Psoriatic arthritis is a form of arthritis that affects people who have psoriasis, a condition that causes red, itchy, scaly rashes, most commonly on the knees, elbows, trunk and scalp. However, it’s important to note that you can develop psoriatic arthritis even before psoriasis appears, or without ever developing the skin condition at all. Because there are several features of psoriatic arthritis, there are different treatment options available to manage the condition effectively.
People react differently to specific treatments, highlighting the personalized nature of managing psoriatic arthritis. Therefore, finding the right treatment plan may involve trying a few options to discover what works best for each individual. This article aims to provide a comprehensive overview of psoriatic arthritis and its treatment options, ensuring you are well-informed about managing this condition.
Understanding Psoriatic Arthritis
Psoriatic arthritis is a chronic inflammatory disease that affects the joints and where tendons and ligaments attach to bone (entheses). It’s an autoimmune condition, meaning the body’s immune system mistakenly attacks healthy tissue. While the exact cause isn’t fully understood, genetics and environmental factors are believed to play significant roles.
The hallmark symptoms of psoriatic arthritis extend beyond joint pain and stiffness. Individuals may experience:
- Joint Pain, Stiffness, and Swelling: This can affect any joint in the body, including fingers, toes, wrists, knees, ankles, and spine. The pain can be symmetrical (affecting the same joints on both sides of the body) or asymmetrical.
- Psoriasis: Characterized by red patches of skin topped with silvery scales. Nail changes, such as pitting, ridging, or discoloration, are also common.
- Enthesitis: Pain and tenderness where tendons and ligaments insert into bone, commonly at the heel, elbow, or knee.
- Dactylitis: Severe swelling of fingers and toes, giving them a sausage-like appearance.
- Fatigue: Persistent tiredness is a common complaint among individuals with psoriatic arthritis.
- Eye Problems: Conditions like uveitis can occur, causing eye pain, redness, and blurred vision.
Understanding these symptoms is the first step towards seeking appropriate treatment and managing psoriatic arthritis effectively.
Treatment Options for Psoriatic Arthritis
The primary goals of psoriatic arthritis treatment are to reduce pain, control inflammation, slow down disease progression, improve physical function, and manage psoriasis. Treatment strategies are typically divided into managing the arthritis symptoms and addressing the skin condition (psoriasis).
Medications for Arthritis
Several types of medications are used to treat the arthritis component of psoriatic arthritis.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are often the first line of treatment to reduce pain and inflammation. They work by blocking enzymes in the body that contribute to inflammation. Common NSAIDs include ibuprofen, naproxen, etoricoxib, and etodolac.
While effective for managing mild to moderate pain, NSAIDs may not be sufficient for everyone with psoriatic arthritis, particularly for those with more severe symptoms or joint damage. Some individuals find that NSAIDs are effective initially but become less helpful over time. In such cases, switching to a different NSAID might provide relief.
It’s important to be aware of potential side effects associated with NSAIDs. These can include digestive issues such as stomach upset, indigestion, and stomach ulcers. To mitigate these risks, doctors often prescribe the lowest effective dose for the shortest possible duration. Proton pump inhibitors (PPIs) like omeprazole or lansoprazole may also be prescribed to protect the stomach lining.
Furthermore, NSAIDs can slightly increase the risk of heart attacks or strokes in some individuals. Doctors will carefully consider other risk factors such as smoking, circulation problems, high blood pressure, high cholesterol, or diabetes before prescribing NSAIDs. It’s also worth noting that in some cases, NSAIDs can worsen psoriasis symptoms; patients should inform their doctor if this occurs.
Steroid Treatment
Steroid treatments can be administered in different forms to manage inflammation and pain in psoriatic arthritis.
Steroid Injections: Injections directly into an affected joint can quickly reduce pain and swelling. However, the effects are temporary, typically lasting a few months. Due to the potential for joint damage with repeated injections, doctors usually limit steroid injections to a specific joint to no more than three times a year.
Steroid Tablets and Systemic Injections: For widespread pain and swelling in multiple joints, steroid tablets or injections into a muscle may be considered. However, these systemic steroid treatments carry a risk of worsening psoriasis as the effects wear off. Long-term use of steroid tablets also poses significant side effects, including weight gain and osteoporosis, a condition that weakens bones and increases fracture risk. Therefore, systemic steroids are generally used cautiously and for short durations in psoriatic arthritis management.
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
Disease-modifying anti-rheumatic drugs (DMARDs) are crucial in the long-term management of psoriatic arthritis. Unlike NSAIDs and steroids that primarily address symptoms, DMARDs target the underlying immune system dysfunction, slowing down disease progression and preventing joint damage. Many DMARDs are effective in treating both the arthritis and psoriasis aspects of psoriatic arthritis.
DMARDs work by modifying the course of the disease and reducing inflammation. However, they are not quick-acting; it can take several weeks to months to experience noticeable benefits. It’s essential to continue taking DMARDs even if immediate relief isn’t felt, and to maintain treatment long-term, often for many years or even lifelong, to sustain disease control.
The choice of DMARD depends on individual factors, including symptom severity, the risk of joint damage, and the presence of psoriasis. DMARDs can be used in combination with NSAIDs and painkillers for symptom management while the DMARDs take effect.
Like all medications, DMARDs have potential side effects. Regular monitoring is crucial, typically involving blood tests, blood pressure checks, and urine tests to assess drug efficacy and detect any adverse effects. Despite potential side effects, the benefits of DMARDs in preventing permanent joint and bone damage are significant.
DMARDs are categorized into different groups, each working through slightly different mechanisms to modulate the immune system. Traditional DMARDs, such as methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine, are commonly used as initial therapy. Methotrexate can be administered orally or via injection. Newer DMARDs, like apremilast and tofacitinib, are also available as oral tablets and target specific pathways in the immune system. These newer options might be considered if initial DMARDs are not effective. Tofacitinib and apremilast can be prescribed alongside methotrexate.
Biological Therapies
Biological therapies represent a more targeted approach to treating psoriatic arthritis. These drugs are engineered to target specific components of the immune system that drive inflammation. They are typically considered when traditional DMARDs have not provided adequate control.
Two main classes of biological therapies are used for psoriatic arthritis:
Anti-TNF Drugs: These drugs block tumor necrosis factor (TNF), a protein that plays a key role in inflammation. Examples include adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab.
Interleukin Inhibitors: These agents target interleukin proteins, another group of signaling molecules involved in inflammation. Examples include secukinumab, ustekinumab, ixekizumab, risankizumab, and guselkumab.
Both TNF and interleukin inhibitors work by interrupting inflammatory pathways, thereby reducing joint inflammation and preventing joint damage. Biological therapies may be used alone or in combination with a DMARD like methotrexate. Similar to DMARDs, biological therapies can take up to three months to reach their full therapeutic effect.
Treatments for Your Skin (Psoriasis)
Managing the skin symptoms of psoriasis is another important aspect of treating psoriatic arthritis. If psoriasis significantly impacts quality of life or if topical treatments are insufficient, referral to a dermatologist may be necessary.
Topical Treatments: Creams, ointments, and gels applied directly to the skin are often the first-line treatment for psoriasis. These include:
- Dithranol Ointments: Help slow down skin cell growth.
- Steroid-based Creams and Lotions: Reduce inflammation and itching.
- Vitamin D Analogues (Calcipotriol and Tacalcitol): Synthetic forms of vitamin D that help regulate skin cell growth.
- Retinoid Gels (Tazarotene): Vitamin A derivatives that normalize skin cell development.
- Salicylic Acid: Helps to soften and remove scales.
- Tar-based Ointments: Reduce inflammation and scaling.
Consulting with a GP, dermatologist, or pharmacist can provide detailed information about the benefits and drawbacks of each topical treatment.
Light Therapy (Phototherapy): If topical treatments are not adequately controlling psoriasis, light therapy, also known as phototherapy, may be recommended. This involves regular, controlled exposure to ultraviolet (UV) light in a clinical setting. Adherence to scheduled appointments is crucial for successful treatment. Phototherapy is not suitable for everyone, particularly individuals with a high risk of skin cancer or children. In some cases, light therapy can paradoxically worsen psoriasis.
Systemic Medications for Psoriasis: Retinoid tablets (acitretin), derived from vitamin A, can be effective for severe psoriasis unresponsive to other treatments. However, they can cause skin dryness and may not be suitable for individuals with diabetes. Importantly, some DMARDs and biological therapies used to treat psoriatic arthritis also effectively manage psoriasis, providing a dual benefit.
Surgery
Surgery is infrequently required for psoriatic arthritis. In rare instances, surgical repair of a damaged tendon may be necessary. Joint replacement surgery might be considered in cases of severe joint damage due to long-standing psoriatic arthritis.
If surgery is planned near a psoriatic lesion, antibiotics may be prescribed to prevent infection. While psoriasis can sometimes develop along surgical scars, it can be managed with standard psoriasis treatments.
Conclusion
Managing psoriatic arthritis requires a multifaceted approach, tailored to the individual’s specific symptoms and disease presentation. A range of effective treatments are available, from NSAIDs and steroid treatments for symptom relief to DMARDs and biological therapies that target the underlying disease process. Treatments for psoriasis, including topical medications and light therapy, are also crucial components of comprehensive care. Working closely with your healthcare provider to develop a personalized treatment plan is key to effectively managing psoriatic arthritis, reducing symptoms, and improving long-term outcomes.
