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Psoriatic Arthritis Stages and Progression

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

  • Psoriatic arthritis (PsA) doesn’t have physician-defined stages like rheumatoid arthritis does. However, it can progressively worsen over time.
  • Psoriatic arthritis that has progressed may cause irreversible joint damage and deformity.

Psoriatic arthritis is a type of inflammatory arthritis that occurs when the immune system mistakenly attacks the joints. The condition affects people differently, so it doesn’t have physician-defined stages like rheumatoid arthritis. However, PsA can progressively worsen over time — especially if it’s not properly treated.

Working with your doctor is critical to measuring the extent and severity of potential psoriatic arthritis. The sooner the condition is diagnosed, the sooner treatment can begin to control inflammation and prevent or slow further disease progression, including the associated joint damage. Even a six-month delay in diagnosis can lead to worse outcomes, so knowing what to look for and when to notify your doctor is crucial.

If you already have psoriasis, it’s especially important to watch out for symptoms of psoriatic arthritis, as your risk factors may be higher. Up to 30 percent of people who have psoriasis develop PsA, according to Cleveland Clinic.

Although PsA doesn’t have specified stages, there are levels of severity that may be helpful in understanding or describing your joint pain. In this article, we use the word “stages” when we talk about progression in PsA. Here’s what to know.

Subclinical Psoriatic Arthritis

Subclinical psoriatic arthritis is psoriatic arthritis that can be diagnosed through laboratory testing and imaging; it doesn’t cause symptoms. Studies have found that up to half of people with psoriasis have subclinical psoriatic arthritis.

Certain biomarkers can be used to detect psoriasis that is on the verge of turning into psoriatic arthritis. In addition, scientists are working on finding specific lesions (abnormalities on imaging tests) in people with subclinical psoriatic arthritis linked to developing symptomatic psoriatic arthritis.

Early-stage Psoriatic Arthritis

The first stages of psoriatic arthritis usually include joint symptoms, such as pain and swelling in the fingers and toes (dactylitis or “sausage digits”), as well as episodes of psoriasis.

You might also notice fatigue and stiffness as symptoms of early-stage psoriatic arthritis. A study of people living with psoriatic arthritis found that 36 percent had seen their primary doctor for musculoskeletal issues, such as joint pain or stiffness, in the five years leading up to their diagnosis.

Symptoms of psoriatic arthritis can also include enthesitis, which is pain and swelling in the tendons and ligaments where they connect to your bones. Enthesitis is common on the bottom of the feet (plantar fasciitis) and in the heels (Achilles tendonitis).

Moderate to Severe Psoriatic Arthritis

Moderate and severe psoriatic arthritis can seriously affect your quality of life. It can make daily physical activities difficult to perform, and it might affect your emotional and physical health. Common painkillers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), may treat the symptoms of the disease. However, stronger medications, such as disease-modifying antirheumatic drugs (DMARDs), are necessary to prevent further damage to the joints and other parts of the body.

Joint Deformity

Psoriatic arthritis that has progressed may cause irreversible joint damage and deformity. Some people with psoriatic arthritis develop spondylitis — inflammation of the spine. Spondylitis can cause neck and lower back pain, or it can lead to complete fusion of bones in the spine.

Chronic inflammation of the finger and toe joints can cause the fingers and toes to shorten and collapse, a rare condition called arthritis mutilans. Less than 5 percent of people with psoriatic arthritis have arthritis mutilans. Although the exact causes of arthritis mutilans are unknown, PsA treatments can reduce your risk of developing the condition.

Damage to Other Parts of the Body

If left untreated, psoriatic arthritis and the associated inflammation can have worsening effects beyond the joints and tendons. Later-stage PsA can cause inflammation in the eyes — a condition called uveitis. Without treatment, psoriatic arthritis can cause permanent damage to the eyes.

PsA also can cause heart damage, liver damage, and inflammation in the digestive system, which may sometimes cause Crohn’s disease.

Are you having symptoms that might be psoriatic arthritis?
Have you experienced psoriatic arthritis progression?
Click here to share your experience in the comments below.

Measuring Psoriatic Arthritis Progression

A dermatologist or rheumatologist can help determine whether you have psoriatic arthritis and how far it has progressed. They will likely examine your affected joints for swelling and tenderness and press on the soles of your feet, near the heels, to look for tenderness.

In addition, they will likely test your range of motion and examine your fingernails — pitted, crumbling, and ridged nails are early symptoms of psoriatic arthritis. The physician will also probably ask you about pain, fatigue, and other physical symptoms, as well as your quality of life.

Imaging tests — such as X-rays, ultrasounds, magnetic resonance imaging (MRI) scans, or computer tomography (CT) scans — help doctors measure the progression of psoriatic arthritis. Using imaging to measure the progression of psoriatic arthritis is called “measuring radiographic progression.”

Certain tests are better at detecting psoriatic arthritis damage to the soft tissues. For example, ultrasound can detect enthesitis even before it causes you pain. MRI scans can also detect damage caused by PsA.

X-rays are useful for diagnosing later-stage psoriatic arthritis. They can detect a phenomenon that’s common in late-stage psoriatic arthritis called the “pencil-in-cup” phenomenon, in which one end of a bone is damaged to the extent that it becomes sharply pointed.

Slowing Psoriatic Arthritis Progression

Many medications — such as over-the-counter painkillers (e.g., naproxen and ibuprofen) and corticosteroid injections — can ease the pain and inflammation of psoriatic arthritis. DMARDs and biologic DMARDs can also limit disease activity and keep psoriatic arthritis from getting worse.

DMARDs

DMARDs reduce joint and tissue damage and slow psoriatic arthritis disease progression. Older DMARDs approved by the U.S. Food and Drug Administration (FDA) for PsA include:

Newer DMARDs, such as apremilast (Otezla), affect certain parts of the immune system that are involved in inflammatory response.

Biologic DMARDs

Biologic DMARDs work against specific proteins that cause inflammation. Tumor necrosis factor (TNF) inhibitors are biologic DMARDs that block certain proteins that maintain inflammation. They have been shown to slow and prevent progression in people with psoriatic arthritis. FDA-approved TNF inhibitors for PsA include:

Newer biologic DMARDs include:

JAK Inhibitors

In recent years, drug manufacturers have developed new medications known as targeted synthetic DMARDs. These drugs are Janus kinase (JAK) inhibitors — they block JAK enzymes that are often activated in autoimmune disorders. These drugs can also block PsA disease progression. The JAK inhibitors approved by the FDA for psoriatic arthritis are Xeljanz (Tofacitinib) and Rinvoq (upadacitinib).

Read more about treatments for psoriatic arthritis.

Finding Community

On MyPsoriasisTeam, the social network for those living with psoriasis and psoriatic arthritis, more than 103,000 members, including more than 10,000 with PsA, talk about life with psoriatic disease.

Are you having symptoms that might be psoriatic arthritis? Have you experienced psoriatic arthritis progression? Comment below or post on MyPsoriasisTeam to share your story.

References
  1. Tumor Necrosis Factor Inhibitors in Psoriatic Arthritis — Expert Review of Clinical Pharmacology
  2. If You Have Psoriasis, Watch for Early Signs of Psoriatic Arthritis — Cleveland Clinic
  3. From Psoriasis to Psoriatic Arthritis: Insights From Imaging on the Transition to Psoriatic Arthritis and Implications for Arthritis Prevention — Current Rheumatology Reports
  4. Psoriatic Arthritis May Have Very Subtle, Early Symptoms That Aren’t Being Recognized — CreakyJoints
  5. Psoriatic Arthritis Signs and Symptoms — Johns Hopkins Arthritis Center
  6. What Is Dactylitis? The ‘Sausage Finger’ Swelling You Should Know About — CreakyJoints
  7. What Is Enthesitis? The Painful Arthritis Symptoms You Should Know About — CreakyJoints
  8. Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis: Section 2. Psoriatic Arthritis: Overview and Guidelines of Care for Treatment With an Emphasis on the Biologics — Journal of the American Academy of Dermatology
  9. Overview of Psoriatic Arthritis — Spondylitis Association of America
  10. What Is Arthritis Mutilans? These Are the Signs You Could Have It — CreakyJoints
  11. Psoriatic Arthritis — MedlinePlus
  12. Psoriatic Arthritis — Versus Arthritis
  13. Psoriatic Arthritis — Mayo Clinic
  14. The 7 Ways Psoriatic Arthritis Can Change Your Nails (and What You Can Do To Avoid It) — CreakyJoints
  15. The Role of Ultrasound in Psoriatic Arthritis — Do We Need a Score? — The Journal of Rheumatology
  16. Magnetic Resonance Imaging in Psoriatic Arthritis: A Descriptive Study of Indications, Features and Effect on Treatment Changes — Journal of Clinical Rheumatology
  17. Psoriatic Arthritis — Cleveland Clinic
  18. DMARDs — Arthritis Foundation
  19. The Stages of Psoriatic Arthritis: Signs of Early to Late Disease Progression — CreakyJoints
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.
Jessica Wolpert works to empower patients through the creation of content that illuminates treatments' effects on the everyday lives of people with chronic conditions. Learn more about her here.

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