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Psoriatic Arthritis — An Overview

Updated on March 01, 2022
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Alison Channon

  • Psoriatic arthritis (PsA) is a type of inflammatory arthritis characterized by joint pain, swelling, and stiffness.
  • About a third of people with psoriasis are also affected by psoriatic arthritis.
  • It’s possible to develop psoriatic arthritis without ever having skin symptoms.

Psoriatic arthritis is a type of inflammatory arthritis related to psoriasis. Approximately one-third of people with psoriasis are affected by PsA. PsA generally affects the joints and the areas where ligaments and tendons connect to bones.

What Causes Psoriatic Arthritis?

Psoriatic arthritis and psoriasis are autoimmune diseases — conditions that occur when the immune system mistakenly attacks healthy tissues, such as your skin and joints. Inflammation from the body’s overreacting immune response leads to symptoms of psoriasis and PsA. Psoriatic arthritis is distinct from osteoarthritis, which is caused by the normal wear and tear of aging, rather than inflammation.

PsA is caused by several complex contributing factors. Researchers have identified dozens of genetic variants that may make a person more likely to develop psoriasis and PsA.

Most scientists believe that genetics and environmental factors both contribute to PsA, but they’re still working to understand exactly why a person develops the condition. Researchers theorize that environmental factors — a physical injury, a virus, or an infection like strep throat — may trigger the development of PsA in some people. These are all situations that set off an immune response.

Watch dermatologist Dr. Raja Sivamani talk about how you can tell if your psoriasis is progressing to psoriatic arthritis.

Risk Factors for PsA

Having psoriasis is the primary risk factor for developing psoriatic arthritis. Psoriatic arthritis affects about 30 percent of people with psoriasis, according to the National Psoriasis Foundation. PsA usually develops in people between the ages of 30 and 50. However, not everyone with PsA receives a psoriasis diagnosis first. Between 10 percent and 15 percent of people with PsA experience joint symptoms without ever having skin symptoms.

Having a family history of psoriasis or psoriatic arthritis is another risk factor — 40 percent of people with PsA have a family history of psoriatic disease, according to the American College of Rheumatology. Whereas being female is sometimes a risk factor for other autoimmune diseases, being a particular sex doesn’t appear to be a risk factor for PsA.

How Is Psoriatic Arthritis Diagnosed?

Your dermatologist or primary care physician may refer you to a rheumatologist if you have symptoms of psoriatic arthritis. A rheumatologist is trained to diagnose and treat joint and tendon symptoms, while a dermatologist is focused on the skin symptoms of psoriasis and other skin conditions. Early diagnosis and treatment of PsA are associated with better outcomes.

A rheumatologist will conduct a physical exam and take a medical history. Your doctor will check to see if your joints are swollen or tender. They will likely pay special attention to the fingers and toes. They may then recommend various tests to look for signs of PsA and to rule out other possible causes.

Tests for Psoriatic Arthritis

There isn’t one simple test for diagnosing psoriatic arthritis. A rheumatologist will need to evaluate several factors before giving a diagnosis. A final diagnosis will be based on your symptoms and the results of various tests.

Imaging Tests

A rheumatologist may order an imaging test to look for signs of psoriatic arthritis. X-rays are most effective at diagnosing later-stage PsA. They’re not generally effective at detecting early-stage PsA. They can detect severe bone changes that indicate PsA.

Ultrasound and magnetic resonance imaging (MRI) may also be used to identify inflammation of joints and tendons.

Blood Tests

No specific blood test can confirm a PsA diagnosis. Instead, blood tests are used to detect inflammation and rule out other types of arthritis. Below are some types of blood tests your doctor may order:

  • Rheumatoid factor (RF) is an antibody found in people with rheumatoid arthritis. A positive RF test can help rule out psoriatic arthritis.
  • C-reactive protein (CRP) tests can detect inflammation.
  • Erythrocyte sedimentation rate (ESR) is another test used to detect inflammation.

Biopsies and Other Tests

Biopsies are sometimes used to help confirm a diagnosis of PsA or rule out other conditions. Your doctor may perform the following types of procedures:

  • Arthrocentesis, or joint fluid analysis, is performed by removing fluid from an affected joint with a needle. It can help rule out gout.
  • A skin biopsy —which involves removing a small skin sample for testing — may be performed to confirm psoriasis or another skin condition.

Learn more about psoriatic arthritis diagnosis and tests.

Do you have psoriatic arthritis?
Click here to share your experience in the comments below.

What Are the Symptoms of Psoriatic Arthritis?

Psoriatic arthritis is characterized by joint pain, swelling, and stiffness. PsA symptoms may be mild or have a severe impact on quality of life.

Dactylitis

Also referred to as “sausage digits,” dactylitis is painful swelling in the fingers and toes. It’s often the first symptom of PsA.

Enthesitis

People with PsA may have enthesitis, a condition characterized by pain or tenderness where ligaments and tendons attach to bone. Enthesitis most frequently occurs in the heels and bottoms of the feet, though it can also affect the elbows.

Nail Changes

White spots, flaking, pitting (shallow or deep dents on your nails), or lifting of the nail bed may also be symptoms of psoriatic arthritis. Up to 90 percent of people with PsA experience nail changes, according to CreakyJoints.

Read more about nail symptoms of PsA.

Skin Psoriasis

Itchy, scaly, red, purple, or silvery lesions appear prior to the onset of psoriatic arthritis in approximately 75 percent of people with PsA, according to DermNet NZ. Skin disease can appear 10 to 20 years before developing joint symptoms, notes John Hopkins Arthritis Center.

Other Psoriatic Arthritis Symptoms

Not all PsA symptoms affect the skin and joints. Other possible symptoms include uveitis (inflammatory eye condition) and fatigue.

Read more about symptoms of psoriatic arthritis.

What Are the Types of Psoriatic Arthritis?

Psoriatic arthritis can be broken into five categories defined by the impacted joints. It’s possible to have more than one type of PsA.

Asymmetric Oligoarthritis

An estimated 35 percent of people with psoriatic arthritis have this type. Asymmetric oligoarthritis typically involves five or fewer joints. It’s known as asymmetric arthritis because it typically doesn’t affect both sides of the body in the same place. For example, it might appear in only one knee or one elbow.

Symmetric Polyarthritis

Symmetric polyarthritis is one of the most common types of psoriatic arthritis — half of all people with PsA are estimated to have this type. Symmetric polyarthritis affects five or more corresponding joints on both sides of the body. This type of PsA is similar to rheumatoid arthritis, but it can be differentiated by a few factors, including a negative RF blood test.

Spondylitis

Psoriatic arthritis that affects the lower back and spine is a type of spondylitis (also called spondyloarthritis). About 5 percent of people with PsA have spondylitis.

Distal Arthritis

Distal arthritis causes inflammation and stiffness in the distal interphalangeal joints, those closest to the tips of fingers and toes. According to Cleveland Clinic Center for Continuing Education, this type affects about 10 percent of people with PsA, usually men. Nail changes are also common with distal arthritis.

Arthritis Mutilans

Arthritis mutilans is the rarest and most severe type of psoriatic arthritis. This form of PsA attacks joints in the hands and feet, causing deformities and impaired movement.

How Is Psoriatic Arthritis Treated?

While there is currently no cure for psoriatic arthritis, treatment options can control disease activity and reduce painful symptoms. Goals for PsA treatment include reducing pain and inflammation and protecting joint mobility.

Treatments To Control Disease Progression

Disease-modifying antirheumatic drugs (DMARDs) reduce joint and tissue damage and slow psoriatic arthritis disease progression. Older DMARDs include methotrexate, sulfasalazine, leflunomide (sold as Arava), and cyclosporine. Newer DMARDs, such as apremilast (Otezla), affect certain parts of the immune system involved in inflammation.

Biologic DMARDs work against specific proteins that cause inflammation. Tumor necrosis factor (TNF) inhibitors are biologic DMARDs that block certain proteins that maintain inflammation. Adalimumab (Humira) is one of the most common TNF inhibitors prescribed for PsA. Others include etanercept (Enbrel), infliximab (Remicade), and golimumab (Simponi).

Other types of biologic DMARDs include ustekinumab (Stelara), secukinumab (Cosentyx), ixekizumab (Taltz), and guselkumab (Tremfya).

Targeted synthetic DMARDs are now available to treat PsA. These drugs are Janus kinase (JAK) inhibitors — they block the JAK enzyme, which is often activated in autoimmune disorders. These drugs can also block PsA disease progression. The JAK inhibitors approved by the U.S. Food and Drug Administration (FDA) for psoriatic arthritis are tofacitinib (Xeljanz) and upadacitinib (Rinvoq).

Treatments for Symptoms

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (sold under the brands Advil or Motrin) can reduce swelling and pain. They’re typically prescribed for mild cases of psoriatic arthritis without joint damage.

Corticosteroids can also be used to treat PsA symptoms. Corticosteroids can be given as an injection to treat inflammation in a specific joint. Oral corticosteroids can be used to treat a PsA flare, though they may exacerbate psoriasis. Long-term use of steroids is generally discouraged due to side effects.

Other Treatments for PsA

Physical therapy can help manage psoriatic arthritis. In cases of severe joint damage, surgery may be appropriate. Lifestyle changes like eating a healthy diet and quitting smoking can also help.

When someone has more than one health condition at the same time, the conditions are known as comorbidities. Cardiovascular disease is the most common comorbidity for people with PsA. Diabetes, obesity, and nonalcoholic fatty liver disease are other conditions that many people have in addition to PsA.

Talk With Others Who Understand

MyPsoriasisTeam is the social network for people with psoriasis and their loved ones. On MyPsoriasisTeam, more than 108,000 members come together to ask questions, give advice, and share their stories with others who understand life with psoriasis.

Do you have psoriatic arthritis? Share your experience in the comments below, or start a conversation by posting on MyPsoriasisTeam.

References
  1. Psoriatic Arthritis — Arthritis Foundation
  2. Related Conditions of Psoriasis — National Psoriasis Foundation
  3. About Psoriatic Arthritis — National Psoriasis Foundation
  4. Osteoarthritis — Mayo Clinic
  5. Large Scale Meta-Analysis Characterizes Genetic Architecture for Common Psoriasis Associated Variants — Nature Communications
  6. Psoriatic Arthritis — National Institute of Arthritis and Musculoskeletal and Skin Diseases
  7. Psoriatic Arthritis — American College of Rheumatology
  8. Psoriatic Arthritis — Mayo Clinic
  9. Psoriatic Arthritis: State of the Art Review — Clinical Medicine Journal
  10. What Is a Rheumatologist? — American College of Rheumatology
  11. Psoriatic Arthritis Diagnosis — Johns Hopkins Arthritis Center
  12. Psoriatic Arthritis — Cleveland Clinic
  13. C-Reactive Protein (CRP) — Testing.com
  14. Erythrocyte Sedimentation Rate (ESR) — Testing.com
  15. Synovial Fluid Analysis — Testing.com
  16. Diagnosing Psoriasis — NYU Langone Health
  17. The Different ‘Types’ of Psoriatic Arthritis — and Why Knowing Your Type Matters — CreakyJoints
  18. Psoriatic Arthritis — DermNet NZ
  19. Psoriatic Arthritis Signs and Symptoms — Johns Hopkins Arthritis Center
  20. Psoriatic Arthritis — MedlinePlus
  21. Psoriatic Arthritis — Cleveland Clinic Center for Continuing Education
  22. Psoriatic Arthritis and Back Pain — Arthritis Foundation
  23. The First Medications for PsA — Arthritis Foundation
  24. Psoriatic Arthritis: Diagnosis and Treatment — American Academy of Dermatology Association
  25. Metabolic Comorbidities of Psoriatic Arthritis — Arthritis Foundation

All updates must be accompanied by text or a picture.
Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Alison Channon has nearly a decade of experience writing about chronic health conditions, mental health, and women's health. Learn more about her here.

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