Psoriatic arthritis (PsA) is a disease that manifests itself in chronic arthritis and skinpsoriasis. Sometimes it takes up other parts of the body, including the eyes and heart, which can also lead to the accelerated development ofatherosclerosisand its complications. The course of the disease is very diverse, ranging from mild (most frequent) to severe, leading to joint damage and disability. In recent years, significant advances have been made in the treatment of psoriatic arthritis, making it easier to control the symptoms of the disease and slow its progression.

The causes of psoriatic arthritis

The exact cause of the disease is unknown. It is likely that people with a genetic predisposition to develop psoriatic arthritis have the abnormal inflammatory process triggered by an additional stimulus. The most important risk factors known so far are:

• genetic susceptibility:the disease is much more common in the family – almost half of the patients have a close relative with psoriasis or psoriatic arthritis; a number of genetic factors increasing the risk of its occurrence were found (including the HLA-B27 antigen)
• viral and bacterial infections, mechanical injuries, significant stress:all these factors initiate an abnormal immune system response in susceptible individuals,
• medications(including lithium salts, beta-blockers, anti-malarial drugs) and other chemicals.

How common is psoriatic arthritis?

Psoriatic arthritis occurs in about 1/3 of people with psoriasis, and 2% of the population suffers from this disease (so it is quite common). It usually begins between the ages of 30 and 50 (although younger or older people can also get sick). Men and women suffer from the disease equally often, although the disease has a different course.

How is psoriatic arthritis manifested?

Psoriatic arthritis has a different course, depending on the degree of involvement of the musculoskeletal system and other organs. It can manifest in only one location (e.g., recurrent finger inflammation) or involve multiple joints. Most often, symptoms appear in people who are already diagnosed with psoriasis or simultaneously with skin lesions. However, it is not uncommon for psoriatic arthritis to start in people without psoriasis skin symptoms, which can be a problem in making a diagnosis.

The course of the disease is usually variable, with periods of flare-up until symptoms disappear (wholly or partially). High disease activity is usually accompanied by “general” symptoms such as fatigue, a feeling of breakdown, and an increase in body temperature.

The characteristic symptoms of psoriatic arthritis in the musculoskeletal area are:

• joint pain, stiffness and swelling with limited mobility;the symptoms of inflammation also affect adjacent structures such as tendons and bursae,
• enthesitis(i.e. places of attachment to the bones of tendons, ligaments or joint capsules) – this is a very characteristic symptom of psoriatic arthritis and other diseases from the group of the so-called seronegative spondyloarthritis; is manifested by pain and tenderness in places such as the heels, the connection of the ribs with the sternum and the spine, but it can also affect many other locations,
• finger inflammation: thedisease affects all the structures of the finger (joints, tendons, subcutaneous tissue), which gives the characteristic symptom of “sausage finger”; the affected finger is completely dilated, painful and sticks out from other fingers, redness of the skin may also occur,
• joint deformities:occur mainly in a mutilating form (in about 5% of patients); the most characteristic of psoriatic arthritis are the so-called telescopic fingers, i.e. shortening of the fingers as a result of bone destruction
• gout:can accompany psoriatic arthritis, especially with extensive skin lesions causing an increase inuric acid levels;A goutattack may be difficult to distinguish from an exacerbation of psoriatic arthritis (the diagnosis is facilitated by puncturing the joint and drawing fluid from it for examination).

There are five main forms of psoriatic arthritis (the first two account for the majority of cases):

Dig. 1.Psoriatic arthritis: psoriatic lesions on the skin of the back of both hands, “telescopic” first finger of the right hand, characteristic involvement of the distal interphalangeal joints of both hands, subluxation of the distal phalanx of the third finger of the left, “sausage-like” second finger of the right hand

• unsymmetrical polyarthritis:affects various sites on either side of the body, typically less than 5 joints are involved; at the beginning, they are most often the joints of the hands and feet (often in the form of “sausage fingers”),
• symmetrical polyarthritis:in this form, the wrists, joints of the hands and feet, ankles are affected; this form must be distinguished from rheumatoid arthritis; is more common in women,
• Inflammation of the distal interphalangeal joints(i.e. the end joints of the fingers and toes): affects 5-10% of people with psoriatic arthritis, more often in men
• axial form(5% of cases): the disease affects the joints of the spine and sacroiliac joints (connecting the spine to the pelvis); more often it affects men; characteristic symptoms are pain and stiffness of the spine (symptoms are most intense at night and in the morning, movement brings relief),
• the mutilating form:affects about 5% of people; causes significant damage and deformation of joints (e.g. telescopic fingers).

Sometimes it is not possible to isolate one form of the disease in a person, and different forms of the disease may overlap.

Other symptoms of psoriatic arthritis:

• skin– psoriatic arthritis usually occurs with psoriasis of the skin (sometimes the skin changes appear later or are minor); red papules with a keratinized surface resembling silver scales are characteristic; lesions may be small or cover most of the skin, most often the head, elbows and knees, navel and buttocks area; the severity of the skin lesions does not usually correspond to the severity of the arthritis
• nails– nail involvement occurs in 80% of patients with psoriatic arthritis (four times more often than in psoriasis itself); characteristic changes are “thimble symptom” (that is, pin-pricked depressions), transverse or longitudinal grooves, yellow spots resembling “oil spots” (caused by hyperkeratosis of the skin under the nail), and peeling of the nail; nail involvement may be the only symptom of psoriasis and should be given special attention
• eyes– their involvement occurs in about 1/3 of people with psoriatic arthritis; the most common is conjunctivitis, less common is uveitis, manifested by pain and redness of the eyeball and visual disturbances – untreated uveitis can lead to serious complications
• atherosclerosis– its accelerated development in psoriatic arthritis is due to chronic inflammation; complications of atherosclerosis (e.g. heart attack,stroke, mesenteric artery atherosclerosis) are life-threatening, therefore it is very important to start fighting its development early
• heart– damage to the heart valves is rare (most often aortic or mitral valve regurgitation), aortic inflammation or disturbances in the conduction of cardiac stimuli; patients with psoriatic arthritis should also be under the care of a cardiologist, especially if they develop symptoms such aschest pain,shortnessof breath , weakness in physical condition or fainting.

What to do in the event of symptoms?

People suffering from psoriasis should inform their doctor if they experience problems with the locomotor system – they may be the first symptom of PsA. Joint pain andswellingrequire consultation with a rheumatologist in order to establish the diagnosis as early as possible and apply effective treatment.

In the course of PsA, some situations require urgent medical attention. You should see a doctor, among others if:

• symptoms worsen or do not improve despite treatment – it is often necessary to increase the dose of drugs or use other preparations to suppress the disease activity as soon as possible,
• you experience pain and redness of the eye, problems with vision – these may be symptoms of uveitis that requires immediate eye treatment
• the patient has recently hada joint puncture, followed by severe pain, swelling and increased joint warmth, orfever– these may be signs of a joint infection requiring prompt treatment;pain in the joint, which disappears within a day after the puncture is performed, do not worry (during this time you should avoid overloading the joint).

Psoriatic arthritis and pregnancy

It is also extremely important to inform the doctor about the planned pregnancy (this applies to both women and men). Psoriatic arthritis is not a contraindication to having children, but pregnancy should be planned in order to modify the treatment early, as most drugs may harm the unborn child.

How is the diagnosis made by the doctor?

The most common diagnosis of a physician is psoriatic arthritis when symptoms of arthritis appear in a patient with psoriasis. If there are no skin lesions, information about a family or past history of psoriasis is key. Symptoms of the disease such as nail changes, enthesitis, “sausage fingers” and eye inflammation are very important – they help to distinguish psoriatic arthritis from other arthritis.

Laboratory tests look for increased ESR and CRP (indicative of inflammation), although in some patients they are normal. Other rheumatological tests are often performed, such as rheumatoid factor (in PsA it is usually absent, which helps to differentiate from other arthritis) and HLA B27 antigen (often found in the group of diseases including PsA, so-called seronegative spondyloarthritis). Radiographs of the affected joints (most often hands and feet) should also be taken.

In patients with suspected axial form, imaging examinations of the spine and sacroiliac joints (radiographs or magnetic resonance imaging) are performed. Ultrasound examination is also helpful in diagnosing the disease, as it allows for the identification of signs of inflammation within the joints and tendon attachments. An ophthalmological examination is necessary in patients with symptoms of conjunctivitis or choroiditis.

What are the treatments?

The goal of treating PsA is to stop the progression of the disease and allow it to function normally. While it may not always be possible to achieve complete remission (that is, when there is no evidence of disease present), it is increasingly possible to keep remission at a low level.

It is essential that treatment is started as soon as possible to prevent disability and other complications of the disease. Management depends on the course of psoriatic arthritis and must be personalized for each patient. The doctor will determine them, taking into account the activity of the disease, the degree of damage to the joints and other organs, and comorbidities. A combination of different treatment methods is most effective, e.g. rehabilitation is important in addition to medication. Complications of psoriatic arthritis, including cardiovascular diseases. It is important to develop an effective treatment plan with your doctor – this involves regular visits and laboratory tests assessing the effectiveness and possible side effects of the drugs used.

The severity of psoriatic skin lesions often does not reflect the severity of psoriatic arthritis (e.g., nail-only psoriasis may be associated with advanced arthritis). Therefore, in addition to dermatological treatment, cooperation with a rheumatologist is necessary. Many systemic drugs reduce both skin and joint lesions.

Anxieties

The most important medications used in this disease are:

• non-steroidal anti-inflammatory drugs– in many people they are sufficient to control the symptoms of arthritis, but they do not affect skin changes (they can rarely worsen them – then you need to use a different preparation); in the period of an exacerbation of the disease, they are taken daily in a sufficiently large dose with a meal; remember about contraindications to their use (such as kidney disease,arterial hypertensionor peptic ulcer disease) and possible side effects (see also:gastric and duodenal ulcers)
• glucocorticosteroids– in psoriatic arthritis, they are administered mainly inside the affected joint in order to effectively reduce the symptoms of inflammation
• drugs that modify the functioning of the immune system:
  • methotrexate– is one of the most commonly used drugs in the case of active arthritis, it often also reduces skin lesions; this drug is administered once a week – orally, subcutaneously or intramuscularly; when using it,folic acidsupplementation is used ,
  • other drugs such as:sulfasalazine,cyclosporine,azathioprine, andleflunomide
• biological drugs– a relatively new group of drugs that have revolutionized the treatment of many inflammatory diseases; several preparations are successfully used in psoriasis and psoriasis (etanercept,infliximab,adalimumab,golimumab), and there are many new substances in clinical trials; these drugs reduce symptoms of arthritis and possibly inhibit joint damage as assessed by imaging tests; the symptoms of the disease in the skin and eyes are also reduced; their use is currently limited to the severe form of the disease, resistant to other drugs.

Other therapeutic methods

In addition to the use of drugs, other therapeutic methods are very important.

Local treatment– applies directly to the affected joint; are performed, among others:

• puncture the joint to decompress it of accumulated inflammatory fluid and inject anti-inflammatory drugs (steroids) inside
• procedures to remove the altered synovial membrane (synovectomy) – there are various ways of performing them: surgical, chemical (by administering a substance that destroys the synovium) or with the use of a radioisotope
• various types of corrective and reconstructive treatments aimed at improving the structure and functioning of deformed joints
• endoprosthesis, i.e. replacing a damaged joint with an artificial prosthesis.

Psychological support– patients with psoriatic arthritis often feel pain and inefficiency of the locomotor system, and skin lesions are an additional cause of their suffering. Being diagnosed with this disease can cause enormous stress and anxiety for the future. It is a natural reflex that most people suffering from a chronic disease struggle with, so it is important to get help and support from relatives and, if necessary, from specialist clinics. Some methods (e.g. biofeedback and behavioral therapy) are very effective in controlling symptoms of the disease and improving self-esteem. Don’t hesitate to talk to your doctor about your concerns!

Rest– some people may feel very tired, especially during the active period of the disease. Allow yourself to rest – short naps during the day will help you regain energy and relieve your sore joints.

Exercises– chronic joint disease favors the abandonment of any physical activity, while it leads to a reduction in joint mobility, contractures and muscle weakness. Regular physical activity prevents and even reverses some adverse changes in the joints; it is advisable to use exercises that increase the range of motion and strengthen the muscles (they will help maintain the mobility and stability of the joints), as well as exercises that improve overall efficiency (e.g. walking, swimming, cycling); the exercise program should be developed by a physiotherapist and adjusted individually to the patient’s abilities, depending on the severity of the disease, the condition of a given person and coexisting diseases. During the exacerbation of the disease symptoms, one should refrain from exercise. Remember that the sooner you start targeted rehabilitation,

Physical therapy– Various techniques such as cryotherapy, ultrasound, massage and balneotherapy help reduce pain and inflammation in the joints and relax the muscular system.

Orthopedicequipment helps to relieve the diseased joints and deal with disability – it includes supports for arms, knees and ankles (so-called orthoses) that help to maintain the correct position of the joints, orthopedic insoles for shoes that improve the structure of the foot and relieve load-bearing joints when walking.

Adequate diet– it’s about maintaining a healthy body weight. Patients should avoid both overweight and obesity (which increases the load on the joints and accelerates the development of atherosclerosis) and malnutrition (which weakens the body and leads to muscle atrophy). It is also important to provide the bones with the right amount of calcium and vitamin D.

Prevention of cardiovascular diseases– the key is to keep the disease activity low and a healthy lifestyle, including proper diet, physical activity, avoiding alcohol consumption, not smoking. Depending on the indications, it is used, inter alia, medicines to lower cholesterol (statins), medicines for diabetes, salicylic acid and omega-3 acids.

Is it possible to recover completely?

Psoriatic arthritis is a chronic disease and it is difficult to say that it can be cured. Quite often, however, it is relatively mild, with long periods of symptom relief (so-called remission). Unfortunately, in some patients (approx. 5%) the disease is aggressive and leads to large joint deformities and disability. Patients with severe psoriatic arthritis live several years shorter than the general population. The available treatment methods more and more often allow for remission and normal functioning.

What should I do after treatment is finished?

Constant rheumatological control is necessary. Often, patients are also under the constant care of a dermatologist and ophthalmologist (in the case of recurrent uveitis). At the onset of the disease and during exacerbations, frequent visits to the doctor are necessary to determine the appropriate doses of drugs and achieve remission. In a stable period, visits may be less frequent (usually every 6–12 months).

Laboratory tests are performed to assess the activity of inflammation, the functioning of internal organs, and to monitor the side effects of the drugs used. It is also recommended cardiological control and assessment of cardiovascular risk, e.g. regular blood pressure monitoring as well as tests for diabetes and lipid disorders (usually once a year). It is also important to remember about the early prevention and treatment ofosteoporosisin order to reduce the risk of bonefractures.

What to do to avoid getting sick?

Unfortunately, we have no influence on the occurrence of psoriatic arthritis. People suffering from psoriasis who notice any problems with the musculoskeletal system should inform their doctor about them. Factors that may start or worsen the disease should be avoided.