Psoriatic Arthropathy

Psoriatic arthropathy, also known as psoriatic arthritis, is a chronic inflammatory disease that causes pain, swelling, and stiffness in the joints. This condition often affects people who have psoriasis, a skin condition that creates scaly, itchy patches, although it can develop even without visible skin symptoms.

Table of contents

• What is psoriatic arthropathy?
• How common is psoriatic arthropathy?
• Types of psoriatic arthropathy
• Symptoms and signs
• Causes and triggers
• Diagnosis
• Treatment and management
• Living with psoriatic arthropathy

What is psoriatic arthropathy?

Psoriatic arthropathy is a type of arthritis (a condition that causes pain and inflammation in the joints) that develops in people who have or have a family history of psoriasis (a skin condition causing red, scaly patches)^[1][2]. Both conditions are autoimmune diseases, which means the body’s immune system mistakenly attacks healthy tissues instead of protecting them^[2].

The disease causes inflammation not only in the joints but also in areas where tendons (tissues connecting muscles to bones) and ligaments (tissues connecting bones to each other) attach to bones. These attachment points are called entheses, and when they become inflamed, the condition is known as enthesitis^[3].

Most people develop psoriasis first, sometimes years before joint symptoms appear^[1]. However, in some cases, joint pain and swelling can occur before any skin symptoms are noticed. The disease typically develops between ages 30 and 50, though it can begin at any age, including childhood^[3][6].

psoriatic arthritis

How common is psoriatic arthropathy?

Psoriatic arthropathy affects less than 1% of all people^[2]. However, it is much more common among people who have psoriasis. Roughly 1 in 3 people living with psoriasis will develop psoriatic arthropathy at some point in their life^[3]. Around 30% of people with psoriasis develop this joint condition^[2].

The condition affects men and women equally^[5][8]. It is more common in white people than in other racial and ethnic groups^[5].

More than 15% of people living with psoriasis may have undiagnosed psoriatic arthropathy^[3]. This means many people may be living with the condition without knowing it, which highlights the importance of regular screening for joint symptoms in people with psoriasis.

Types of psoriatic arthropathy

Healthcare providers classify psoriatic arthropathy based on which joints are affected and on which side of the body symptoms appear. There are five main forms of the disease^[2]:

• Distal interphalangeal predominant psoriatic arthritis affects the joints near the ends of fingers and toes. This is the most common type that affects fingernails and toenails, which may look discolored, flaky, or covered with tiny dents called pits^[2].
• Symmetric polyarthritis affects five or more joints at the same time on both sides of the body, such as both knees and both elbows. This is one of the most common forms of psoriatic arthropathy^[2].
• Asymmetric oligoarticular psoriatic arthritis affects two to four joints on different sides of the body, such as one knee and one elbow. This is another very common form of the disease^[2].
• Spondylitis causes inflammation in the joints between the bones of the spine, called vertebrae. It can also cause pain in the hips and shoulders^[2].
• Arthritis mutilans causes severe symptoms in the hands and feet. The inflammation is usually severe enough to cause bone loss (a process called osteolysis). This is the rarest form, affecting fewer than 5% of all people with psoriatic arthropathy^[2].

Symptoms and signs

Psoriatic arthropathy can affect any joint in the body. Symptoms can range from mild to severe and usually come and go in periods called flares^[1][2]. During a flare, symptoms worsen, while at other times they may ease or even disappear for a while.

The main symptoms of psoriatic arthropathy include pain, swelling, and stiffness in one or more joints^[1][3]. Joint stiffness is often worse in the morning or after periods of rest^[3]. Affected joints may feel tender, appear red or discolored, and feel warm to the touch^[3].

Additional symptoms include:

• Dactylitis, which is swelling of entire fingers or toes, making them look like sausages. This “sausage digit” can be quite painful and is a sign of severe disease^[1][3][6].
• Nail changes, such as pitting (tiny dents on the nail surface), discoloration, or separation of the nail from the nail bed^[1][3][6].
• Foot pain, especially at the heel or sole, where tendons and ligaments attach to bones (enthesitis)^[1][6].
• Lower back pain, particularly above the tailbone, when the spine is affected^[3].
• Fatigue or feeling drained of energy^[3][7].

Some people may also experience psoriasis symptoms, such as dry, scaly skin patches, at the same time as joint symptoms^[7]. The skin patches may be red, purple, or brown depending on skin color^[1]. Psoriasis affecting the scalp, behind or inside the ear, or around the anus is most commonly associated with joint problems^[6].

Early symptoms are important to recognize. Before diagnosis, people often report experiencing joint pain, fatigue, and stiffness for about a year^[6].

Causes and triggers

The exact causes of psoriatic arthropathy are not fully understood. The disease involves a complex interaction between genetics and environmental factors that results in immune-mediated inflammation affecting the skin, joints, and other organs^[4].

Genetics play an important role. About 33% to 50% of patients with psoriatic arthropathy have at least one first-degree relative (parent, sibling, or child) with psoriatic arthropathy or psoriasis^[4]. The chance of developing psoriatic arthropathy is higher for people who have a family member living with the condition^[3].

Certain genes are associated with the disease, including those involved in how the immune system recognizes and responds to threats. However, the genetic links between psoriatic arthropathy and psoriasis are not identical—some genes associated with joint disease are not associated with skin disease, and vice versa^[4].

It’s not clear why some people with psoriasis develop psoriatic arthropathy while others do not^[7][16]. For some people, an overactive immune system response may be triggered by various factors.

Common triggers that may worsen symptoms or cause flares include:

• Stress^[3]
• Smoking or alcohol use^[3]
• Injuries or trauma to the skin or joints^[3]
• Illness, such as infections like strep throat^[3][6]
• Certain medications^[3]
• Changes in weather^[3]
• Diet^[3]

A flare may include new or increased joint pain, tenderness, swelling, or stiffness. Flares can last for different amounts of time and vary in severity^[3]. Triggers differ from person to person—what worsens symptoms for one individual may have no effect on another.

Diagnosis

Unfortunately, there is no single definitive test for psoriatic arthropathy. Diagnosis is made mostly through a healthcare provider’s observations and a process of elimination^[3]. The symptoms are similar to those of other conditions, including rheumatoid arthritis, gout, and reactive arthritis^[3].

Psoriatic arthropathy is best diagnosed and treated by a rheumatologist, a doctor who specializes in diseases affecting muscles, joints, bones, and related immune conditions. Some people may also need to see a dermatologist, who specializes in skin conditions^[3][5].

To make a diagnosis, healthcare providers consider several factors^[3][9]:

• Physical examination of the skin, joints, and nails. The provider may check for swelling or tenderness in joints, look for signs of nail pitting or peeling, and press on areas like the bottoms of feet and around heels to check for sore spots^[3][9].
• Blood tests can help rule out other conditions. For example, a rheumatoid factor test checks for an antibody found in people with rheumatoid arthritis. If this antibody is missing, it may help confirm psoriatic arthropathy instead of rheumatoid arthritis^[9].
• Joint fluid tests involve removing a small sample of fluid from a swollen joint using a needle. If the fluid contains uric acid crystals, this may indicate gout. Some people can have both gout and psoriatic arthropathy^[9].
• Imaging tests such as X-rays can show changes in the joints that are common in psoriatic arthropathy but not seen in other types of arthritis. MRI scans create detailed pictures of bones, joints, and soft tissue and are especially helpful for checking tendons and ligaments in the feet and lower back. Ultrasound scans may also be used^[3][9].

Early diagnosis and treatment are important because they can help relieve symptoms and may prevent permanent joint damage^[3]. Although it may take a few appointments to get the correct diagnosis, getting an accurate diagnosis is very important for managing symptoms, preventing permanent joint damage, and caring for overall health^[3].

You should see a healthcare provider even if you do not have psoriasis, if you experience joint pain, stiffness, and swelling that keeps coming back^[7][16].

Treatment and management

There is no cure for psoriatic arthropathy. However, treatment can help lessen symptoms, protect joints from damage, and improve your ability to move and stay active^[1][2].

Treatment is personalized to your symptoms and the severity of your disease. The goals of treatment are to slow the disease and possibly put it into remission, relieve pain and other symptoms, and protect your skin and joints^[11]. One of the main treatment options is prescription medicine called disease-modifying antirheumatic drugs, often shortened to DMARDs^[9].

You may need to work with a team of specialists, including a rheumatologist to manage joint pain and a dermatologist for skin symptoms^[11]. Treatment should be started early, as the earlier the treatment begins, the more likely you can prevent serious damage^[13].

Medications

Several types of medications may be used to treat psoriatic arthropathy^[9][11]:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen come as tablets, creams, or gels and can help with mild symptoms. These are often the first medications tried^{[7][9][11][13]}.
• Steroid injections deliver steroid medicine directly into a joint to help ease pain and reduce swelling^[7][9].
• Disease-modifying anti-rheumatic drugs (DMARDs) are used for moderate to severe symptoms. These drugs work on the immune system to reduce inflammation and prevent damage. Common DMARDs include methotrexate, sulfasalazine, leflunomide, and azathioprine. DMARDs can take several months to work, so it’s important to keep taking them even if you do not feel better right away^{[7][9][11][13]}.
• Biological treatments (biologics) are usually given by injection and can be used if DMARDs do not help. Biologics target specific parts of the immune system rather than affecting the entire immune system. Common biologics include adalimumab, etanercept, infliximab, golimumab, certolizumab pegol, secukinumab, ixekizumab, ustekinumab, guselkumab, risankizumab, and abatacept^{[7][8][9][11]}.
• Targeted synthetic DMARDs such as apremilast and Janus kinase (JAK) inhibitors like tofacitinib and upadacitinib work by targeting specific pathways in the immune system^[8][9][11].

If a medicine does not help with your symptoms, tell your doctor. Another medicine may work better for you^[7][16]. Figuring out what works best may take trial and error, so be patient, stay positive, and be open with your doctor^[5].

Other treatments

In addition to medication, other treatments can help manage symptoms:

• Physical therapy can teach you exercises to help strengthen your joints, prevent joint damage, and maintain flexibility. A physical therapist can work with you to help maintain joint and muscle strength^{[7][9][13][19]}.
• Occupational therapy can help you find ways to do daily tasks more easily. An occupational therapist may recommend equipment or adjustments at home and work that make certain tasks easier^[7][9][19].
• Surgery may be considered in severe cases. Patients in severe pain or with significant joint damage may be referred for procedures like joint replacement or synovectomy (removal of inflamed joint lining)^[13].

Treatment needs to be monitored regularly. Frequent visits with your rheumatologist ensure your treatment stays on track and allow you to explore other treatment options as needed^[13]. If long-term remission is achieved with no joint damage, there may be a conversation about decreasing treatment, but this must be done carefully because there is always potential for relapse^[13].

Living with psoriatic arthropathy

You play a big role in controlling your psoriatic arthropathy. In addition to sticking with your medications, there are many steps you can take to keep doing the things you love and manage your symptoms^[5].

Weight management

Maintaining an ideal body weight is essential for psoriatic arthropathy. Losing weight can be difficult, but fat cells produce chemicals that fuel inflammation. This means your medications won’t work as well if you are overweight^[5][21]. Even a little weight loss can make a difference, but the biggest weight losses bring the biggest benefits^[5]. Losing 10% of body weight in people who are overweight or obese is like adding a new treatment^[13].

Exercise and physical activity

Regular exercise is one of the best things you can do. It’s hard to think of an aspect of psoriatic arthropathy that physical activity doesn’t help. Exercise can reduce inflammation, keep your joints mobile, help with weight loss, strengthen bones, lungs, and heart, and improve mood and sleep^[5][18][21].

Exercise will not harm your joints or cause more pain. You don’t have to do only gentle exercises—few exercises are off-limits for people with arthritis. Aim for 30 minutes of cardiovascular exercise most days and weight training at least twice a week^[18]. Low-impact exercises like swimming, walking, yoga, and tai chi can help strengthen and protect your joints^[7][17].

However, it may not be appropriate to start a new exercise program if you are in the middle of a flare. If tendons or joints are inflamed, high-impact exercise is best avoided until you recover^[21].

Healthy eating

An anti-inflammatory or Mediterranean-style diet can improve symptoms. The idea is to eat mainly fruits, vegetables, nuts, fatty fish (like salmon, sardines, mackerel, or cod), and extra-virgin olive oil. Limit red meat, sugar, and processed foods^[18]. If making big changes to your diet feels overwhelming, start with one change at a time^[18].

Stress management

Stress is a common trigger for psoriasis flares and can affect the immune system^[3][18][19]. The combination of inflammation and stress can make you even more sensitive to pain^[17]. Find healthy ways to manage stress that work for you—this could include meditation, yoga, deep breathing, walking in nature, spending time with pets, or pursuing hobbies^[18][19].

Smoking and alcohol

If you smoke, quit. Studies show that stopping smoking is the best thing you can do for yourself. It will lower your disease activity and make your medications work better^[18]. Do not smoke because it can make symptoms worse^[7][16]. Cut down on alcohol, especially if you’re taking medicines, as alcohol can affect how medications work^[7][16].

Sleep and rest

Getting enough sleep helps your joints relax and recover at the end of each day and helps you manage stress better^[17]. Stick to a regular bedtime and avoid taking technology to bed with you^[17].

Hot and cold therapy

Ice and heat therapy can complement each other. Ice constricts blood vessels to help reduce inflammation, while heat increases circulation and relaxes stiff muscles^[17][19]. Generally, apply heat or cold for about 15 minutes at a time^[17].

Adaptive devices and daily living

Adaptive devices like finger grips, large-handled utensils, and grab bars can help ease strain on your hands, wrists, and fingers during daily activities^[19]. Comfortable shoes with extra toe room and cushioned insoles can help ease stress on your foot and leg joints^[18].

Learn and track

Learn all you can about psoriatic arthropathy. Keep a daily journal of your symptoms, pain levels and locations, energy, stress levels, and other information to share with your doctor and track your progress^[5]. Be aware of your psoriatic arthropathy and know what may trigger symptoms or flares for you personally^[21].

Support and resources

Consider enlisting family, friends, and work colleagues to help make your psoriatic arthropathy manageable, leading to a productive and enjoyable life overall^[21]. Look for resources such as support groups—organizations like the National Psoriasis Foundation offer several support programs that may be helpful^[21].

Build a healthcare team you trust. Keep up with regular doctor visits and follow-up appointments^[5][13]. Continue to see your primary care doctor for regular check-ups, as psoriatic arthropathy has been associated with other conditions affecting the heart, eyes, and gastrointestinal tract^[8][14].

It is important to treat psoriatic arthropathy no matter the severity. If left untreated, psoriatic arthropathy can cause permanent joint damage, which may be disabling^[14]. However, with proper treatment and self-care, psoriatic arthropathy is a manageable condition, and you can still live an active and productive life^[19].