Psoriatic arthritis progressive
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Psoriatic arthritis is an inflammatory arthritis that occurs in association with psoriasis.
Information from the American College of Rheumatology and the Arthritis Foundation
The exact cause remains unknown although genetic associations have been identified.
The histopathology of psoriatic arthritis is similar to that of other forms of inflammatory arthritis such as rheumatoid arthritis. There does appear to be more T-cell infiltration of the synovium though, than there is with rheumatoid arthritis. However, the cytokines that drive psoriatic arthritis are different from the ones that drive rheumatoid arthritis.
Psoriatic arthritis occurs in 5-25% of patients who have psoriasis. Risk is higher in patients who have a family history of psoriatic arthritis or “pitting” of the fingernails. Patients range in age from 30 to 60. Men and women appear to be affected in equal numbers. However, when psoriatic arthritis involves the spine, men generally tend to be affected about twice as often as women.
Psoriatic arthritis tends to develop after the skin disease has been present. Roughly, 5 per cent of the time it will occur concurrent with the skin disease and 5 per cent of the time it will precede the skin disease.
Five common variants of this disease are seen:
• The most common is an asymmetric inflammatory arthritis that affects small and large joints. Swelling of fingers and toes (sausage digits) are seen.
• A second variant that affects the last row of finger joints (DIP joints) is commonly associated with pitting of the nails.
• The third variant looks like rheumatoid arthritis. It is symmetric but patients often are negative for rheumatoid factor in the blood.
• Spondylitis or inflammation of the spine, the fourth type, is seen in 20% of patients with psoriatic arthritis. About half of these patients will have the genetic marker, HLA-B27.
• Finally, the fifth kind, arthritis mutilans, is a destructive arthritis that affects the hands and feet. It leads to severe deformity and disability.
Psoriatic arthritis tends to come on slowly and progress. It may present as either a peripheral arthritis or may also present as an arthritis affecting the spine... or both.
When psoriatic spine disease occurs, patients will have stiffness, pain, and limited motion in the spine (low back and neck).
Inflammation where the tendon meets the bone (enthesitis) is often seen at a number of sites including the medial knee, anterior knee, the heel, or in the hip.
Psoriatic arthritis usually presents in patients who have had established psoriasis. Sometimes, though, the arthritis may precede the skin disease by many years. The amount of skin psoriasis doesn’t correlate well with the extent of arthritis; however, extensive nail involvement does seem to correlate with the extent of arthritis.
Skin disease may be seen in the scalp, crease between the buttocks, armpits, umbilicus, groin knees, and elbows.
Nail involvement presents as pitting and onycholysis (the nail raises up).
Inflammatory eye involvement is seen in up to 30% of patients.
Laboratory tests will show an elevated erythrocyte sedimentation test (ESR)in many patients with active disease. Joint fluid obtained from an involved joint is inflammatory with many white blood cells.
X-ray changes include soft tissue swelling and erosions. Spinal involvement is indicated by characteristic findings of inflammation involving the sacroiliac joints and bony spurs. Magnetic resonance imaging is more sensitive.
Treatment goals include reduction of inflammation, preservation of function, maintenance of quality of life, and induction of remission.
Non drug therapies include patient education, joint protection, physical and occupational therapy, and vocational guidance.
Skin disease may respond to ointments, ultraviolet light, and drugs such as psoralen.
For the arthritis, non steroidal anti-inflammatory drugs are considered first line therapy,
Low doses of steroids may also be used.
Injecting severely involved joints is helpful.
Disease modifying anti rheumatic drugs (DMARDS) such as those used for rheumatoid arthritis are also used for psoriatic arthritis. Among the more common DMARDS used are sulfasalazine (Azulfidine) and methotrexate.
More recently biologic agents have been used with great success. In fact, simultaneous institution of methotrexate or sulfasalazine and anti-TNF therapy gives the patient with progressive disease a good chance for remission. More targeted therapies aimed at the unique cytokines that drive psoriatic arthritis are undergoing research.
Surgery is indicated for patients with intractable pain or loss of function.
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