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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.
The sooner someone’s diagnosed, the sooner they can start treatment 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 PsA, 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.
Subclinical PsA 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 PsA.
Certain biomarkers can be used to detect psoriasis that is on the verge of turning into PsA. In addition, scientists are working on finding specific lesions (abnormalities on imaging tests) in people with subclinical PsA linked to developing symptomatic PsA.
When PsA begins, there are usually 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 PsA. A study of people living with PsA 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 PsA 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 tendinitis).
Moderate or severe PsA can seriously affect your quality of life. It can make daily physical activities difficult to perform and 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.
PsA that has progressed may cause irreversible joint damage and deformity. Some people with PsA 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 PsA have arthritis mutilans. Although the exact causes of arthritis mutilans are unknown, PsA treatments can reduce your risk of developing the condition.
If left untreated, PsA and the associated inflammation can have worsening effects beyond the joints and tendons. Later on in the course of PsA, some people may experience uveitis, which is inflammation in the eyes. Without treatment, PsA can cause permanent damage to the eyes.
PsA can also cause heart damage, liver damage, and inflammation in the digestive system, which may sometimes cause Crohn’s disease.
A dermatologist or rheumatologist can help determine whether you have PsA 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 PsA. The physician will also probably ask you about pain, fatigue, and other physical symptoms, as well as discuss your quality of life.
Imaging tests such as X-rays, ultrasounds, MRI scans, or CT scans help doctors measure the progression of PsA. Using imaging to measure the progression of PsA is called “measuring radiographic progression.”
Certain tests are better at detecting PsA 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 help diagnose PsA as the condition becomes advanced. At this point, X-rays can detect a common occurrence called the “pencil-in-cup” phenomenon, in which one end of a bone is damaged to the extent that it becomes sharply pointed.
Many medications such as over-the-counter painkillers (e.g., naproxen and ibuprofen) and corticosteroid injections can ease the pain and inflammation of PsA. DMARDs and biologic DMARDs can also limit disease activity and keep PsA from getting worse.
DMARDs reduce joint and tissue damage and slow PsA 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 the inflammatory response.
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 PsA. FDA-approved TNF inhibitors for PsA include:
Newer biologic DMARDs include:
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 PsA are tofacitinib (Xeljanz) and upadacitinib (Rinvoq).
Read more about treatments for PsA.
On MyPsoriasisTeam, the social network for those living with psoriasis and psoriatic arthritis, more than 114,000 members, including more than 12,000 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 your Activities page to share your story.
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.
