Psoriatic arthritis (PsA) is a type of inflammatory arthritis that occurs when the immune system mistakenly attacks the joints. Because the experience of psoriatic arthritis varies widely for different people, PsA doesn’t have physician-defined stages like rheumatoid arthritis. However, it can progressively worsen over time — especially if it’s not properly treated. In this article, we use the word “stages” when we talk about progression in PsA.

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

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.

Although PsA doesn’t have specified stages, there are levels of severity that may be helpful in understanding or describing your joint pain. 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 in people with subclinical psoriatic arthritis that are associated with progression to 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 of 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. Daily physical activities may be difficult to perform, and the impact of the disease might affect your emotional and physical health. Common painkillers, such as nonsteroidal anti-inflammatory drugs, may treat the symptoms of the disease. However, stronger medications, such as disease-modifying antirheumatic drugs (DMARDs), are needed 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. Only about 5 percent of people with psoriatic arthritis have arthritis mutilans, and most people with arthritis mutilans have gone without treatment for their PsA.

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 psoriatic arthritis can cause inflammation in the eyes — a condition called uveitis. Without treatment, psoriatic arthritis can cause permanent damage to the eyes. It can also cause heart damage and inflammation in the digestive system, which may sometimes cause Crohn’s disease.

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 the affected joints for swelling and tenderness and press on the soles of your feet near the heels 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, magnetic resonance imaging (MRI), ultrasounds, or CT scans, help the doctor 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. MRIs can also detect damage caused by PsA.

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

Slowing Psoriatic Arthritis Progression

Many medications — over-the-counter painkillers, such as naproxen and ibuprofen, and corticosteroid injections — can ease the pain and inflammation of psoriatic arthritis. Other medications can also limit disease activity and keep psoriatic arthritis from getting worse. These drugs are called DMARDs and biologic DMARDs.

Disease-Modifying Antirheumatic Drugs

Disease-modifying antirheumatic drugs reduce joint and tissue damage and slow psoriatic arthritis disease progression. Older DMARDs include Methotrexate (sold under brand names including Trexall), Sulfasalazine, Arava (Leflunomide), and Cyclosporine. Newer DMARDs, such as Xeljanz (Tofacitinib) and Otezla (Apremilast), affect certain parts of the immune system that are involved in inflammatory response.

Biologic Disease-Modifying Antirheumatic Drugs

Biologic DMARDs work against specific proteins that cause inflammation. Tumor necrosis factor (TNF) inhibitors are biologic DMARDs that prevent the body from overproducing certain types of proteins. They have been shown to slow and prevent progression in people with psoriatic arthritis. Humira (Adalimumab) is one of the most common TNF inhibitors for PsA. Others include Enbrel (Etanercept), Remicade (Infliximab), and Simponi (Golimumab).

Newer biologic DMARDs include Stelara (Ustekinumab), Cosentyx (Secukinumab), and Taltz (Ixekizumab).

Read more about treatments for psoriatic arthritis.

Finding Community

On MyPsoriasisTeam, the social network for those living with psoriasis and psoriatic arthritis, more than 87,000 members — including nearly 8,000 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? — CreakyJoints
8. Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis, Section 2 — 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 — VersusArthritis
12. Psoriatic Arthritis: Diagnosis and Treatment — Mayo Clinic
13. The 7 Ways Psoriatic Arthritis Can Change Your Nails (and What You Can Do to Avoid It) — CreakyJoints
14. The Role of Ultrasound in Psoriatic Arthritis — Do We Need a Score? — Journal of Rheumatology
15. Magnetic Resonance Imaging in Psoriatic Arthritis — Journal of Clinical Rheumatology
16. Psoriatic Arthritis: Diagnosis and Tests — Cleveland Clinic
17. DMARDs — Arthritis Foundation
18. The Stages of Psoriatic Arthritis: Signs of Early to Late Disease Progression — CreakyJoints

Jessica works to empower people through the creation of content that illuminates treatments' effects on the everyday lives of people with chronic conditions. Learn more about her here.

Ariel Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Learn more about him here. Review provided by VeriMed Healthcare Network.