Juvenile Psoriatic Arthritis

Juvenile psoriatic arthritis is a form of arthritis that affects some children with psoriasis, causing joint inflammation, skin changes, and other symptoms that can range from mild to severe.

Table of contents

• What is juvenile psoriatic arthritis?
• Causes and genetics
• Signs and symptoms
• How is it diagnosed?
• Treatment options
• Outlook and disease course

What is juvenile psoriatic arthritis?

Juvenile psoriatic arthritis is a form of arthritis that affects some people with psoriasis, which is a long-lasting skin and nail disease. Psoriasis causes red, scaly rashes and thick, pitted fingernails.^[1] This condition is a form of juvenile idiopathic arthritis (JIA), which is a term for arthritis that begins before the age of 16 and has no known cause.^[3]

About one-third of children with psoriasis will develop psoriatic arthritis.^[1] It is characterized by ongoing joint inflammation and swelling, as well as an increased risk for eye inflammation that may not cause symptoms.^[1] The condition accounts for approximately 5 to 6 percent of all cases of juvenile arthritis.^[1][3]

Not all children with psoriatic arthritis have the psoriasis skin rash. In many cases, the skin disease starts before the arthritis, but in some children, arthritis develops before the psoriasis appears.^[4][5] This can make diagnosis more difficult.

Recent studies suggest that there may be different subgroups of patients with juvenile psoriatic arthritis based on age of onset and clinical features. A two-phase pattern has been noted, with early-onset disease characterized by female predominance, small joint involvement, and certain antibodies in the blood. Late-onset juvenile psoriatic arthritis resembles adult-onset disease, with male predominance, psoriasis, and inflammation where tendons and ligaments attach to bone.^[6]

Causes and genetics

The cause of psoriatic arthritis is not known. However, factors such as the immune system and the environment may play a role.^[1][4] This is an autoimmune condition, which means the body’s immune system mistakenly attacks its own healthy tissues.^[4]

Genetics also appear to be involved. Between 40 and 80 percent of children with psoriatic arthritis have an affected first- or second-degree family member, such as a sibling, parent, grandparent, or aunt or uncle.^[1] Children with this condition often have a family member with arthritis or psoriasis.^[5]

Signs and symptoms

The symptoms of psoriatic arthritis vary from child to child and range from mild to severe.^[1] Each child’s symptoms may differ, and not all children with psoriatic arthritis have the psoriasis skin rash.^[1]

Children with psoriatic arthritis may have any of the following symptoms:

• Swelling of the small and large joints, often in the fingers and toes^[1]
• Inflamed, swollen, and painful joints^[5]
• Morning stiffness in the joints^[1]
• Inflammation where the tendons and ligaments attach to bone, called enthesitis^[1]
• Swelling of an entire finger or toe, called dactylitis, which makes them look like sausages^[1]
• Arthritis of the lower back, called sacroiliitis^[1]
• Arthritis of the spine, called spondylitis, which is more common in older children^[1][5]
• Inflammation of the eyes, called uveitis, which can cause eye pain and redness^[1][5]
• Back pain or stiffness^[1]
• Pitting or peeling of the nails^[1]
• Red nail beds or cuticles^[1]
• Reddened skin over the affected joints^[5]
• Severe tiredness, also called fatigue^[5]

When psoriasis is present, it causes a scaly, red, itchy rash on the knees, elbows, scalp, face, and the folds of the buttocks. It can also appear inside the belly button or behind the ears.^[5][8] The skin condition may start before or after the arthritis.^[5]

Sausage-like swelling of fingers and toes, plus swollen wrists, is more common in girls ages 1 to 6.^[5] Deformed joints can develop from ongoing inflammation if the condition is not treated.^[5]

How is it diagnosed?

According to the classification system used by doctors, juvenile psoriatic arthritis is diagnosed in children or teenagers with arthritis AND either psoriasis or two of the following symptoms: typical nail changes seen in psoriasis called nail pits (little dents in the fingernails or toenails), dactylitis (sausage-like swelling of the fingers or toes), or a first-degree family member (parent or sibling) with psoriasis.^[3][8]

It is easier to confirm the diagnosis if your child already has psoriasis. If the skin symptoms have not yet occurred, diagnosis may be harder.^[5] Your child’s health care provider will take your child’s health history and do a physical exam. They will ask about your child’s symptoms.^[5]

Your child may have blood tests, such as:

• Erythrocyte sedimentation rate (ESR or sed rate): This test looks at how quickly red blood cells fall to the bottom of a test tube. When swelling and inflammation are present, the blood’s proteins clump together and become heavier than normal. They fall and settle faster at the bottom of the test tube. The faster the blood cells fall, the more severe the inflammation.^[5]
• Uric acid: High blood uric acid levels are linked to psoriatic arthritis.^[5]
• Complete blood count: This test checks for low counts of red blood cells (anemia), white blood cells, and platelets.^[5]
• Antibody blood tests: These tests look for certain kinds of proteins, called antibodies, in the blood. These tests can be positive for many kinds of rheumatic diseases. Younger children are more likely to have a positive antinuclear antibody test.^[5]

Other tests may include:

• X-rays: This test uses a small amount of radiation to create images of organs, bones, and other tissues.^[5]
• Eye exam: This is done by a pediatric eye care provider (ophthalmologist). The exam looks for uveitis, which is a swelling of the middle layer of the eye.^[5]

Early diagnosis and treatment help to ease pain and prevent joint damage from getting worse.^[4]

Treatment options

Treatment for juvenile psoriatic arthritis depends on your child’s age and weight, symptoms and severity of the arthritis, area affected, and overall health.^[9] The treatment team will include your child’s primary health care provider, as well as a pediatric rheumatologist and an ophthalmologist.^[5] Treatment is done for both the skin condition and the joint inflammation.^[5]

The goal of treatment is to reduce or prevent joint damage. Once joint damage occurs, it is irreversible.^[9] More treatments are available now for juvenile psoriatic arthritis than ever before.^[9]

Pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs)

These medications, such as aspirin, ibuprofen, and naproxen, may be suggested by your child’s health care provider to help ease pain and reduce swelling related to psoriatic arthritis. The dosage is based on the age and weight of your child.^[9]

Corticosteroids

These medications can be given by pills or injection into an affected joint to help lower inflammation and reduce pain and swelling. The response occurs quickly and can last for months. However, corticosteroid injections are considered a short-term relief for severe disease flares. Corticosteroids can be used while waiting for other medications to take effect.^[9]

Oral systemics

These are medications that work more broadly throughout the body or target specific cells or parts of cells to reduce inflammation and swelling related to arthritis. Such medications may take several weeks or longer before relief occurs, so other medications such as NSAIDs may be used in combination. Examples include methotrexate, cyclosporine, leflunomide, or sulfasalazine. Methotrexate is the most commonly used treatment, with folic acid supplementation recommended.^[9]

Biologics and biosimilars

Biologics and biosimilars are medications that target specific proteins in the immune system that play a role in the development of psoriasis and psoriatic arthritis. By targeting specific proteins, biologics block parts of the immune system that cause inflammation and swelling. Biologics may offer relief within a few weeks and are given either by injection or intravenous infusion.^[9]

Examples of such medications used to treat active psoriatic arthritis in children and teens include:

• Tumor necrosis factor (TNF) inhibitors: Simponi Aria (golimumab), approved in 2020, is given by intravenous infusion in children ages 2 years and older. Enbrel (etanercept), approved in 2023, is given by injection in children ages 2 years and older.^[9]
• Interleukin-17 (IL-17A) inhibitor: Cosentyx (secukinumab), approved in 2021, is given by injection in children ages 2 years and older.^[9]
• Interleukin-12/23 (IL-12/23) inhibitor: Stelara (ustekinumab), approved in 2022, is given by injection in children ages 6 years and older. Wezlana (ustekinumab-auub) is an interchangeable biosimilar to Stelara and was approved in 2023 for children ages 6 years and older.^[9]
• T-cell inhibitor: Orencia (abatacept), approved in 2023, blocks T-cell activity and is given as an injection or infusion in children ages 2 years and older. It can be used either alone or with methotrexate.^[9]

Because few treatments have been approved for children and teens, your child’s health care provider may consider other options. Clinical trials continue to explore treatment options to help expand what medications can be used for children and teens.^[9]

Other treatment options

In addition to medication, other treatment options may include:

• Alternating for 10 minutes each between hot and cold packs to help reduce swelling and pain^[9]
• Occupational and physical therapy to help maintain joint and muscle strength and flexibility, and to assist with new techniques for daily activities^[9]
• Adaptive devices like finger grips, large-handled utensils, and bath and shower bars to ease the strain on hands, wrists, and fingers^[9]

Outlook and disease course

Some children and teenagers have relatively mild psoriatic arthritis, and others have a more severe form. For some, it may resolve during childhood, and for others, it may persist into adulthood.^[8]

Recent studies report improved outcomes, likely due to the widespread use of traditional and biologic disease-modifying medications.^[6] However, data suggests that the condition can have aggressive characteristics: one study found that 24.6 percent of children have joint damage 4.6 years after symptom onset.^[6]

While this is a long-lasting condition, if you have been diagnosed with psoriatic arthritis, you can still live an active and productive life. Learning how to manage the disease is one of the most important tools for living with a chronic illness.^[20]

Maintaining a healthy weight, following a balanced diet, staying physically active, and managing stress are all important aspects of managing psoriatic arthritis and preventing other health conditions.^[17] Working closely with your rheumatologist and following the prescribed treatment plan is essential.^[20]