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Psoriatic Arthritis

What is psoriatic arthritis?

Psoriatic arthritis (PsA) is a type of inflammatory arthritis that usually appears in people with a skin disease called psoriasis. Between 10 and 30% of people with psoriasis will get PsA. PsA affects both men and women in equal numbers and usually appears between the ages of 20 and 50 years. 

There is no cure for PsA, but when you are diagnosed early and start the right treatment, you can take control of your disease and avoid severe damage to your joints. Most people with PsA can lead active and productive lives with the help of the right medication, surgery (in some cases), exercise, rest and joint protection techniques.

Psoriasis is an autoimmune disease that occurs when the immune system becomes confused and begins to “attack” the skin. This results in red (inflamed) patches of skin, which are covered with a silvery-white scale. Psoriasis can involve only a few small patches to much larger areas of skin. Psoriasis can also develop in finger and toe nails. In most people, psoriasis tends to be mild and some people do not even realize they have it at all. 

PsA is a type of inflammatory arthritis and is also an autoimmune disease. In PsA, the joints are the target of the immune attack. This causes swelling, pain and warmth (inflammation) in the joints; you may also develop back and neck pain. In most people, PsA starts after the onset of psoriasis. Yet having psoriasis does not mean you will have PsA. In fact, most people with psoriasis will never develop PsA. However, those with nail psoriasis are at higher risk of developing PsA.

PsA usually begins slowly, spreading to other joints over a few weeks to a few months. Less commonly, PsA can develop quickly and be severe. PsA is an unusual type of arthritis because it can look very different from person to person.

There are five general patterns of PsA:  

  • Asymmetric  PsA  affects one to four joints on different sides of the body 
  • Symmetric  PsA  involves many more joints and looks very much like rheumatoid arthritis (RA)  
  • Distal PsA  involves the end joints of the fingers closest to the nails  
  • Spinal PsA involves the joints of the spine and the sacroiliac joints that link the spine to the pelvis  
  • Destructive PsA is an uncommon but severe, painful, deforming type of arthritis (also known as arthritis mutilans)  

PsA can also cause inflammation were tendons and ligaments attach to bone. Some of the common spots for this are the back of the heels, underneath the heel, on the sides of the elbows, and on the outside of the hips. In other people, PsA can cause the fingers or toes to swell up like sausages. 

FAQs 

What are the warning signs of PsA? 

As most people who develop PsA already have psoriasis, new unexplained joint pain in someone with psoriasis may be a warning sign. Sometimes arthritis occurs before the skin rash is visible. If any of the following symptoms lasts for more than two weeks, you should see your doctor: 

  • You start to feel unusual pain and stiffness in a joint or joints occasionally with back pain 
  • This pain and stiffness is worse in the morning, typically lasting an hour or more than before the joints loosen up and start feeling better 
  • The pain and stiffness can be with you (to some degree) most of the day, even causing discomfort while you try to sleep at night 
  • Some people notice that they feel more tired when PsA starts 

How is PsA diagnosed? 

There is no single test for PsA. However, if you have joint pain and stiffness together with psoriasis in your skin and/or nails, you may have PsA.  

The symptoms of PsA can be similar to other forms of inflammatory arthritis. In order to rule out other forms of arthritis, your doctor will use a physical examination, blood tests and X-rays (or other forms of imaging such as ultrasound, MRI) to help confirm the diagnosis. Sometimes PsA starts after an injury to a joint and can be wrongly diagnosed. 

Establishing an accurate diagnosis is very important because there are many treatment options to manage the symptoms of PsA.

What are the risk factors for PsA? 

No one knows what causes PsA, but genetics plays a big role. If someone in your family has psoriasis or PsA, there is a greater chance that you will develop it. One way of looking at this is to imagine you are outdoors and you want to start a campfire. You first gather and arrange enough wood and paper for the fire. If you gather lots of dry wood and newspaper, chances are the fire will light. If you gather soaking wet wood, chances are you will not be able to get the fire started. People who develop PsA have genes that “set them up” to get the disease. They have the dry wood and paper that are ideal for lighting the “fire” of PsA. If they have genes like the wet wood, the fire of PsA will not be lit.

How common is PsA? 

About 0.25% of Canadians have or may have PsA, but the exact numbers are unknown. Doctors do know that PsA is diagnosed in about 30% of patients attending psoriasis clinics. PsA is also detected in about 15% of people with psoriasis seen by family doctor.

However, just because you have the genes that set you up to develop PsA does not necessarily mean you will develop PsA. Something is always needed to trigger it (a match, in our campfire example). There are many possible triggers that could start PsA.  It could be a viral infection, injury or something else in the environment, and there may be more than one trigger acting at one time. We do not yet know the causes or the cure for PsA. 

Treatment

Medication 

Arthritis medications are designed to control the disease, slow its progression and help manage pain and improve physical function and quality of life. There is a wide range of options—with new medications being developed—so understanding all possible treatments is not easy.

These medications can be very complex, so you are encouraged to ask for in-depth explanations from your health-care team— including pharmacists, who are an excellent source of information.  

The Arthritis Society has developed a comprehensive expert guide that delivers detailed information on medications used to treat PsA and other types of arthritis. 

EXPLORE: Arthritis Medications – A Reference Guide.

The optimal treatment varies in each individual case— so speak with your doctor and/or pharmacist about what kind of medications are most appropriate for you.

Surgery

Surgery is something that you and your doctor may consider if one of your joints becomes badly damaged and is no longer functioning. Some people with severe, advanced PsA who have not responded to conservative pain management for their damaged joints may benefit from surgery. Benefits include less pain and better movement and function. It is important to remember that surgery is not a treatment for the inflammation of PsA. 

Physiotherapy 

A physiotherapist (PT) can develop an individualized program that's designed to help you increase your strength, flexibility, range-of-motion, and general mobility and exercise tolerance through a wide variety of therapeutic treatments and strategies. These include exercise prescription, physical interventions, and relaxation, in addition to advising you on other techniques for reducing pain and increasing your overall quality of life. PTs can also refer you to other health professionals and community services for further measures that will help you adapt to your changing circumstances.

Occupational therapy

An occupational therapist (OT) trained in arthritis management can analyze everything you do in a day and develop a program to help you protect your joints and minimize fatigue. If necessary, they can help you redesign your home or workplace to make it easier for you to work or simply get around. They can also make or recommend a number of different splints, braces, orthopedic shoes and other aids that can help reduce your pain and increase your mobility and functionality. Their goal is to prepare you, using assistive devices and adaptive strategies, to live as full and comfortable a life as possible.

Self-Management

Physical activity 

Physical activity protects joints by strengthening the muscles around them. Strong muscles and tissues support those joints that have been weakened and damaged by PsA. A properly designed program of physical activity reduces pain and fatigue, improves mobility and overall fitness, and reduces depression. Physical activity allows someone with PsA to have a more productive, enjoyable life. There are different types of exercises that you can do to lessen your pain and stiffness: 

  • Range of motion exercises reduce pain and stiffness and keep your joints moving. To achieve the most benefit, these exercises should be done daily. 
  • Strengthening exercises maintain or increase muscle tone and protect your joints. 
  • Moderate stretching exercises help to relieve the pain and keep the muscles and tendons around an affected joint flexible. 
  • Endurance exercises strengthen your heart, give you energy, control your weight and help you feel better overall. These exercises include things like walking, swimming and cycling. It is best to avoid high-impact exercises like step aerobics, jogging or kickboxing, especially if your joints are sore or stiff. 

Heat and cold  

Taking a warm shower and using warm packs are great ways to help reduce pain and stiffness. Always use a protective barrier, such as a towel, between the warm pack and the skin. Heat is ideal for: 

  • Relieving pain 
  • Relieving muscle spasms and tightness 
  • Enhancing range of motion 

To avoid making symptoms worse, heat should not be applied to an already inflamed joint. 

Using a commercial cold pack or a homemade one (from crushed ice, ice cubes or a bag of frozen vegetables) can be helpful. Always use a protective barrier, such as a towel, between the cold pack and the skin. Cold is ideal for: 

  • Decreasing swelling 
  • Decreasing pain 
  • Constricting blood flow to an inflamed joint 

Protecting your joints  

You should always use your joints in ways that avoid excess stress. This allows you to experience less pain, perform tasks more easily and protect your joints from damage. Techniques to protect your joints include: 

  • Pacing by alternating heavy or repeated tasks with lighter tasks. Taking a break reduces the stress on painful joints and conserves energy by allowing weakened muscles to rest. 
  • Positioning joints wisely promotes proper alignment and decreases excess stress. For example, squatting and kneeling may put extra stress on your hips or knees. When lifting or carrying heavy items, keep items at waist height and avoid carrying them up and down stairs. 
  • Talk to your doctor about seeing an occupational therapist or physiotherapist, who may prescribe splints, braces or orthotics (shoe inserts) to help align and support your joints. 
  • Using assistive devices conserves energy and makes daily tasks easier. Raise seat levels to decrease stress on hip and knee joints. Use a reacher to pick up items from the ground. Use a cane to decrease stress on hip and knee joints. Enlarge grips on utensils, such as spoons or peelers, to decrease stress on delicate hand joints. Other devices to consider include carts for carrying objects and jar/tap openers. 

Skin care 

Properly caring for your skin will help you manage your symptoms. If you have severe psoriasis, you should see a dermatologist. 

Some types of psoriasis may be worsened by sun exposure.  But in most types of psoriasis, moderate exposure to sunlight can reduce symptoms of psoriasis by slowing cell growth. However, too much sunlight can damage your skin, so it is important to take steps to avoid sunburn.  

Relaxation and coping skills

Developing good relaxation and coping skills can help you maintain balance in your life, giving you a greater feeling of control over your arthritis and a more positive outlook. Relaxing the muscles around a sore joint reduces pain. There are many ways to relax. Try deep breathing exercises. Listen to music or relaxation podcasts. Imagine or visualize a pleasant activity, such as lying on a beach. 

Healthy eating  

The most important link between your diet and arthritis is your weight. Being overweight puts an extra burden on your weight-bearing joints (back, hips, knees, ankles and feet). Maintaining an appropriate weight will help you more than any food supplements. If you are overweight and have arthritis, consider a balanced diet as a way to help you achieve and maintain a healthy weight. For others, healthy eating may give you the energy to complete your daily activities. Moreover, losing weight may help reduce the severity of psoriasis. Proper nutrition is vital to controlling body weight and managing arthritis symptoms. 

Complementary therapy

Living with a chronic disease like arthritis can be very frustrating, especially if the medications prescribed by your doctor don’t seem to have the desired effect. In these instances, it can be tempting to try all possible solutions for bringing your pain under control. A popular option for many people with arthritis is complementary and alternative therapies, which are treatments that fall outside the scope of traditional medicine. Examples include naturopathic medicine, special herbs, acupuncture and meditation. These methods are not a substitute for the medications, but may be considered as complementary therapies. 

Before you try any of these treatments, always inform your health-care provider of any complementary and alternative therapies you are taking, receiving or would like to try. Your health-care provider can offer valuable advice about these treatments. 

Massage 

Massaging of muscles and other soft tissues, by a professional massage therapist, may lead to a decrease in stiffness and pain. Other benefits may include a reduction in stress and anxiety as well as improved mobility and overall function of the joints.   

People looking to alleviate their symptoms with massage therapy should first consult with their doctor or rheumatologist in order to determine what type of massage therapy is safest and most effective for their particular condition. For example, many sources suggest that people with arthritis avoid deep tissue massage, or massage performed directly on or near any arthritic points on the body. 

Meditation 

Meditation is a mind-body practice intended to quiet the mind by focusing on your breathing. Some studies have found that meditation, if practiced regularly, can ease pain and anxiety in individuals with PsA. It can also offer people a heightened sense of calmness and control. 

Acupuncture 

Acupuncture, an ancient Chinese therapy, involves pricking the skin or tissues with needles to alleviate pain and treat various physical and mental health conditions. There is some research showing that acupuncture can relieve pain and, in turn, may reduce stress. If you are interested in trying it, it is important to find a certified practitioner. 

What Now

Living well with arthritis

There is a lot you can do to take control and actively manage your arthritis. Below we have listed a few resources to help you learn more about actively managing your arthritis to live better.

Flourish

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Online Learning

Our online courses are jam-packed with helpful tips and information.  Each course is devoted to a specific issue or symptom linked to arthritis.

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Workshops and Webinars

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Navigating Through Arthritis

Learn about information and services available.

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Contributors

This information was last updated September 2017, with expert advice from

Vinod Chandran, MB BS MD DM PhD
Associate Professor of Medicine, Division of Rheumatology, University of Toronto
Staff Physician, Division of Rheumatology, University Health Network

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