Psoriatic Arthritis of the Spine: Symptoms, Treatments, and Diagnosis

Around one-third of the 7.5 million people in America living with psoriasis also have the rheumatic disease psoriatic arthritis (PsA) — a chronic inflammatory condition that causes pain and stiffness in the joints, typically in the extremities. Among people with PsA, approximately 20 percent will experience psoriatic arthritis of the spine, which may also be called psoriatic spondylitis.

Symptoms of Psoriatic Arthritis of the Spine

Spinal (or axial) involvement is a complication of PsA that may occur later in the disease's progression. The primary symptom of PsA of the spine is chronic pain in the lower back and the sacroiliac joints (the hips and buttocks). Inflammatory back pain is different from back pain caused by wear and tear. PsA-related back pain is due to an inflammatory autoimmune response and usually has the following characteristics:

• The pain begins before you’re 35 years old, persists for three months or longer, and worsens gradually over many years.
• The pain leads to morning stiffness, in which back pain and range of motion are worse after a period of immobility (like after a night’s sleep).
• The pain and stiffness tend to improve after physical activity.
• The back pain responds well to nonsteroidal anti-inflammatory drugs (NSAIDs).

If you have PsA of the spine, you may also experience other symptoms of PsA, including joint pain in other areas like the hands and feet on one side or both sides of the body. You may notice dactylitis (inflammation in the fingers and toes) and enthesitis (inflammation in the areas where tendons and ligaments connect to bone).

PsA may also cause extra-articular symptoms (nonjoint-related symptoms), which may include:

• Skin symptoms, such as psoriasis
• Eye involvement, such as uveitis or iritis
• Nail changes, such as pitting
• Gastrointestinal symptoms related to inflammatory bowel disease

Diagnosing Psoriatic Arthritis of the Spine

Approximately 15 percent of people with psoriasis may have PsA that’s unrecognized or undiagnosed. Diagnosing PsA, especially in the absence of psoriasis, can be challenging because its symptoms are similar to conditions such as rheumatoid arthritis, osteoarthritis, gout, and ankylosing spondylitis. People who have PsA and spondylitis may experience back-related symptoms for as many as 10 years before being diagnosed.

Part of the difficulty is, there’s no singular test to diagnose PsA. There are also no universally accepted diagnostic criteria for PsA. A dermatologist or rheumatologist is best positioned to determine whether you have psoriatic arthritis and to track how far your condition has progressed. Your doctor will likely take a medical history and perform imaging tests and blood tests to confirm PsA or rule out other conditions.

Medical History

Doctors can sometimes make a PsA diagnosis based on clinical symptoms and by obtaining a family history or personal history. Your doctor will likely ask if you or a family member have previously had psoriatic disease such as PsA or psoriasis. Having a family member who has or has had psoriatic disease is one of the main risk factors of developing PsA. Forty percent of people with PsA have a family history of psoriatic disease. If an identical twin has PsA, there is a 75 percent chance that the other twin will have it as well.

Imaging

A health care provider can use imaging tests — such as CT scans, MRI, ultrasounds, and X-rays — to detect PsA and any resulting damage to the soft tissues. Imaging tests can also be used to measure the progression of PsA and monitor any damage that may have occurred.

Blood Tests

Your doctor may also ask for a blood sample. There are no specific markers in the blood to indicate psoriatic arthritis, but certain proteins in the blood can point to inflammation and help your doctor make an appropriate diagnosis. In particular, your doctor may look for the presence of HLA-B27, a gene that is associated with a higher risk of spinal involvement.

Treating Psoriatic Arthritis of the Spine

Early diagnosis is important for beginning treatment promptly and preventing long-term, irreversible joint damage. Treatment of psoriatic arthritis generally aims to manage inflammation and chronic pain and slow or halt disease progression.

Symptom Management

Many medications, including corticosteroid injections and nonsteroidal anti-inflammatory drugs (NSAIDs, such as naproxen and ibuprofen), can be used to manage the inflammatory pain of PsA.

Slowing Disease Progression

Disease-modifying antirheumatic drugs (DMARDs) may sometimes be used as part of your treatment plan to help slow disease progression and prevent lasting joint and tissue damage.

Examples of older DMARDs include:

• Arava (leflunomide)
• Cyclosporine (sold as Gengraf, Neoral, and Sandimmune)
• Sulfasalazine
• Methotrexate (sold as Otexup, Rasuvo, and Trexall)

Newer DMARDs, including Xeljanz (tofacitinib) and Otezla (apremilast), work by targeting specific parts of the immune system that contribute to the body’s inflammatory response.

Biologics, such as tumor necrosis factor (TNF) inhibitors, are another type of DMARD that target specific proteins that cause inflammation. TNF inhibitors can slow or halt PsA progression in some people. TNF inhibitors include:

• Enbrel (etanercept)
• Humira (adalimumab)
• Remicade (infliximab)
• Simponi (golimumab)

Biologic DMARDs also include Cosentyx (secukinumab), Stelara (ustekinumab), and Taltz (ixekizumab).

Talk With Others Who Understand

MyPsoriasisTeam is the social network for people with psoriatic disease and their loved ones. More than 101,000 members come together to ask questions, give advice, and share their experiences with others who understand life with psoriasis and PsA.

Do you have psoriatic arthritis of the spine? Share your experience in the comments below or join the conversation on MyPsoriasisTeam.