As a result, it is not really possible to say if psoriatic arthritis in one persons’ fingers is more or less painful than rheumatoid arthritis in the digits of someone else.

Absolutely. Stress has a tremendous impact on the health of the human body as a whole and this is particularly true when it comes to pain.

Stress tensions muscles which makes any disease such as psoriatic arthritis that affects the tissues that ultimately connect joints (entheses), even worse. 

Prolonged periods of stress are also very likely to speed up the progression of psoriatic arthritis.

Finally, the effect of stress on sleeping/ eating patterns, tends to weaken the bodies’ overall defence, meaning that the same level of pain is now felt more acutely by someone who is exhausted and generally run down.

 

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References –

1. The Psoriasis Organisation (https://www.psoriasis-association.org.uk/)
2. TalkPsA (www.talkpsa.co.uk)

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