DID YOU KNOW?
- Psoriatic arthritis (sore-ee-AA-tic) is a type of inflammatory arthritis that usually appears in people with a skin disease called psoriasis (sore-EYE-ah-sis).
- Between 10 – 30 per cent of people with psoriasis will get psoriatic arthritis (PsA).
- PsA affects both men and women in equal numbers and usually appears between the ages of 20 and 50.
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.
WHAT IS PSORIATIC ARTHRITIS?
The word arthritis means inflammation of the joint (“arthr” meaning joint and “itis” meaning inflammation). Inflammation is a medical term describing pain, stiffness, redness and swelling.
There are more than 100 types of arthritis. Some are caused by joint inflammation, while others are caused by progressive bone and joint damage. Arthritis is among the leading causes of disability in Canada, affecting more than four million people of every age, physical condition and ethnic background.
Psoriasis is an autoimmune disease that occurs when the immune system becomes confused and decides 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 of skin to much larger areas of the skin. In most people, psoriasis tends to be mild and some don’t even realize they have it at all.
Psoriatic arthritis (PsA) is a type of inflammatory arthritis and an autoimmune disease. In PsA, the joints are the target of the immune attack. This causes swelling, pain and warmth (inflammation) in the joints. In most people, psoriatic arthritis 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 psoriatic arthritis.
PsA usually begins slowly, spreading to other joints over a few weeks to a few months. In rare instances, PsA can develop quickly and be severe. PsA is an unusual type of arthritis because it can look very different from person to person.
Doctors have discovered five general patterns of psoriatic arthritis. In the asymmetric pattern, one of the mildest forms, the psoriatic arthritis affects one to three joints on different sides of the body. In the symmetric pattern, PsA involves many more joints and looks very much like rheumatoid arthritis. In the distal pattern, PsA involves the end joints of the fingers closest to the nails. In the spinal pattern, PsA involves the joints of the spine and the sacroiliac joints linking the spine to the pelvis. Finally, in the destructive pattern, which affects only a few people, PsA is a severe, painful, deforming type of arthritis. This is also known as arthritis mutilans.
PsA can also cause inflammation in tendons around the joints. This is called enthesitis (en-thees-EYE-tis). Some of the common spots for this are the back of the heels, underneath the bottoms of the feet and on the outside of the hips. In other people, PsA can cause the fingers or toes to swell up like sausages. This is referred to as a dactylitis (dac-till-EYE-tis).
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 precedes the psoriatic skin rash. 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. Sometimes PsA starts after an injury to a joint and can be wrongly diagnosed.
- This pain and stiffness is worse in the morning, typically lasting more than 30-60 minutes before the joints “loosen up” and start feeling better.
- However, 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 and some people gain a little weight because they haven’t been as active.
HOW DOES YOUR DOCTOR DIAGNOSE PsA?
There is no single test for psoriatic arthritis. However, it is easier to diagnose if you have psoriasis along with red, swollen fingers or toes, and if your nails and skin are affected along with your joints.
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 perform a physical examination and order other tests, such as blood work and X-rays to help confirm the diagnosis.
Establishing an accurate diagnosis is very important because there are many treatment options to manage the symptoms of PsA.
WHAT DO YOU DO IF YOUR FAMILY DOCTOR THINKS YOU HAVE PsA?
If your family doctor believes you have PsA, you should be referred to a rheumatologist as soon as possible and begin treatment immediately. A rheumatologist is a doctor who is an expert in arthritis.
WHY IS EARLY TREATMENT FOR PsA SO IMPORTANT?
PsA causes inflammation (swelling, pain and warmth) in the affected joints. You can think of this inflammation like a “fire” burning in the joints. If the fire of inflammation is left “burning,” it can permanently damage the joint. Once a joint is damaged, it cannot be fixed with medicine.
Just as you would try to put out a fire in your home with a fire extinguisher before it spreads, you want to put out the fire in your joints as quickly and as safely as possible with the help of your rheumatologist.
To emphasize, PsA can cause permanent joint damage quickly when it is not treated and controlled. This damage can occur even when the pain is not severe. Once damage occurs, it is not reversible and can cause significant pain and disability. Fortunately, we know that much research has confirmed that treating PsA early and aggressively often improves the long-term outcome and significantly reduces damage.
WHY DO PEOPLE GET PsA?
No one knows what causes PsA, but genetics plays a big role. If someone in your family has psoriasis or psoriatic arthritis, there is a greater chance that you will develop it.
To simplify things, let’s again think of the inflammation of PsA like a fire. This time, imagine you’re 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 won’t be able to get the fire started. People who develop PsA have genes (DNA) 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.
However, having genes that predispose to PsA does not necessarily mean you will develop this disease. Something is always needed to trigger it.There are many “triggers” that can start PsA. Unfortunately, we don’t know what that “trigger” is. It could be a viral infection, trauma or something else in the environment. There may be more than one trigger.
We do not yet know the causes or the cure for psoriatic arthritis. The Arthritis Society funds many leading-edge research projectsthat bring vital new insights and lead to new and better treatments for PsA.
HOW CAN I MANAGE PsA?
Once your diagnosis is confirmed, there are many treatments that can help decrease your pain and increase your movement. Non-medication therapies, such as physiotherapy, occupational therapy, education, physical activity and relaxation techniques, are a very important part of the treatment of PsA. While you can perform them on your own, it’s best that you first ask a health-care professional, such as a physiotherapist or occupational therapist, for guidance.
Physical activity protects joints by strengthening the muscles around them. Strong muscles and tissues support those joints that have been weakened and damaged by arthritis. A properly designed program of physical activity reduces pain and fatigue, improves
mobility and overall fitness, and alleviates depression. Physical activity allows someone with arthritis 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.
For more information, refer to The Arthritis Society's Physical Activity & Arthritis Guide [PDF].
Heat and Cold
Heat: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.
Cold: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.
For further details on using heat and cold to manage your arthritis, speak with your health-care team.
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.
Relaxation & 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 tapes. Imagine or visualize a pleasant activity, such as lying on a beach.
Properly caring for your skin will help you manage your symptoms. If you have severe psoriasis, you should see a dermatologist.
Moderate exposure to sunlight can usually benefit those with psoriasis by slowing cell growth. However, too much sunlight can damage your skin, so it is important to take steps to avoid sunburn. Some types of psoriasis may be worsened by UV sun exposure.
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. Proper nutrition is vital to controlling body weight and managing arthritis symptoms.
For more information, read The Arthritis Society's Nutrition & Arthritis Guide [PDF] and watch the Nutrition and Arthritis video.
WHAT MEDICATIONS ARE USED FOR PsA?
The general approach to treating PsA is to reduce joint inflammation and prevent long-term damage to the joints. The cornerstone of therapy is Disease- Modifying Anti-Rheumatic Drugs (DMARDs, pronounced DEE-mardz).
DMARDs are often used in combination with Non- Steroidal Anti-Inflammatory Drugs (NSAIDs) and/or Corticosteroids (steroids). Although NSAIDs and steroids slow down the day-to-day inflammation, they don’t affect the long-term outcome of the disease.
A newer class of medications called biologics has revolutionized the treatment of PsA. These medications, which can be used in combination with DMARDs, also suppress inflammation and help prevent damage to the joint.
Please discuss the use of any arthritis medication with your doctor.
For more detailed information on arthritis medications see Arthritis Medications: A Consumer's Guide [PDF].
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
DMARDs are a class of medications used to treat inflammatory types of arthritis, such as psoriatic arthritis. DMARDs slow down the biologic processes that are the driving force behind the persistent inflammation (pain, swelling and stiffness) in the joints. DMARDs are important because they help to prevent damage to the joint. Doctors know that prescribing a DMARD early on is important to slow or even stop the progression of joint damage, but it cannot fix joint damage that has already occurred.
DMARDs generally work well in most people; however, they do take some time to work. Most DMARDs will start to work in about six to 12 weeks; however, some may take longer – up to three or four months. While you are waiting for the DMARD to work, your doctor might prescribe an additional medication, such as a steroid or an NSAID, to help control the symptoms. Your doctor will recommend a therapy that is best suited to your type and stage of arthritis, other medical problems and medications.
Unfortunately, taking DMARDs carries some risk, which must be balanced against the potential benefits. It is important to recognize that the risk of joint damage and permanent disability is much greater than the risk of side effects from DMARDs used to control the disease. When properly monitored, the vast majority of side effects are rare and most are reversible by adjusting the dose or switching medications.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications used to treat the pain and inflammation of arthritis. They do not contain steroids, hence the name “non-steroidal.” It is important to remember that these medications work to improve symptoms and have no proven long-term success in addressing the process that causes joint damage. As such, these medications can be taken on an as-needed basis and do not need to be taken regularly. That being said, some patients may find it helpful to take their NSAID on a regular basis to control their symptoms. Your doctor will advise you on what is suitable.
Some patients will notice the effects of an NSAID within the first few hours of taking a dose. In other patients, the effects may not be evident for a few days and even up to a week or two after the medicine has been started. If it hasn’t helped within two to three weeks, it is unlikely to be of much benefit. Your doctor might ask you to try a few different NSAIDs, as some may work better for you than others; what works varies from person to person. Waiting for the potential benefits of a better NSAID is not a good strategy, however, since it may delay the beginning of DMARD treatment.
Indigestion, heartburn, stomach cramps and nausea are the most common side effects of NSAIDs. NSAIDs can affect the protective lining of the stomach, making you more susceptible to ulcers and bleeding.
COXIBs are a newer class of NSAIDs that have been developed to reduce the risk of gastrointestinal ulcers and bleeding. Although COXIBs are safer on the stomach, they have all of the other side effects of NSAIDs and may still cause indigestion, nausea, stomach cramps and heartburn. All NSAIDS have the potential to cause fluid retention in the body (edema) and may raise the blood pressure or precipitate heart or kidney failure in some individuals. Speak to your doctor about whether you are at risk for these kinds of side effects.
Cortisone is a hormone produced naturally by the body’s adrenal glands that regulates routine inflammation from minor injuries and infection. Major traumas, such as broken bones or surgery, depend upon the adrenal gland to produce even more cortisone. But the adrenal gland cannot produce enough cortisone to meet the challenge of inflammatory arthritis. In the 1950s, physicians found that giving extra cortisone to patients with rheumatoid arthritis dramatically improved their symptoms.
From this discovery, corticosteroids, also known as steroids, were developed and are some of the oldest, most effective and fastest working medications for inflammatory arthritis. Steroids can be given by mouth, injected into the joint, injected into a muscle or administered through an intravenous drip.
Steroids are often used as interim measures to get control of inflammation while waiting for the slower acting DMARDs to take effect. Steroids work quickly (usually within a few days) and some patients start to feel better within hours of taking the first dose. To maximize benefits and minimize side effects, doctors prescribe corticosteroids in doses as low as possible and for as short a time as possible. Dosages vary widely and are based on your disease and the goals of treatment.
Biologics are a class of medications specially designed to treat inflammatory types of arthritis. There are a number of biologics available that work by different mechanisms. Like DMARDs, biologics are used to suppress inflammation and help prevent damage to the joint.
Biologics are administered in two ways: infusion and injection. Your doctor can provide you with information on the way in which different medications are administered and help make the right choice for you. An infusion means that the medication will be given to you through a needle placed in a vein in your arm. An injection means that the medication will be given by a needle under the skin of your abdomen or thigh.
Biologics are generally successful with most people; however, they can take some time to work. Some people may notice the effects of the medication quite quickly (within days to weeks), while others may take three to six months to feel the effects. Biologics can be combined with DMARDs.
Your doctor will recommend a therapy that is best suited to your type of arthritis, other medical problems and other medications. Your doctor will discuss the benefits of each biologic, how the medication is given and its potential side effects.
Biologics often work by suppressing your immune system, which can make it slightly harder for you to fight off infections. Please inform your doctor if you are prone to frequent infections. It is advisable to stop your medication and call your doctor if you develop a fever, if you have or think you have an infection or if you have been prescribed antibiotics. Any woman who is pregnant or may become pregnant should not take a biologic.
COMPLEMENTARY THER APY
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 exhaust 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.
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.
For further information, refer to The Arthritis Society's Complementary and Alternative Therapies Guide [PDF].
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’s important to remember that surgery is not a treatment for the inflammation of PsA.
W HAT QUESTIONS SHOULD I ASK MY DOCTOR?
Patients who learn more about their treatment program and talk to their doctor about it tend to report fewer symptoms, including less pain and greater mobility.
Be sure to talk with your doctor about your PsA and ask questions about the disease and the different kinds of treatments. Before making a decision, you should understand what you can expect from a medication, what its possible side effects are and other important information. Also, ask what steps you can take to get your disease under control.
To help you get started, here are some common questions you may want to ask your doctor about about PsA treatment:
- What local resources are available so I can better educate myself about PsA ?
- Should I be referred to a physiotherapist or occupational therapist?
- With regard to my medications:
- What are the possible side effects and how often do they occur?
- What should I do to minimize the chances of side effects?
- How can I keep track of the blood test results used to monitor me?
- How will I know if the drug is working, and how long will this take?
- Who do I contact if I have concerns about the medication?
- Are there drugs that I should stop taking now that I am beginning this new treatment?