Psoriatic Arthritis

What is it Psoriatic Arthritis?

Psoriatic Arthritis is defined as an inflammatory condition of the joints (arthritis) associated with Psoriasis. Since in these cases, usually the rheumatoid factor test is negative, Psoriatic Arthritis is called as a sero-negative arthritis. Practically, in addition of all the symptoms of Rheumatoid arthritis, Psoriatic Arthritis also has psoriasis.

Psoriatic Arthritis is an autoimmune disease and it affects the ligaments, tendons, fascia, and joints. Psoriasis is an obstinate skin condition in which red patches of various sizes develop on the skin that is covered with dry, silvery scales.

In psoriasis the skin becomes inflamed and red eruptions appear on the surface of the skin that begins to itch excessively. These areas form thickened areas (plaques) that are covered with silvery scales over the reddened lesions. The skin at the joints may crack.

Psoriasis most often occurs on the elbows, knees, scalp, lower back, palms, and soles of the feet. However, no area of the skin is exempt, including the genital area. The disease may also affect the fingernails and toenails. About 15 percent of people with psoriasis have joint inflammation that produces arthritis symptoms. This condition is called psoriatic arthritis.

When patient’s suffering from psoriasis develops pain, swelling and inflammation in the joints, it is termed as psoriatic arthritis. Any joint can be affected. The small joints, large joints or the spine can get affected. A single or a few joints may get affected, or several small and big joints may be affected. The typical picture is that of a patient suffering from psoriasis from several years suddenly develops acute joint pain and stiffness, thereby announcing the arrival of Psoriatic Arthritis. Many patients develop arthritis after several years of suffering from psoriasis but a few patients develop arthritis in the early stage of psoriasis.

Patients with extensive psoriasis have more chances of developing psoriatic arthritis. However, mild cases of psoriasis may also present with psoriatic arthritis. Also, it is not a rule that all the cases of psoriasis will have psoriatic arthritis.

Some patients after using steroidal creams for psoriasis may see good relief in the skin, but may subsequently develop arthritis, as the disease goes deeper due to suppression of skin eruptions.

Some patients can develop psoriatic arthritis even with a mild form of skin psoriasis. And a few patients can develop psoriatic arthritis in the absence of psoriasis on the skin. (Seen in around 10 % cases)

In most patients it is of a mild to moderate severity, but some patients will present with severe pain, restriction of movements, difficulty in walking and disability. In the severe forms, one can see deformity and destruction in the joints.
Flares and remissions usually characterize the course of psoriatic arthritis. Winter, Stress and infections are likely to aggravate the condition.

  • Sex: Men and women are affected equally; men are more likely to be affected by the spondylitic form of psoriatic arthritis and females are more likely to be affected by the rheumatoid form.
  • Age: Psoriatic arthritis characteristically develops in persons aged 35-55 years, but it can occur in persons of almost any age.

The Psoriatic Nail

About 50 percent of persons with active psoriasis have psoriatic changes in fingernails and/or toenails. In some instances psoriasis may occur only in the nails and nowhere else on the body. Nail changes in psoriasis fall into general categories that may occur singly or all together:

  • The nail plate is deeply pitted or depressed
  • The nail has a yellow to yellow-pink discoloration
  • White areas appear under the nail plate. There may be reddened skin around the nail.
  • The nail plate crumbles in yellowish patches (onychodystrophy)
  • The nail may be entirely lost

Causes of Psoriatic Arthritis

Approximately 40% of patients with psoriasis or psoriatic arthritis have a family history of these disorders in first-degree relatives.

Psoriatic arthritis is associated with an increased frequency of HLA-B7.

Psoriatic arthritis may be triggered by pro-inflammatory cytokines such as Tumor necrosis factor-alpha (TNF-a) and Interleukin IL-1, IL-6, Il-2 and IL-8.

Psoriatic Arthritis is immunologically medicated disease which has some genetic links, which could at times be triggered by long-term emotional stress.

Symptoms of Psoriatic Arthritis

The most common picture is of a patient suffering from Psoriasis starts experiencing pain and stiffness in the joints. The stiffness is most marked in the morning or after rest. The stiffness may be worse in initial movements but may gradually reduce with continuous movements or as the day progresses.

The symptoms may be of varying severity, ranging from mild, moderate or severe. The patient may experience pain in the ankles, knee, elbows or shoulders or the back.

Some times the pain and swelling may be severe and incapacitating, causing restriction in movements, with the affected joint looking, red, hot and inflamed. Some times only one or two small joints of the finger or toes may be involved, but presenting with swelling of the entire digit, giving them the appearance of a, “sausage”. The characteristics of Psoriatic Arthritis are asymmetrical joint affections.

Psoriatic arthritis can also cause inflammation of the spine (spondylitis) and the sacrum, causing pain and stiffness in the low back, buttocks, neck and upper back. Psoriatic spondylitis is more common in men. Around 50 % of these patients have spondylitis and 50 % suffer from sacroilitis.

The back disease is usually slowly progressive with little radiological deterioration as compared with Ankylosing Spondylitis.

Nail changes are commonly seen in psoriatic arthritis. Pitting and ridges are seen in finger and toe nails of 80% of patients with psoriatic arthritis.

Clinical Symptoms

Psoriatic arthritis may be present with or without obvious skin eruptions, with minimal skin eruptions or with only nail deformity.

In some patients arthritis appears before psoriasis; in these cases one may detect a family history of psoriasis. Some times psoriasis of the scalp may have passed off as dandruff.

Inflammation at the sites where tendons and ligaments attach to the bone is a characteristic of Psoriatic Arthritis. The enthesis is composed of fibrocartilage and collagen and it aides to absorb and dissipate mechanical stress. Psoriatic Arthritis chiefly affects this site, where the tendons and ligaments attach the bones, and here, it becomes different from Rheumatoid Arthritis.

Patients with psoriatic arthritis can also develop inflammation of the tendons (tendonitis) and around cartilage. Inflammation of the tendon behind the heel causes Achilles tendonitis, leading to pain with walking and climbing stairs. Inflammation of the chest wall and of the cartilage that links the ribs to the breastbone (sternum) can cause chest pain, as seen in costochondritis.

Initial symptoms may be acute. When localized to the foot or toe, symptoms may be mistaken for gout. Around 5 % patients of psoriatic arthritis may have an associated raised serum uric acid.

Types of Psoriatic Arthritis

  1. Asymmetrical Oligoarticular Arthritis: this is the commonest type and seen in 60 % patients up to five small joints are involved. The affection of joints is asymmetrical and involves a few scattered distal interphalangeal (DIP), proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints, knees, ankles and feet. They are often associated with dactylitis, which presents with diffuse swelling of one or more finger and toes in a sausage digit configuration. This diffuse swelling is due to the intense and diffuse inflammatory changes that occur in the joints and soft tissues, and is not present in RA.
  2. Symmetrical Polyarthritis: The hands, wrists, ankles, and feet may be involved.
    It is differentiated from rheumatoid arthritis (RA) by the presence of distal interphalangeal (DIP) joint involvement, the relative asymmetry, the absence of subcutaneous nodules, and a negative test result for rheumatoid factor. This condition generally is milder than RA, with less deformity.
  3. Distal interphalangeal Arthropathy: DIP joint involvement is considered classic and unique to psoriatic arthritis; it occurs in around 5-10% of patients, primarily men and is characterized by inflammation and stiffness in the joints nearest to the ends of the fingers and toes. Digits affected have characteristic psoriatic nail changes. These patients may or may not have skin lesions of Psoriasis.
  4. Arthritis Mutilans: This is a very destructive form of arthritis, which can cause rapid damage to the joints.
    It affects 5 % of all cases of Psoriatic Arthritis. Resorption of bone (osteolysis) with dissolution of the joint, observed as the “pencil-in-cup” radiographic finding is most commonly seen in the fingers and toes.
  5. Spondylitis with or without sacroiliitis: Clinical evidence of spondylitis, sacroiliitis, or both can occur in conjunction with other subgroups of psoriatic arthritis. Spondylitis may occur without radiological evidence of sacroiliitis, which frequently tends to be asymmetric, or it may appear radiological without the classic symptoms of morning stiffness in the lower back. Thus, the correlation between symptoms and radiological signs of sacroiliitis can be poor. Vertebral involvement differs from that observed in Ankylosing Spondylitis. Vertebrae are affected asymmetrically, and the atlantoaxial joint may be involved with erosion of the odontoid and subluxation.
  6. Juvenile Psoriatic Arthritis: Juvenile psoriatic arthritis affects 10-20 % of children suffering from arthritis and is monoarticular at onset. The mean age of onset is 9-10 years. The disease is usually mild, although occasionally it may be severe and destructive. In patients presenting with an undefined seronegative polyarthritis, looking for psoriasis in hidden sites such as the scalp (where psoriasis is frequently mistaken for dandruff), perineum, intergluteal cleft (the groove or crack between the buttocks) and umbilicus is extremely important.
  7. Nail involvement includes the following:
    • Onycholysis: Onycholysis is the gradually and painless separation of the nail plate from the nail bed. The nail gets lifted from its bed at its end and presents an irregular border between the pink portion of the nail, the white outside edge of itself and a greater portion of the nail is opaque. In some rare cases of Onycholysis the spontaneous nail plate separation can be confined to the nails lateral borders although it usually starts at the distal free margin and progressing proximally.
    • Transverse ridging, and
    • Uniform nails pitting; are 3 features of nail involvement that should be noted. When skin and joint disease begin simultaneously, nail involvement is frequently present at the onset. Nails are involved in 80% of patients with psoriatic arthritis but in only 20% of patients with uncomplicated psoriasis. Severe deforming arthritis of the hands and feet is frequently associated with extensive nail involvement.
  8. Ocular involvement may occur in 20% of patients with psoriatic arthritis, including conjunctivitis in 20% and acute anterior uveitis in 7%. Uveitis should be managed by an ophthalmologist.

Diagnosis of Psoriatic Arthritis

The diagnosis of Psoriatic Arthritis is mostly clinical and based on the history. Most patients are likely to he known cases of psoriasis and at a later stage experience involvement of joints. The hallmark of Psoriatic arthritis is asymmetrical pattern of digit involvement. Interphalangeal joint involvement is characterized with sausage appearance of the digits (dactylitis). The inflamed joints are swollen and have a purplish- red discoloration. Along with the joint inflammation, psoriasis may be visible on the skin of the joints. The nail changes may be observed in many patients.

Conventional Treatment for Psoriatic Arthritis

The conventional treatment of psoriatic arthritis consists of:

  1. Non-steroidal anti-inflammatory drugs (NSAID’s): They do not modify the course of the disease, nor do they prevent erosions, but they are effective to relieve pain and stiffness.
  2. Disease-modifying antirheumatic drugs (DMARD’s) such as Methotrexate and Cyclosporine. Methotrexate is effective both for psoriasis and psoriatic arthritis. One has to take folic acid supplements along with it to safe guard the liver. One requires frequent monitoring of liver function tests, while on Methotrexate.

Side effects of Methotrexate:

  1. Biological agents (Etanercept, Infliximab) these are Anti-TNF agents and are in advanced clinical trials.
  2. Systematic corticosteroids are very effective in the acute flare ups, but have potential side effects for long term application.
  3. Physical therapy is invaluable importance in several cases.
  4. Reconstructive surgery is required in selective cases with end stage joint destruction.

Investigations for Psoriatic Arthritis

The Erythrocyte Sedimentation Rate (ESR) is elevated. Serum Uric Acid may be elevated in a few patients. Anti Nuclear Antibodies (ANA) and Rheumatoid Factor (RA) are usually negative.

X-Ray Findings

The DIP joints of fingers and the interphalangeal joints of the toes show erosions.

Bony Ankylosis of the DIP joints of the hands and the toes, along with bony proliferations of the base of the distal phalanx, and Resumption of the tufts of the distal phalanges of the hands and feet are seen.

Fluffy periostitis of the large, “pencil in cup” appearance of the DIP joints, absence of symmetry and gross destruction of isolated small joints is also seen.

Radio graphically, spine changes and sacroilitis joint changes appear similar as in Ankylosing Spondylitis, but are often unilateral in Psoriatic Arthritis.

Magnetic Resonance imaging (MRI) is more effective to detect enthesites and early articular and periarticular involvement.

Adverse effects of Cyclosporine

Cyclosporine is a immunosuppressant drug widely used in post-allogeneic organ transplant such as kidney, liver or heart to reduce the activity of the patient’s immune system.

Cyclosporine is a conventionally used medicine for autoimmune diseases such as Psoriasis, Rheumatoid arthritis, Crohn’s disease, Nephrotic Syndrome, etc. where the patient does not respond to the treatment with corticosteroids or methotrexate.

Cyclosporine is a very good immune-suppressive medicine but makes the patient susceptible to infection including cancer such as lymphoma.

The adverse effects could be listed as.

Adverse effects, which require immediate medical help (alarming signs), are:

  • Hypertension: Above 50% of patients taking cyclosporine develops high blood pressure. Known case of hypertension has a risk of developing heart disease.
  • Kidney Dysfunction:Scanty urine presenting as decreased frequency of urination or no urine at all.
  • The risk of both these problems increases with higher doses and longer treatment with cyclosporine.
  • Allergic reactions presenting as hives, swelling of face lips and throat or difficulty in breathing.
  • Seizure (convulsion)
  • Tachycardia (fast heart rate), muscle weakness or pain
  • Flu like symptoms as fever chills and sore throat
  • Jaundice presenting as yellowing of skin and sclera, dark urine, nausea, clay colored stools.
  • Drowsiness, confusion and mood changes
  • Easy bruising and bleeding
  • Swelling and weight gain
  • gum disease or overgrowth

Less serious side effects include

  • Abnormal Hair Growth: Both men and women may develop hair growth in abnormal amounts on the face, chest and arms.
  • Nausea and diarrhoea
  • Tremor: Above 50 % people develop tremors characterised by shaking. Leg cramps or muscle contractions might also be experienced.

Special precautions before starting Cyclosporine

  • A person suffering from any kidney disease, uncontrolled hypertension or cancer are not eligible to take this drug.
  • Psoriasis patients who have had certain previous treatments like PUVA, UVB, coal tar, radiation therapy, methotrexate,etc are at higher risk to develop skin cancer.
  • Any “live” vaccine taken while you are being treated with cyclosporine will not be effective.
  • There are many other medicines like vitamins, minerals, etc. which can cause serious medical problems if you take them together with cyclosporine.
  • Do not start using any new medication without informing your doctor.
  • Safest way is to keep a list of all the medicines you use and show this list to the doctor.
  • Avoid eating grapefruit or drinking grapefruit juice.

Psoriatic Arthritis: Adverse effects of Cyclophosphamide

Cyclophosphamide is a powerful drug which can stop the process of cell division irrespective of which phase of cell division is in progress. Adverse reactions of Cyclophosphamide can be serious or ‘not-so serious’. There are a few life-threatening adverse effects as well. It may be noted that all the patients receiving Cyclophosphamide may not produce all the adverse effects of it. The most commonly encountered adverse reactions fall in the ‘not-so-serious’ group. Some of them are:

Digestive System
  • Poor appetite.
  • Nausea and vomiting.
  • Inflammation of the oral cavity (stomatitis).
  • Pain in abdomen accompanied by diarrhea.
  • Constipation.
  • Ulcers in the oral cavity as well as in the large intestine.
  • Bloody diarrhea with jaundice.
  • Elevated levels of liver enzymes.
Urinary System
  • Inflammation of the urinary bladder.
  • Fibrosis of the urinary bladder.
  • Inflammation of the urethra causing blood in urine.

Blurred vision with headache and dizziness

  • Wide spread skin rashes.
  • Nails and skin show pigmentation.
  • Sudden formation of blisters (Steven-Johnson Syndrome)
  • Necrosis (death of the skin tissue).
  • Jaundice (yellow discoloration of the skin).
  • Moderate to severe forms of hair loss.
Blood and Circulatory System
  • Reduced production of neutrophils (a form of white blood cells which fight against infections). This can result in frequent fevers and infections.
  • Reduced production of thrombocytes (cells responsible for blood clotting).
  • Occasionally anemia (reduced hemoglobin in the red blood cells) is seen in people receiving cyclophosphamide.Decrease in the actual number of white blood cells (leucopenia)
Respiratory System

Inflammation of the lung tissues that ultimately result in fibrosis.

Some of the more serious adverse effects of this drug are as follows:

  • This drug has proven harmful to the fetus when given to pregnant women.
  • There are incidences where it has resulted in infertility in both men and women.
  • Even in non-regnant women, the drug can cause menstrual irregularities or even suppress the menses for months together (amenorrhea).
  • It can also lead to the fibrosis of the ovaries.
  • Cancers of the kidney (in particular, the renal pelvis) have been reported.
  • Inflammation of the urinary bladder and urethra causing bloody urine which can lead to serious blood loss.
  • Inflammation of the blood vessels supplying the brain has been reported.
  • Cyclophosphamide can lead to inflammation of the heart muscles which can eventually lead to congestive heart failure.

Psoriatic Arthritis: Adverse effects of Methotrexate (Conventional Medicine used for Psoriasis and other Diseases)

What is Methotrexate?

Methotrexate is a conventional medicine used for diseases such as cancer, autoimmune diseases, Psoriasis, Ankylosing Spondylitis, rheumatoid arthritis, Crohn’s disease, etc. It is administered either oral or by injection. Usually, it is supposed to be administered after failure with milder medicines.

What are the adverse effects of Methotrexate?

Methotrexate being a strong chemotherapeutic agent, produces a range of adverse effects in different patents. It may not produce all the side effects in all the users. Some of the adverse effects can be extremely severe and even life-threatening.

The adverse effects could be listed here:

  • Mouth: Inflamed gums, inflamed stomach, ulcers in mouth, loss of appetite, nausea, vomiting, diarrhea, bleeding from stomach and intestines, inflamed pancreas.
  • Blood, bone-marrow and lymphatic system: Anemia, aplastic anemia, low white cells, low platelets cells.
  • Heart and cardiovascular system: Inflammation of heart’s outer layer (Pericarditis), low blood pressure, thromboembolic such as arterial thrombosis, cerebral thrombosis, deep vein thrombosis, thrombophlebitis, and pulmonary embolus.
  • Brain and CNS: Vertigo, temporary blindness, Headaches, drowsiness, speech disorder, convulsions.
  • Infections: Use of Methotrexate may make one prone to certain infections such as pneumonia, sepsis, nocardiosis; histoplasmosis, cryptococcosis, Herpes zoster, Herpes simplex, hepatitis, etc.
  • Eye related: Conjunctivitis, blurred vision
  • Lungs: Pulmonary fibrosis, lung failure, pneumonitis
  • Skin: Erythematous skin rashes, itching, urticaria, photosensitivity, pigmentary changes, alopecia, ecchymosis, telangiectasia, acne, furunculosis, erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson syndrome, skin necrosis, skin ulceration, and exfoliative dermatitis.
  • Kidney: Kidney failure, inflamed bladder, bleeding from urinary tract, defective sperm formation
  • Hormonal: Menstrual dysfunction, vaginal discharge, enlargement of breast in males (gynecomastia), infertility, abortion, fetal defects, etc.
  • Others: Inflamed joints and veins, loss of libido (lack of sex desire), diabetes, osteoporosis, sudden death, lymphomas, soft tissue necrosis and osteonecrosis. Anaphylactic reactions, etc.

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