Psoriatic arthritis is a condition that causes swelling and pain in and around the joints. It can affect a number of joints including the fingers, wrists, toes, knees, ankles, elbows and shoulder joints, the spine and joints in the lower back (called sacroiliac joints). Psoriatic arthritis also affects tissues surrounding the joints including tendons and ligaments. It may cause a swelling of the whole digit called “sausage” finger or toe. There is also skin inflammation, particularly on the elbows, knees and scalp. Psoriatic arthritis is linked to psoriasis, a disorder causing areas of the skin to become inflamed and be covered with silvery or grey scales.

Psoriatic arthritis causes not only the joints to swell, but also the surrounding tissues (muscles, skin, tendons, ligaments). If you have psoriatic arthritis your fingers or toes may become red and swell, and have a sausage-like appearance. Not all the fingers or toes may be involved. Your nails might also get small holes in them (this is called pitting) or may detach from the skin.

The other common features of psoriatic arthritis include tendinitis (swelling of the tendons) and enthesitis (pain and swelling at sites where tendons and ligaments attach to the bone). Common examples of these conditions are heel spurs, tennis elbow and tendinitis of the Achilles tendon (cord at the back of the heel). Most people with psoriatic arthritis do not have back pain, but if you do, it will probably be worse at night and first thing in the morning, with stiffness gradually decreasing as you become more active during the day.

Psoriatic arthritis will generally develop in one of two ways:

• “Localized” mild psoriatic arthritis develops slowly, with mild symptoms, and affects less than five joints. People with this type of psoriatic arthritis will often live without symptoms for an extended period of time.
• “Generalized” disabling psoriatic arthritis is a more serious form of the disease that affects five or more joints at the same time. This form of the disease will often lead to permanent joint damage and disability, and requires medication early. In severe cases, surgery and rehabilitation may be required.

If your doctor thinks you have psoriatic arthritis, he or she will refer you to a rheumatologist to begin treatment. A rheumatologist specializes in the diagnosis and treatment of problems with joints, muscles and bones.

While no one knows for sure what causes psoriatic arthritis, it is known that heredity plays a big role. Children of parents with psoriasis are three times more likely to have it. If an identical twin has psoriasis, there is a 75% chance the other one will have it too. Up to 30% of people with psoriasis develop psoriatic arthritis.

Other possible causes of psoriatic arthritis are exposure to infection or changes in the environment.

Your doctor will probably be able to more easily diagnose you having psoriatic arthritis if you have psoriasis along with a single or several red, swollen fingers or toes. Usually, if your nails and skin are affected along with your joints, a firm diagnosis can be made.

However, since this form of arthritis is similar to other forms such as gout, Reiter's (pronounced rIt-erz) syndrome and rheumatoid arthritis, your doctor may perform a physical examination and order various tests to assist in diagnosis.  X-rays are often ordered to look for changes to the bone.  Blood and joint fluid tests may be done to rule out other conditions such as rheumatoid arthritis, reactive arthritis or gout.
 
Once the diagnosis is confirmed various treatments can help decrease your pain and stiffness and increase your movement. Treatment of psoriatic arthritis is for both the skin condition and the arthritis. For mild psoriatic arthritis the treatment plan usually is comprised of medication, physiotherapy and daily-living adjustments.  Your active involvement in developing your prescribed treatment plan is essential.

Medicine

Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are a very large category of medications, some of which you can obtain without a prescription, such as ASA (Aspirin, Entrophen, Novasen) and ibuprofen (Advil or Motrin). The list of NSAIDs is long with over 20 currently available today.

It is important to remember that NSAIDs work to improve symptoms and have no proven long term benefits in PsA. As such, these medications can be taken on an as needed basis and donot need to be taken regularly. That being said, some patients find it helpful to take their NSAID on a regular basis to control their symptoms. 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. If you develop signs of stomach bleeding, such as vomit that looks like it has “coffee grounds” in it, vomiting blood, or black, tarry bowel movements, while taking NSAIDs,see a doctor immediately. COXIBs are NSAIDs that have been custom-designed to minimize the risk of stomach problems.

Health Canada has reviewed all of the available studies on NSAIDs and COXIBs and found that NSAIDs and COXIBs are both associated with an increased risk of cardiovascular events angina, heart attacks, and strokes). The risk is greatest in those patients who use these medications for long periods of time and have risk factors for, or a history of, heart disease or stroke.
Please discuss this with your doctor.

Disease-modifying anti-rheumatic drugs (DMARDS)
DMARDs are often prescribed to relieve severe symptoms of psoriatic arthritis. These medications are designed to prevent psoriatic arthritis from getting worse, but do not reverse permanent joint damage. It will usually take several months for DMARDs to make a noticeable improvement in the inflammation.

The most common DMARDs are gold salts, methotrexate, sulfasalazine, leflunomide (Arava®), hydroxychloroquinine, chloroquinine and azathioprine. DMARDs are often given along with other medications such as NSAIDs. Common side effects of DMARDs are mouth sores, diarrhea and nausea.

Corticosteroids
Corticosteroids are man-made drugs that closely resemble cortisone, a hormone natural produced by the body. In RA, these drugs are used to treat extreme inflammation that is accompanied by severe pain and stiffness. They are also used to treat systemic RA, which may affect the lining of the lungs and blood vessels.

Corticosteroids sometimes are given as injection into one or more joints or other areas of inflammation. While eliminating the serious side effects, injections may have their own harmful results on the joints if given more than a few times a year.

The most common form is prednisone, taken in pill form. Side effects from long term use may include cataracts, high blood pressure, sleep problems, muscle loss, bruising, thinning of the bones (osteoporosis), weight gain and susceptibility to infections. The goal with this and most drugs is to find the lowest effective dose that will avoid as many of the side effects as possible. 

Biologic Response Modifiers (“Biologics”)
Biologics are DMARDs that are made up of genetically modified proteins, based on substances that naturally occur in the body. They work by blocking specific parts of the immune system, called cytokines, which play a role in causing psoriatic arthritis. Biologics block one of two important cytokines, either tumor necrosis factor (TNF) or interleukin-1 (IL-1). Several other biologics that interfere with T cells (cells that are important in the immunological response) have been approved for the treatment of psoriasis and some are also effective for psoriatic arthritis.

The Cochrane Musculoskeletal Review Group (CMSG) is a specialized group of researchers and consumer representatives that belong to the Cochrane Collaboration, an international not-for-profit organization that encourages informed decisions about health care by preparing, maintaining and promoting reviews of the effects of various health care treatments.

CMSG members review the best available literature to determine the best evidence to support specific arthritis treatments. They explore the evidence for and against the effectiveness and appropriateness of treatments (medications, surgery, education, etc) in specific circumstances. The results are medical reviews that are then included in The Cochrane Library and made available to health professionals around the world.

For members of the public who also want to be informed about the evidence concerning health care practices and decisions in their lives, the Cochrane Musculosketal Review Group have summarized their reviews into consumer fact sheets. For the Cochrane consumer reviews related to psoriatic arthritis, visit www.arthritis.ca/cochrane.

Along with the physical symptoms of arthritis, many people experience feelings of helplessness and depression. Learning daily living strategies to manage your arthritis gives you a greater feeling of control and a more positive outlook. To get the best results, people affected by arthritis need to form close ties with their doctors and therapists, and become full partners in their treatment. From our perspective, it's all part of 'living well with arthritis.' There are several resources you can use in finding out how best to manage your own arthritis. Here are a few:

• The Arthritis Self-Management Program (ASMP) is a unique self-help program offered by The Arthritis Society to help you better control and manage your arthritis.
• The Open Forum within this Web site is an opportunity to discuss and share information with other visitors - people who, through their own experiences, may be able to offer some useful insights.

Of course, there are many other valuable resources for people with arthritis. If you're unclear about where to look for help, be sure to call The Arthritis Society at 1-800-321-1433.