Orthopedics

Psoriatic arthritis is a chronic, immune-related disease marked by swelling in the joints or ligaments (arthritis, enthesitis, spondylitis, and dactylitis). It is usually found in people with psoriasis. About 30% of people with psoriasis may develop this form of arthritis, which can negatively affect the joints in their fingers, spine, and tendon attachments.

Disorders from psoriasis often lead to psoriatic arthritis in unique ways.

• Having skin psoriasis is most common, and it usually takes years before joint inflammation appears.
• Sometimes, people show skin and joint symptoms at the same time.
• A small number of patients have joint pain and stiffness as their initial signs of psoriasis.
• Typical psoriatic arthritis may appear in patients who never experience skin symptoms of psoriasis¹

Psoriatic arthritis and psoriasis are autoimmune diseases in which the immune system mistakenly attacks the body's healthy tissues. These diseases do not have a cure; hence, timely diagnosis and treatment are the only ways to reduce the severity of the discomfort and pain caused by them.

However, its symptoms are manageable. The inflammation, flare-ups, joint damage, and pain can be brought down with medication and other therapies. If this psoriatic arthritis goes unaddressed, the results can cause long-term damage and disability. 

New studies suggest that inflammatory proteins stop synovial cells from growing, resulting in the buildup of abnormal tissue in psoriatic arthritis². The main parts of this autoimmune process are:

• An immune system problem causes the body to attack its own healthy joints and skin.
• During an inflammatory cascade, particular proteins (cytokines) cause widespread inflammation.
• Joints can be damaged, and lesions on the skin can develop if inflammation continues without treatment

People with psoriatic arthritis may experience symptoms not only in their joints and skin but also in other parts of the body, such as the eyes, heart, lungs, and gastrointestinal system.

Psoriatic arthritis and psoriasis can worsen if not treated on time. The patient will experience "flare-ups," i.e., symptoms that can manifest as mild to severe sporadically. They may even go away or improve on their own, but only temporarily. Different symptoms of psoriatic arthritis may look very different in each person. It resembles rheumatoid arthritis, appearing in many joints on the hands, knees, feet, and elbows.

The main symptoms in the Musculoskeletal System are:

• Pain and tenderness in the peripheral joints are usually not the same on both sides.
• Dactylitis: There is complete swelling of the fingers or toes, causing them to resemble a sausage.
• Enthesitis: Inflammation occurs where tendons and ligaments attach to the bones.
• Lower back pain and stiffness, similar to ankylosing spondylitis, are symptoms of spinal involvement.
• Morning stiffness: Joints stay tough and rigid to bend for a duration of more than 30 minutes after waking

• Ocular issues: Uveitis (eye inflammation), conjunctivitis, dry eyes
• Nail defects may include pitting, separation from the bed (onycholysis) or discolouration.
• Typical skin lesions often occur before any joint symptoms.
• There are systemic symptoms such as continuous tiredness and lowered overall well-being.

Problems in the digestive tract: Higher risk of inflammatory bowel disease. 

If your family members have psoriatic arthritis, there are high chances for you to develop it too. Factors like infections, injuries, smoking, and being overweight or obese due to a sedentary lifestyle can serve as catalysts. Some people can also develop psoriatic arthritis despite having no family history.

Psoriatic arthritis diagnosis

You should see a doctor if you develop joint pain because psoriatic arthritis can degenerate joints, bones, and tissues. You will be referred to a rheumatologist. They diagnose and treat conditions that affect the joints, bones, ligaments, and tendons. There is no specific test that can lead to a psoriatic arthritis diagnosis.

Sometimes it also becomes difficult for the doctor to determine whether the patient has psoriatic arthritis, rheumatoid arthritis, osteoporosis, or gout. Some preliminary tests can give clarity. These are as follows:

Physical exam: The doctor will investigate whether you have any joint tenderness and swelling. They will also check for scaliness, red and flaky skin on the body, and pitting of the nails, which are all common signs of psoriatic arthritis.

Imaging tests: MRIs (Magnetic resonance imaging), ultrasound scans, and X-rays may be done for greater clarity and to check for swelling and inflammation that is not visible to the naked eye.

Lab testing: The doctor will do a Rheumatoid factor test to determine whether the patient has rheumatoid arthritis or psoriatic arthritis. Rheumatoid factor is a protein that attacks healthy cells in the body. High amounts indicate the presence of rheumatoid arthritis. Besides this test, the doctor may also take a sample of joint fluid to determine whether the patient has gout or psoriatic arthritis. Both these conditions can exist at the same time. 

Psoriatic arthritis may prove difficult to diagnose since most people with the condition lack the common indicators that appear during blood tests. This implies that physicians regularly have to consider symptoms and health history to determine whether an individual has PsA or not.

The decisions that doctors make to determine that it is PsA:

• They ask whether the individual has psoriasis (a skin condition that causes redness and scaling). The presence of psoriasis today is considered an added value to the diagnosis, and even the history of psoriasis is relevant.
• Symptoms they seek out include swollen fingers or toes (a.k.a sausage digits) that are typical of PsA.
• Another indicator may be changes in the nails, such as pitting or thickening, because psoriasis usually involves the nails.
• Physicians can analyse blood to eliminate rheumatoid arthritis, which is another form of arthritis.
• Imaging studies such as X-rays, ultrasound, or the MRI can be used to detect a change or changes in the joints or bones, which are not noticeable yet and indicate PsA.³

It is important to diagnose Psa at an early stage so that non-treatment may cause disability and joint destruction. However, since the symptoms may also be diverse and may overlap with other conditions, sometimes the diagnosis may be postponed.

The patients tend to go through the following:

• Stiffness and pain in joints, specifically in the morning
• Edema of the entire fingers or toes
• Any alterations of the skin or nails in association with psoriasis
• Inflammation of tendons where they attach to bones can cause back or heel pain in some cases.

Doctors use a checklist known as the CASPAR criteria to aid in diagnosis. This scoring system provides points for factors such as the presence of psoriasis, nail changes, abnormal blood tests for rheumatoid factors, and some symptoms of joints. When these points accumulate to a sufficient extent, they favor the diagnosis of PsA.

Laboratory Investigations:

• ESR and CRP are used to show the level of disease activity.
• Rheumatoid factor is typically absent (negative) in psoriatic arthritis.

You could have an HLA-B27 finding if you have spinal issues.

Besides seeing a rheumatologist, the patient may also have to see a dermatologist for their psoriasis. A physiotherapist can help with physical therapy to relax joints and allow better mobility. If psoriatic arthritis has affected your feet, then seeing a podiatrist who can make special insoles for your shoes so you can have a relaxing time walking and even standing should be helpful.

Today, management of psoriatic arthritis depends on guidelines that encourage early care and focus on the right therapies. The main purpose of treating psoriatic arthritis is to help patients achieve the best possible health-related quality of life by easing symptoms, avoiding damage, recovering full function, and participating socially.

• In case of mild psoriatic arthritis, different types of pain-relieving medication may be prescribed, including nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs) in the short term.

• In cases of greater severity, they usually begin to use a drug called methotrexate to help control inflammation and protect the joints.

• It is also recommended that treatment be received early in order to manage the symptoms and avoid joint destruction.
• Your doctor will assist you and develop the most appropriate treatment plans, including any necessary additional medicines.
• Healthy habits, such as exercising and avoiding cigarettes, in addition to the medicine, will also help reduce your condition.
• Surgery: This is only when the severity of joint damage is so great that knee replacement surgery is needed. It's not often that people with psoriatic arthritis need to go through a surgical procedure.

In many cases, a psoriatic arthritis patient may require knee replacement surgery.

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• Maintaining joint movement and health depends on physical therapy.
• Suggests changes in daily schedules and at work
• Involvement of dermatologists and ophthalmologists ensures proper care for skin and eye-related symptoms of PsA.
• Teaching patients about the disease which medications to take and how to change their lifestyle⁴

Psoriatic arthritis affects several parts of the body and needs detailed, evidence-based treatment. Lately, discovering new ways diseases work and developing new medicines has greatly improved how patients fair. Promptly identifying and treating rheumatology conditions and getting care from several medical professionals, can help save the joints and improve quality of life.

The change from old treatment methods to advanced targeted therapies has revolutionized the management of psoriatic arthritis, allowing patients to hope for enhanced long-term results and fewer challenges.