Remember those weird commercials about the “heartbreak of psoriasis?” Though the ad prompted ridicule, psoriasis is no joke. Neither is a related condition, psoriatic arthritis.
The National Psoriasis Foundation reports that psoriasis is the most prevalent autoimmune disease in the United States, and as many as 7.5 million Americans suffer from the condition. Psoriatic arthritis is second only to rheumatoid arthritis when it comes to forms of inflammatory arthritis; it can cause pain, stiffness, swelling of the joints and permanent joint destruction. Effective treatments are available, but there is no cure.
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Some 15 to 20 percent of people who suffer from psoriasis — scaly red and white patches on the skin — also develop psoriatic arthritis. It is sometimes diagnosed in people who don’t have psoriasis if relatives have the disease. The American College of Rheumatology reports that psoriatic arthritis usually develops in people between 30 and 50, though it can start in childhood. Women and men are equally at risk.
Relationship to Rheumatoid Arthritis
“For a long time, medical experts thought what we now know as psoriatic arthritis was a coexistence of rheumatoid arthritis and psoriasis. About 50 years ago, they began to realize the pattern is different,” said Dr. Neal Birnbaum, director of the Division of Rheumatology at California Pacific Medical Center, a clinical professor of medicine at the University of California in San Francisco and past president of the American College of Rheumatology.
“Psoriatic arthritis can range from mild to terrible,” Birnbaum added. “As with any kind of arthritis, it can cause significant pain and make the tasks of daily living difficult. No blood test confirms you have it, and diagnosing it can be difficult. That’s why you may need a rheumatologist.”
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My own mild case of psoriatic arthritis was first diagnosed as gout when, 10 years ago, three of my toes swelled up like little sausages. The toes responded well to the anti-inflammatory medication prescribed by my internist, shrinking back to normal — and then they grew again.
Next, I was sent to a podiatrist. On the third visit, he recommended I see a rheumatologist, who made the correct diagnosis, but too late to save my toes from joint damage.
Nevertheless, the condition has not stopped me from chasing buses or dancing or going where I want to go. As with other forms of arthritis, discomfort from psoriatic arthritis can be eased with mild exercise.
Types of Psoriatic Arthritis
Birnbaum noted there are several types of psoriatic arthritis, affecting different joints and causing varying levels of damage. Sometimes the small joints at the ends of the fingers and toes are involved. One type causes back or neck pain and stiffness.
The most severe type, in 5 percent of all cases, can cause severe inflammation that damages the joints and may result in deformation or shortening of the fingers.
Symptoms of the Disorder
According to the National Psoriasis Foundation, symptoms of psoriatic arthritis include:
- generalized fatigue
- tenderness, pain and swelling over tendons
- swollen fingers and toes
- stiffness, pain, throbbing, swelling and tenderness in one or more joints
- reduced range of motion
- morning stiffness and tiredness
- changes in nails — separation or pitting or infections resembling nail fungus
- redness and pain of the eye, such as conjunctivitis
“Particularly suspicious for psoriatic arthritis are swelling of the small joints on fingers with pitted nails and ‘sausaging,’ or profuse swelling, of any finger or toe,” Birnbaum said. “Anyone with psoriasis who develops joint pain should be evaluated by a dermatologist or rheumatologist.”
Breakthrough in Treatment
Methotrexate, a drug used as chemotherapy in the 1950s, has been used in low doses for decades to treat psoriatic arthritis and other forms of arthritis, as have nonsteroidal anti-inflammatory drugs. Then, in the late 1990s, biological response modifiers (known as “biologics”) were introduced.
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“The biologics were a big breakthrough, and it’s been a different ballgame ever since,” Birnbaum said. Several biologics are available. Given by injection or intravenous infusion, the medications are derived from living cells that target specific parts of the immune system.
The biologics used today to treat psoriatic arthritis include Cimzia, Enbrel, Humira, Remicade, Simponi and Stelara. Sometimes, these medications are prescribed in conjunction with other medications; sometimes they are prescribed alone. In some people, the biologics cause infections ranging from minor to serious. In rare instances, biologics may be linked to development of nervous system disorders, blood disorders or certain types of cancer.
“When you look at the risk/benefit analysis, the biologics are easy to prescribe,” Birnbaum said. “All in all, they are very effective and quite safe.” They are expensive however, often several thousand dollars a month, a consideration that Birnbaum noted makes some people anxious. In many cases, insurance companies cover most of the cost. Also, some manufacturers offer assistance programs to help people who can’t afford the biologics.
One year ago, the U.S. Food and Drug Administration approved Otezla, a new pill that blocks an enzyme involved in inflammation in psoriatic arthritis. “This pill looks like it has a very good safety profile. It may not be quite as effective as some of the injectible biologics, but it can be paired with them,” Birnbaum said.
He added, “Overall, the outlook today for people with psoriatic arthritis is a lot better than it was 15 or 20 years ago, when we had people go on disability because of the disease — and that is cause to be upbeat.”