What Do We Know About Psoriatic Arthritis

You've probably seen the old commercial that talks about "the heartbreak of psoriasis." But it isn't just the skin lesions that create so much trouble for patients. Up to half of all patients with psoriasis develop disabling arthritis. And psoriatic arthritis (PsA) is chronic, inflammatory, and deforming.

In this review article, surgeons from New York University Hospital for Joint Diseases bring us up-to-date on this condition. They discuss causes, symptoms, the diagnosis, and treatment. Complications of medical management and outcomes of treatment are also presented.

Fortunately, psoriasis only affects a small portion of the adult population in the United States (somewhere between 0.6 to less than five per cent). Men and women who develop psoriatic arthritis are usually in their 30s and 40s. Skin changes may appear first but some people notice joint pain, stiffness, and swelling before they break out.

The reason psoriatic arthritis occurs still remains somewhat of a mystery. There is a genetic link for some patients associated with trauma or infection. But exactly why the immune system goes haywire in this fashion is not clearly understood.

Studies show that there are actually five different types of psoriatic arthritis based on clinical presentation. In all cases, the hands are the main area affected but the toes, spine, and sacroiliac joints can also be involved. The different patterns are seen in which joints are affected, whether the condition is symmetric (affecting both hands at the same time), and the severity of the joint destruction.

There is no special blood or lab test that can diagnose the problem. Most of the time, the diagnosis is made based on the physician's examination and observations of the patient. Of course, X-rays clearly show joint erosion, damage, and deformities in the later stages of the disease. X-rays of the hands, feet, and spine are recommended to make sure all areas affected are identified and treated.

Treatment is really a matter of medical management. In fact, it could be said that "it takes a village" to treat psoriatic arthritis. Dermatologists, rheumatologists, medical doctors, and physiotherapists must work together to guide the patient and prevent as much damage as possible.

The specific treatment approach used is individual and based on symptoms and severity of the disease. It is recognized now that early aggressive treatment with medications to control the disease process is important. Medications typically prescribed include antiinflammatories and disease modifying antirheumatic drugs (DMARDs).

New treatment called biologic treatment uses special immune-blocking agents to stop the inflammatory process at different points in the cascade of events leading to the effects of this disease. If there is severe joint destruction and damage, surgery may be needed to reduce pain and improve function. A variety of different surgical procedures can be used including debridement (cleaning the joint of thick tissue and debris), joint fusion, and joint replacement.

A major concern after surgery is skin infection. The skin lesions called psoriatic plaques often harbor bacteria that can lead to wound infections. Complications from infection can lead to further joint destruction and even systemic infection resulting in death.

Studies reporting the long-term results of surgical management of psoriatic arthritis are limited. In general, there appears to be some improvement in pain and function but stiffness and recurrent, progressive disease are common.

For anyone newly diagnosed with psoriatic arthritis (or even someone with long-term disease), this article provides a thorough review of the condition and its treatment. Physicians treating patients with psoriatic arthritis may also find the update helpful. The authors suggest there is a need for future studies to report on the results of treatment to help guide physicians, surgeons, and patients in making the choice that will yield the best outcomes.

Reference: Michael Sean Day, MD, MPhil, et al. Psoriatic Arthritis. In Journal of the American Academy of Orthopaedic Surgeons. January 2012. Vol. 20. No. 1. Pp. 28-37.

Share this page