Psoriatic Arthritis
About Psoriatic Arthritis
For you or a loved one with psoriatic arthritis, this section goes into the medical treatment methods and alternative therapies available. Perhaps most importantly, though, it emphasizes the importance of a support network and empowers people with practical things they can do to make it easier to live with the condition.
What is psoriatic arthritis?
Psoriatic arthritis (PsA) is a long-term disease that affects both the joints and the skin.
- PsA in joints: psoriatic arthritis causes pain and swelling in the membranes that hold together and protect the bones in your joints. This can bend and stretch the tendons and ligaments, and eventually harm the bone and cartilage in your joints as well. PsA can also affect other body organs and tissues.
- PsA in skin: psoriatic arthritis causes skin lesions or plaques - patches of dead skin - that can appear to be rough, dry and thick as dead skin builds up, red and irritated with silvery scales and a distinct border between the plaque and normal skin. Sometimes the lesions itch, burn, or bleed. Patches are most often seen on the elbows, knees, and torso, but can appear anywhere, including the scalp. Fingernails and toenails can also be affected - nails become thickened, lift up from the skin or become pitted (small holes form in them).
Affecting less than 1% of the population (US data), psoriatic arthritis is a chronic disease, meaning once it starts, it likely persists life-long. Symptoms usually come and go in waves, and though we don’t yet know what triggers PsA or how to cure it, we do know about the types of psoriatic arthritis symptoms, how to treat symptoms, and how the disease progresses.
What causes psoriatic arthritis?
Psoriatic arthritis is caused by a malfunction of the immune system, in which your immune system mistakenly attacks healthy cells in your own body, in this case your joints and skin. Scientists are not sure why this happens, but the nature of PsA puts it in the category of “autoimmune diseases”.
Scientists are studying the potential causes:
- Genetics: some people have genes that set them up to develop psoriatic arthritis - although carrying these genes is not enough to develop the disease
- Triggering event: the condition is set off when the body reacts to a stressful period in life, an infection, or something else in the environment
- Family link: someone who has a relative with PsA is at higher risk of developing the disease
- Psoriasis first: up to 40% of people with psoriasis develop psoriatic arthritis. Most have psoriasis for about 10 years before PsA develops
- Arthritis is a term used to describe a family of more than 100 different conditions ranging from mild to serious.1,2
- Psoriatic arthritis (PsA) affects under 1% (0.16%) of the population (US data).3
- PsA affects men and women equally.1
- PsA can begin at any age, including in childhood, but is usually diagnosed between the ages of 20 and 50.1
- Between 10% and 30% of people with psoriasis develop PsA.1,2
- Only about 15% of people have arthritis before psoriasis appears, which then changes their diagnosis to PsA.4
- PsA is an unusual form of arthritis that can appear very differently from one patient to the next.1
- According to a University of Toronto study, half of people with psoriatic arthritis feel some fatigue and close to 30% experience severe fatigue.5
References:
- The Arthritis Society. 2015.
- Arthritis Foundation. 2015.
- Liu J-T et al. Psoriatic arthritis: Epidemiology, diagnosis, and treatment. World J Orthop 2014;18; 5(4):537-543.
- MedBroadcast. Psoriatic arthritis. 2016.
- Husted JA et al. Occurrence and correlates of fatigue in psoriatic arthritis. Ann Rheum Dis 2009;68(10):1553-1558.
What are the effects of psoriatic arthritis?
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Inflammation is a natural process that your body normally uses to protect itself from harm. Inflammation is behind the pain and swelling you feel from:
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Joints or areas of skin affected by psoriatic arthritis may become red, swollen and painful, and feel hot or warm to the touch: this is called inflammation. The joints of people with PsA also get stiff, especially in the first hours after waking up.
The symptoms of psoriatic arthritis tend to change over time, and appear differently in each person. People with PsA often suffer from a cycle of very painful periods of time - flares - followed by periods when the symptoms disappear, called remissions.
Pain can be mild or extreme, the period when symptoms appear can be short or very long, and the length of time between flares can range from weeks to years.
If inflammation from psoriatic arthritis is left untreated, it can eventually lead to joint deformities and severe stiffness that make daily activities difficult. PsA is a form of arthritis in which joint damage can appear particularly quickly.
Fortunately, there are many ways to treat psoriatic arthritis and prevent damage before it happens.
Psoriatic arthritis usually begins slowly, in one or a few joints, and spreads to other joints over weeks or months. Skin and joint symptoms often appear at the same time.
PsA psoriasis can appear anywhere on the body, but is most often seen on:
- Elbows
- Knees
- The lower back
- The scalp
Psoriatic arthritis truly can look very different from person to person. It is impossible to predict how it will affect you — some people have skin problems worse than the arthritis; in others, it may be the opposite.
It is common in psoriatic arthritis to see nails become rough, ridged, and thick, and for fingers to become swollen and “sausage-looking” — called dactylitis. Nail changes like pitting, splitting, cracking, and separating from the skin are also common. Over time, joints in the hands may change shape, lock, or fuse together. The toes can be similarly affected.
In addition to the joints, PsA can cause swelling in tissues around them, like muscles, skin, or tendons and ligaments. This is called enthesitis. It occurs in about one in five people with psoriatic arthritis, most often in the elbows, heels, the bottom of feet, and the outer hip area.
In up to a third of people with PsA, swelling of eye muscles and tissues, called uveitis, also occurs. Conjunctivitis, or red eye, is also common.
Are there other symptoms?
Psoriatic arthritis doesn’t just affect the joints - it sometimes also brings on flu-like symptoms:
- Feeling extremely tired
- Feeling generally ill
- Having a low fever
- Losing your appetite
- Losing weight
Support means everything
No man is an island: in other words, it is not helpful to try to live with psoriatic arthritis by yourself. Your friends and family can help, along with your treatment team of health care professionals.
Living with any chronic disease can make you feel isolated – especially when you have to adapt or change your daily routine, see many health care practitioners, and learn medical terms. But you don’t need to do it alone.
When you have psoriatic arthritis, it’s invaluable to keep the lines of communication open with your family, friends and coworkers: they can’t understand what it’s like to live with PsA if you don’t talk openly about it.
Here are some tips and helpful insights we’ve learned from PsA patients:
- Ask those closest to you to learn about your condition. This way they’ll understand your symptoms, or even go with you to your appointments. They can read this or other web sites, or consult reliable sources like libraries, or the Canadian Arthritis Society.
- Let them know you need their support. This could be just a sympathetic ear when you need to talk. Be sure to tell them that inflammatory diseases always have good and bad days.
- Always be open and honest about your PsA. It’s the only way people can help you. Remember, if you’ve ever told a friend or family member, “You don’t know what it’s like”, that’s maybe because you haven’t told them.
When we stop doing the things we love, our mood drops, symptoms seem worse, and it becomes even harder to get motivated. Keeping fun in your life is absolutely essential - make it a top priority. It boosts your mood, your relationships, and your energy level. Find one activity you love - even a small one - that you can add to each week without fail, and one you can add to each day. Once they become routine, you'll start feeling better and will want to add more.
Psoriatic arthritis is different for every patient, and treatment must be tailored for each individual case. The key is to communicate regularly with your doctor about your progress and the effects of your treatment, and to follow your treatment instructions every day, as medication can take time to work. If you feel there’s a problem with your regimen, or are experiencing any side effects, talk to your doctor right away about trying alternative methods. Don't hesitate to ask questions and get involved in decision-making regarding your health. And keep in mind there are many options available to you, so if one approach isn’t working, another one just might.
There are independent patient associations and organizations that may be able to help you learn more.
Learn moreLifestyle options
If you have psoriatic arthritis, there are many things you can do to ease your symptoms. Moderate exercise, soothing skin care routines, healthy eating and relaxation techniques are all important factors in caring for your skin and joints. Ask your health care professional if you’re unsure.
Exercise doesn’t make stiff and painful joints feel worse. In fact, a bit of moderate exercise may be just the trick to relieving joint tension. And physical activity strengthens muscles and tissues, so weakened or damaged joints are better supported.
To keep exercising fun:
- Know your limits and trust your instincts on the amount of exercise your joints can handle
- Start slowly if you haven’t been active for a while
- Don’t overwork your muscles
Try smooth, low-impact activities like stretching, swimming, tai chi or light yoga. Always make sure that you don’t overdo it. For extra motivation, you can ask a professional to design a fitness regimen. Be sure to tell them about your condition, so the routine will be right for you.
Proper skincare will help you manage some psoriasis symptoms. To soothe your skin:
- Soak up a little sun: moderate exposure to sunlight usually helps by slowing the growth of skin cells. However, too much sun damages your skin, so always use sunscreen. Be aware that in rare cases, UV exposure makes some types of psoriasis worse
- Control air humidity: use a humidifier to prevent dry air, which can aggravate psoriasis, especially in winter
- Moisturize: keep your skin moist with topical creams and lotions that contain cocoa butter, lanolin, petroleum jelly, light mineral oil or baby oil
- Avoid irritating products: don’t use strong soaps and moisturizers that contain perfumes or chemicals
- Take daily baths: gently washing your skin every day helps to remove dead skin and calm inflammation
- Use medicated creams and ointments: your pharmacy has non-prescription products that can help reduce itching and scaling. For scalp psoriasis, try a medicated shampoo. Always follow label directions and your doctor’s advice
Imagine the extra strain it would put on your joints to carry around a heavy backpack and suitcases all day long. Extra body weight can have the same damaging effect.
If you have psoriatic arthritis, maintaining a healthy weight is the main reason to watch what you eat. Losing just a few pounds can mean big stress relief on your knees and other joints. Choose nutrient-packed foods for optimal health and energy.
Protect your joints from damage by making a few changes to daily activities:
- Protect your knuckles - use gadgets to twist open lids, enlarge the grip on tools and kitchen utensils, and push doors open using your body instead of just your fingers
- Lift big pans and other heavy objects with two hands, and carry them close to your body
- Use a reacher to pick up items from the ground, or a cane to decrease pressure on a knee or hip
- Use a computer wisely: make sure your neck, wrists and lower back are in relaxed and neutral positions. Take a break and stand up every half hour or so
- Balance periods of activity and rest: neither sitting nor standing all day is good for you
- Pick a raised seat to decrease stress on hip and knee joints.
One of the symptoms of psoriatic arthritis is extreme tiredness, and dealing with pain can be exhausting. Even so, it’s important to keep up some level of activity and movement. Prevent strain by alternating between demanding activities and easier ones. The key is to rest and take breaks, and listen to what your body is telling you.
Stress can lead to an increase in blood pressure, interrupt sleep, and play a role in the intensity of psoriatic arthritis symptoms. The first step is identifying stress triggers - then developing relaxation and coping skills to improve your overall wellbeing and give you a greater sense of control over your psoriatic arthritis.
Complementary therapy options
For some people, complementary and alternative therapies - treatments that fall outside the scope of traditional western medicine - can sometimes work very well for relief of arthritis and psoriasis symptoms. Ask your health care professional about alternative therapies.
Both heat and cold can help reduce pain associated with psoriatic arthritis, but there are instances when it’s better to avoid them.
- Heat: Stiff joints can benefit from a bit of heat, including first thing in the morning. Take a warm shower or hot bath, or apply warm compresses to help relax the muscles and relieve joint stiffness and pain. However, heat should never be applied directly to joints that are swollen or already warm. This will make symptoms worse.
- Cold: Applying a cold compress (or a plastic bag of ice cubes wrapped in a towel) to hot and inflamed joints for about 15 minutes can help constrict blood flow, and decrease the pain and swelling. Cold can make a joint feel stiffer, however, so don’t use it on already stiff joints.
Omega-3 fatty acids (fish oil) supplements may reduce inflammation associated with psoriasis. Vitamin E is also thought to benefit skin and nails. Talk to your health care professional for more guidance.
Some people add natural relief therapies to their medical treatments for psoriatic arthritis, such as acupuncture, acupressure, Swedish or “classic” massage therapy, vitamin or mineral supplementation (e.g. glucosamine), or biofeedback (with or without hypnosis). Always first discuss these treatment options with your physician, and be sure to tell any alternative health specialist about your condition in order to avoid injury.
Surgery
You and your doctor may consider surgery if medical therapies are not working well enough for you. In severe or advanced cases of psoriatic arthritis, it can return function to a badly damaged joint or restore posture in the spine and neck. Back surgery is reserved for only the most severe cases, where deformities prevent almost all normal movement. The decision usually depends on the amount of pain and disability in the affected joint. Surgery can sometimes improve the appearance of deformed joints. Or, doctors may perform surgery to get a closer look at the damaged joint to better understand how to treat it.
Medical treatments
The general approach to treating psoriatic arthritis is to reduce joint inflammation and prevent long-term damage to the joints, as well as to manage outbreaks of psoriasis. Psoriatic arthritis medications are divided into two general categories: those that relieve symptoms and inflammation, and those that can relieve symptoms and modify progression of the disease. Psoriasis medications relieve symptoms and inflammation, and interrupt the cycle of increased production of skin cells. Some medications can have a positive effect on both arthritis and psoriasis.
Your doctor can explain the differences, benefits and side effects of each medication. You will likely try different therapies or combinations before finding the best prolonged pain relief.
Four types of medication are used to treat the symptoms of arthritis in PsA.
Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications that can be used to treat the pain and inflammation of PsA. NSAIDs do not control the disease, they only treat symptoms. Therefore, they are only taken on an as-needed basis.
Your doctor may recommend an NSAID to reduce swelling and relieve joint pain, tenderness, and stiffness. You may start to see benefits within a few weeks.
There are many NSAIDs available, including prescription and non-prescription types. All NSAIDs have an anti-inflammatory effect. Each person reacts differently to different drugs, so you may find that one NSAID brings you more relief than another.
The most common side effects associated with NSAID use are indigestion, heartburn, and stomach and abdominal pain. They can also alter the protective lining of the stomach and gut, making you susceptible to ulcers and bleeding, so you should avoid taking more than two different kinds of NSAIDs together. COX-2 inhibitors are custom-designed types of NSAIDs that minimize the risk of ulcers and bleeding. People with heart disease, or a history of stroke or chest pain, should not take NSAIDs. Discuss the use of NSAIDs with your doctor if you have kidney, stomach or heart problems.
The body naturally produces cortisone and other steroids to regulate inflammation in the body. Physicians use corticosteroids as fast-working medication for particularly severe and painful symptoms of psoriatic arthritis. They provide the same type of relief as NSAIDs, but are stronger, and not meant for chronic or long-term use. They can have severe side effects, so they are usually taken for limited periods of time, or used to provide relief while waiting for slower acting medications to take effect.
Corticosteroids can be injected directly into a joint or taken orally. Some of the side effects of oral corticosteroids include facial rounding, fluid retention, fatty deposits in arms, legs or back, increased appetite and weight gain, difficulty sleeping, acne, hair growth, blurry vision, increase in blood pressure, increase in blood sugar levels, and mood swings. As dosage is decreased or stopped, these side effects disappear.
Disease-modifying anti-rheumatic drugs (DMARDs) are prescription medications that relieve psoriatic arthritis symptoms and limit joint damage. While they cannot reverse damage that has already happened, early treatment with DMARDs can prevent damage that may occur with psoriatic arthritis over time, and slow or even stop the progression of the disease. With DMARDs, it can take time - sometimes weeks or months before there is a noticeable difference in pain and joint swelling. During this time, you might also be prescribed a steroid or NSAID, to help control symptoms.
In addition to their effects on arthritis, DMARDs can be prescribed to relieve the psoriasis symptoms of skin inflammation and decrease the production of skin cells.
DMARDs are meant for long-term management of psoriatic arthritis and may be taken consistently for months or years in order to keep PsA in remission. They can be taken alone, but are sometimes prescribed with NSAIDs, other DMARDs or biologic medications. Your doctor will recommend a therapy that is best suited to your type and stage of arthritis, other medical problems and medications.
Common side effects of DMARDs include nausea, diarrhea, upset stomach, dizziness, increased risk of infection, and liver problems. Regular blood work is needed to monitor blood cell counts and liver function.
Biologic response modifiers, or biologics for short, are medications specifically designed to target your body’s immune system. Like DMARDs, biologics are used to slow the progression of psoriatic arthritis, help prevent joint damage, and ease joint swelling, tenderness and pain. And like DMARDs, they are also used to slow the production of skin cells, and ease the pain and swelling of psoriasis plaques and scales.
Biologics can take time to work. Some people notice the effects of the medication quickly (within a week), while others take months to feel the effects. Biologics are often combined with other medications to treat PsA, such as DMARDs. They are also prescribed to people who fail to respond to other PsA therapies.
Common side effects with biologics include mild skin reactions at the injection site, nausea, abdominal pain and headaches. Rarely, people who take biologics may develop serious infections, lupus-like reactions, nervous system diseases, and cancer. You should not take a biologic if you are pregnant or nursing, or have a history of multiple sclerosis or cancer. Tell your doctor if you have a history of tuberculosis, hepatitis B, or recurrent infections.
Biologics are administered in two ways: infusion or injection. Your doctor can provide you with information and help make the right choice for you.
Understanding biologic and biosimilar medications
Most people are familiar with conventional medications such as pain relievers. These medications are made from chemicals (chemically synthesized).
Some of you may also have heard about biological or “biologic” medications which are used to treat serious illnesses, such as cancer, inflammatory bowel disease, psoriasis and rheumatoid arthritis. Biologics are special medications created using the biologic processes within living cells.
Conventional medicines and biologic medicines have important differences.
| Conventional medicines | Biologic medicines |
|---|---|
| Made from chemicals | Created in living cells |
| Generally small molecules | Complex large molecules |
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Some history on biologics...
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It is common knowledge that when the patent expires on a conventional medication, other companies are allowed to make copies called generics. Although the active ingredient in a generic is exactly the same as the active ingredient in the original conventional medication, non-medicinal ingredients, like fillers and colouring, may be different.
When the patent on a biologic medication expires, other companies are allowed to make copies. However, since it is impossible to make exact copies of biologic medications because of the way they are made, the copies are not called generics or even biogenerics. The correct term is biosimilar since it can only be similar and not identical to the original. In Canada, the official term for a biosimilar medication is Subsequent Entry Biologic or SEB.
Is a biosimilar a generic version of the original biologic drug?
No, biosimilars are similar to, but not identical to the original biologic drug. This is because the group of cells used to produce the drugs (the cell line), the actual drug molecule and the manufacturing process are different.
In Canada, manufacturers of biosimilars are required to show Health Canada that their product is similar to the original biologic and that the benefits of their product outweigh the risks. SEBs must have a label that is different from the original biologic medication.
Does the difference between a biosimilar and the original biologic matter to me and my care?
Yes, original biologics and biosimilars may act differently in your body and could have different side effects.
Since original biologics and the biosimilar versions are not identical, it’s important that you review your prescription with your doctor so you know which one is being prescribed.
Health Canada does not support automatic substitution of a biosimilar for an original biologic at the pharmacy.
For more information about biosimilar medicines, visit:
Alliance for Safe Biologic Medicines (USA) www.safebiologics.org
Treatments that can be used for symptoms of psoriasis in psoriatic arthritis:
Applied directly to the affected area, topical corticosteroids are the most frequently prescribed for treating mild-to-moderate psoriasis. They slow cell turnover, which reduces inflammation and relieves itching. They should only be used for limited periods, because long-term use or overuse of strong corticosteroids can cause thinning of the skin and resistance to the treatment's benefits.
Brief exposure to small amounts of sunlight, or to controlled doses of UVB light from an artificial source, may improve mild-to-moderate psoriasis symptoms. During UVB treatment, psoriasis may worsen temporarily before improving, and light therapy can cause short-term side effects such as redness, itching and dry skin. Moisturizers help lessen these side effects.
Combining UVB with other therapies may increase efficacy dramatically and allow for lower doses of medication.
Reserved for moderate-to-severe cases, PUVA (psoralen plus long-wave ultraviolet A light) can be used to clear psoriasis. PUVA uses a light-sensitive compound in addition to light therapy, and usually works in over 85% of people with chronic psoriasis lesions.
The short-term side effects with PUVA include nausea, headache, burning and itching. The long-term side effects can include dry and wrinkled skin, freckles, and increased risk of skin cancer (including melanoma, the most serious form of skin cancer).
If your psoriasis is severe and doesn't respond to other treatments, your doctor may recommend using a drug from the retinoid family. It’s not known exactly how retinoids work, but they reduce skin cell production and the speed at which they grow and shed.
With retinoids, symptoms usually return once the therapy is stopped. Common side effects are dry skin and mucous membranes, itching, and hair loss. Women must avoid pregnancy for at least three years after taking retinoids since they can cause severe birth defects.
Disclaimer
Please note that the information on this Web site should not be used as a substitute for seeking medical advice or treatment from a physician. You should not use this information to diagnose or treat a medical condition or health problem. Speak to your health care provider if you have any questions about your medical condition, symptoms or treatment options. The information found on this Web site can be referenced at www.arthritis.ca and www.dermatology.ca.
The Arthritis Society
arthritis.caLeading the way for over 60 years, The Arthritis Society is the only charitable organization in Canada dedicated to the fight against arthritis, and to helping people live well while creating a future without arthritis.
The Canadian Association of Psoriasis Patients (CAPP)
communautepsoriasis.ca/index.php/enWeb site for the Canadian Association of Psoriasis Patients (CAPP), whose goal is to get this challenging and misunderstood skin condition out in the open, help all patients manage their lives with psoriasis, and to make sure every Canadian can access the treatment they need.
Canadian Arthritis Patient Alliance
arthritispatient.caCAPA uses the power of information, research, and communication to help people living with arthritis find their voice and support others.
Canadian Psoriasis Network
canadianpsoriasisnetwork.comThe Canadian Psoriasis Network is a national, non-profit organization dedicated to improving the lives of people living with psoriasis and psoriatic arthritis.
Canadian Spondylitis Association
spondylitis.caThe Canadian Spondylitis Association (CSA) is a national association created to advocate for and support those suffering from ankylosing spondylitis, psoriatic arthritis, and associated spondyloarthritis diseases.
The Canadian Spondylitis Association is run entirely by an executive director and volunteers who have spondyloarthritis. Find out more about us and what we do. And check out our In your province pages for more information on your specific province or territory.
