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Psoriatic Arthritis

What is psoriatic arthritis? Psoriatic arthritis is

What is psoriatic arthritis?Labelled plaque

Psoriatic arthritis is a type of arthritis that can be seen in people with psoriasis. Psoriasis is a chronic skin condition that can cause patches of inflamed, red or scaly skin. In most cases of psoriatic arthritis, psoriasis was present before the arthritis. However in a minority of people, arthritis occurs at the same time or even before the skin rash appears.

What causes psoriatic arthritis?

The exact cause of psoriatic arthritis is unknown. Genetic, immunologic and environmental factors seem to play a role in its development.

Symptoms of psoriatic arthritis

Psoriatic arthritis is an inflammatory type of arthritis. This means there is not only pain but also swelling and stiffness in the joint. Pain and stiffness are usually worse in the morning and improve throughout the day or with activity.

In addition, psoriatic arthritis has a few unique features:

  • It is essentially the only inflammatory arthritis that can involve the distal part of the fingers also known as DIPs. The other type of arthritis that commonly affects these joints is osteoarthritis, which is not an inflammatory arthritis.
  • It is one of the few types of inflammatory arthritis that can involve the spine (the other ones in this family, known as seronegative spondyloarthropathies, are ankylosing spondylitis, inflammatory bowel-disease associated arthritis, and reactive arthritis).
  • Nail abnormalities like pitting or crusting can be a harbinger of arthritis in the distal part of fingers
  • Unlike rheumatoid arthritis, which is usually symmetrical, psoriatic arthritis can be asymmetric. For example, it can affect the left knee and the right wrist only.
  • Psoriatic arthritis can sometimes cause swelling of an entire finger or toe, making a digit look like a sausage. This is known as “dactylitis” or “sausage digit”.
  • Psoriatic arthritis can be associated with inflammation of the area where tendons attach to bones. This is known as “enthesitis”. Some of the commonly affected tendons include the Achilles tendon (back of the heel) and plantar fascia (sole of the foot)

Besides the joints, People with psoriatic arthritis can sometimes experience iritis, which is inflammation and redness in the eye. People with psoriatic arthritis may also be at higher risk of heart disease and stroke.

Psoriatic_arthritis labelnail pitting label

 

 

Iritis PSADactylitis-6

 

How is psoriatic arthritis diagnosed?

Psoriatic arthritis is diagnosed by a combination of medical history, physical examination, labs and x-rays.

Medical history:

A personal history of psoriasis makes it more likely that your inflammatory arthritis is in fact psoriatic arthritis. Features of inflammatory arthritis may include pain that is worse in the morning, stiffness in the morning lasting more than 30 minutes, and improvement of pain and stiffness with activity.

Physical examination:

Presence of psoriasis, swelling in joints, joint tenderness in the distal part of fingers or toes, inflammation of the entire finger or toe, an asymmetric involvement of joints can be suggestive of psoriatic arthritis.

Laboratory studies:

There currently is no specific blood test to diagnose psoriatic arthritis. People with psoriatic arthritis usually have a negative rheumatoid factor and CCP antibody (both seen in rheumatoid arthritis). A small percentage may have a positive ANA, a nonspecific antibody which can be seen in a variety of diseases including lupus. Some people with psoriatic arthritis who also have involvement of their spine may have a positive HLA-B27.

X-rays:PsA xray

There are specific features that may clue a radiologist or rheumatologist to the presence of psoriatic arthritis. For example, the type of deformity that can be caused by psoriatic arthritis looks different from that of rheumatoid arthritis or osteoarthritis.

Psoriatic arthritis treatment:

Like all inflammatory arthritides, early treatment of psoriatic arthritis is associated with a greater chance of joint preservation and disease remission.

Treatment is usually selected based on severity of the disease, patient preference, and other medical conditions someone may have. Medications from each category may be used alone or in combination with a medication from another category to achieve maximum results if necessary.

    1. Nonsteroidal anti-inflammatory drugs (NSAIDs). In order for these drugs to be effective, it is usually recommended that they are taken regularly.
      • Examples include ibuprofen, naproxen, Celebrex, meloxicam, diclofenac
    2. Disease-modifying anti-rheumatic drugs (DMARDs). These oral medications decrease inflammation, reduce pain, and can prevent joint damage. Laboratory monitoring is required every 2-3 months.
      • Methotrexate
      • Sulfasalazine
      • Leflunomide
    3. Biologic drugs – these medications target a specific component of the immune system thereby decreasing inflammation and pain. They are administered either intravenously or subcutaneously.
      • TNF-inhibitors (Humira, Enbrel, Remicade, Simponi, Cimzia)
      • Stelara (Ustekinumab)
      • Cosentyx (Secukinumab)
      • Orencia (Abatacept) and Rituxan (Rituximab)- are currently being studied
    4. Otezla (Apremilast) – This oral drug suppresses multiple molecules that cause inflammation.

 

ALSO SEE

Ankylosing Spondylitis

Categories:

Diagnosis and Treatment of Ankylosing Spondylitis

How is it diagnosed?

Ankylosing spondylitis is diagnosed starting with a thorough history, asking about symptoms and risk factors discussed in previous sections. A detailed exam is necessary to find any kind of inflammatory back signs, peripheral arthritis, or extra-articular manifestations. Certain maneuvers and measurements should be performed in the office. Below are just a few exam techniques that may be used to diagnose AS, such as:Patrick's_test

  • Occiput-to-wall test: to measure the cervical spine range of motion
  • Chest expansion test: to measure the thoracic spine range of motion
  • Schober test: to measure lumbar spine range of motion
  • Patrick’s test: Also known as FABER test, to test to sacroiliac joint inflammation

 

 

After exam, certain labs can be ordered to check for inflammation (ESR and CRP levels). An HLA-B27 can also be checked through blood work if there is a high suspicion for AS. However, imaging helps greatly in the diagnosis. X-rays can show changes in the SI joint and lumbar spine (such as Bamboo Spine). If it is early in the disease course, an MRI may be needed to catch subtle changes, such as erosions or inflammation.

Ankylosing-spondylitis labeledNormal Lumbar

 

 

 

 

 

 

 

 

 

 

How is it treated?

Treatment is aimed at maintaining mobility of the joints (especially the vertebrae), decreasing stiffness, and decreasing pain. Some modifiable risks include smoking cessation and increasing exercise. Home exercises and stretches can be beneficial, but a supervised physical therapy program usually provides greater benefit. Exercises usually focus on postural training, range of motion stretching, recreational activities, hydrotherapy, and local treatment with heat and cold.nr55552058

When medications are decided on, Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually first line therapy. Examples of NSAIDs includes:

  • Ibuprofen (Advil, Motrin)
  • Naproxen (Aleve)
  • Meloxicam (Mobic)
  • Celecoxib (Celebrex)
  • Diclofenac (Voltaren)
  • and others…

NSAIDs are used to decrease pain and inflammation, and hopefully aim to control back pain and stiffness.

However, it the inflammation and symptoms are not controlled, the next step in therapy is biologic medications. The main-stay is Anti-TNF biologics, which work by blocking TNF-alpha, an important component of the immune system which causes inflammation and ultimately leads to joint damage. Examples include:

  • Adalimumab (Humira) – subcutaneous injection every 2 weeks
  • Etanercept (Enbrel) –  subcutaneous injection weekly
  • Infliximab (Remicade) – IV infusion every 2 – 8 weeks
  • Golimumab (Simponi) – subcutaneous injection monthly
  • Certolizumab (Cimzia) –  subcutaneous injection monthly

The newest FDA-approved medication for treatment is Secukinumab (Cosentyx), which works differently than the Anti- TNF medications. This medication inhibits an inflammatory protein known as IL-17, which is believed to play major role in other inflammatory diseases such as psoriatic arthritis, rheumatoid arthritis, and inflammatory bowel disease.

These medications are injectable or infusion based, and should be prescribed by a rheumatologist or trained physician. Steroids can be used, but show little long-term benefit. These medications all have possible side effects, and should be discussed with your rheumatologist prior to use.

Overall, if treated early and adequately, ankylosing spondylitis should not limit a patient’s daily life significantly, and patients can be expected to live a long, healthy life

 

MORE SECTIONS on AS

What is Ankylosing Spondylitis?

Signs and Symptoms of Ankylosing Spondylitis

 

ALSO SEE

Psoriatic Arthritis

 

References

https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Spondyloarthritis

https://www.uptodate.com/contents/clinical-manifestations-of-axial-spondyloarthritis-ankylosing-spondylitis-and-nonradiographic-axial-spondyloarthritis-in-adults?search=ankylosing+spondylits&source=search_result&selectedTitle=2%7E150

https://www.spondylitis.org/Ankylosing-Spondylitis

https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808

Categories:

Signs and Symptoms of Ankylosing Spondylitis

What are the symptoms of Ankylosing Spondylitis?

AS is characterized mainly by inflammatory back pain (described below). Inflammation can occur in several areas, leading to pain and stiffness. These include:1280px-Sacroiliac_joint_svg

  • Sacroiliac and spinal joints
  • Hip and shoulder joints
  • “Peripheral” arthritis: smaller joint such as the hands, wrists, elbows, knees, and feet
  • Joints involving the ribs, clavicle, and sternum and there attachments

Inflammatory back pain is usually reported in almost all AS patients. The characteristics of “inflammatory” back pain include:

  • Pain at night (that improves with waking up and moving)
  • Insidious onset
  • Improves with exercise
  • Does not improve with rest
  • Age of onset < 40 years old

Other bony symptoms include:

  • Impaired spinal mobility: inability to fully bend at the waist or move the neck. Chronic, untreated disease can lead to fusion of the spine. Fusion at the cervical spine limits neck motion, fusion at the thoracic spine limits chest expansion (and breathing), and fusion of the lumbar spine limits the way a person sits and bends
  • Abnormalities in posture: Patients can experience “hunching” of the back (hyperkyphosis) with long term disease, leading to a stooped posture
  • Buttocks and hip pain: Which can alternate sides depending on the sacroiliac joint that is involved
  • Enthesitis: inflammation at the attachment site of tendons and ligaments to bones that presents as pain and sometimes swelling. These include areas such as the Achilles tendon, the plantar fascia, and costochondral joints (cartilage of the ribs), and the superior iliac crest (areas of the pelvic bone)
  • Dactylitis: Also known as “sausage digits”. This occurs in about 6% of patients with AS

Dactylitisankylosing spondylitis 2

 

 

 

 

 

 

Symptoms can also occur that are not related to the joints or bones, known as “extra-articular” symptoms. These can be related to the active disease or complications of AS, and include:Iritis

  • Uveitis: Also known as Iritis. It is inflammation of the anterior portion of the eye. It is a common manifestation in AS patients with up to 35% of patients experiencing this sometime in there disease course. It can occur in one or both eyes, and can “jump” from eye to eye. Can be a one-time phenomenon, or recurrent, and usually improves when the AS is treated effectively
  • Lung issues: fibrosis of the lungs can occur from the inflammation (scar tissue formation), as well as restrictive lung disease from the inability to expand the chest
  • Heart disease: There is an increased risk of heart disease and acute coronary syndromes due to the active inflammation of the disease. Other cardiac manifestations include aortitis (inflammation of the aorta), conduction abnormalities, and pericarditis (inflammation of the lining of the heart).
  • Discitis: Inflammation of the vertebral discs
  • Kidney disease: Nephropathy from antibody deposition (IgA) and secondary amyloidosis from chronic inflammation
  • Neurologic conditions: Chronic inflammation and damage in the spine can affect the adjacent nerve roots or even the spinal cord itself
    • Cauda equine syndrome: damage to the lumbar nerve roots leading to sensation changes in the legs, impotence, and bladder and bowel incontinence
    • Spinal cord injury: mostly related to fractures, and can lead to paralysis
    • Atlantoaxial subluxation: instability in the C1 and C2 vertebrae, leading to compression of the spinal cord, which can also lead to paralysis

 

MORE SECTIONS on AS

What is Ankylosing Spondylitis?

Diagnosis and Treatment of Ankylosing Spondylitis

 

ALSO SEE

Psoriatic Arthritis

 

References

https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Spondyloarthritis

https://www.uptodate.com/contents/clinical-manifestations-of-axial-spondyloarthritis-ankylosing-spondylitis-and-nonradiographic-axial-spondyloarthritis-in-adults?search=ankylosing+spondylits&source=search_result&selectedTitle=2%7E150

https://www.spondylitis.org/Ankylosing-Spondylitis

https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808

Categories:

Ankylosing Spondylitis

What is Spondyloarthritis?

Spondyloarthropathies (or Spondyloarthritis) are a family of inflammatory disease that cause arthritis, and are different than other inflammatory arthritides because the can affect the spine and soft tissues such as tendons and ligaments (known as enthesitis). The 4 main spondyloarthropathies are ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and enteropathic arthritis associated with inflammatory bowel diseases (ulcerative colitis and Crohn’s disease).

Ankylosing Spondylitis is the most common condition from this group. Also known as AS, this form of arthritis primarily affects the spine, and can cause chronic pain, discomfort, stiffness, and eventually fusing of the bones, leading to decreased mobility.Blausen_0037_AnkylosingSpondylitis

Who gets it?

There are several risk factors to be aware of for AS. These include:

Age: Unlike most other forms of arthritis, AS is usually seen in younger people. It usually begins in the teens or 20’s, with typical age of onset anywhere from age 17 – 45

Gender: It is likely to happen in 2 – 3 times more frequently in the males than females, unlike many other rheumatologic conditions

Genetics: Having a family member with AS puts a patient at higher risk of getting it, partly due to an inherited gene known as the HLA-B27 gene. The HLA-B27 gene is actually present in about 8% of healthy individuals in society. Of this 8% of people with a positive HLA-B27 gene, only 2% of them develop ankylosing spondylitis. If you have a first degree relative that is affected and you are HLA-B27 positive, your risk increases to 15 – 20%. Though infrequent, 90% of white AS patients and 50 – 80% of non-white AS patients have a positive HLA-B27.

Race: The highest frequency of this condition is in more northern populations, such as Scandinavians, Alaskans, Siberian Eskimos, and Native American tribes. These populations have a higher prevalence of the HLA B-27 genes, and the prevalence of the disease decreases from north to south as you near the equator. African Americans seem to be affected the least of all races.

What exactly happens in the disease?

It is not completely understood how the condition occurs, but it seems to start after some kind of triggering event in genetically susceptible individuals (HLA-B27 positive). The trigger has been hypothesized to be some type of infection, exposure to an unknown antigen, or molecular mimicry where your body confuses itself with an infecting organism.

 

MORE SECTIONS on AS

Signs and Symptoms of Ankylosing Spondylitis

Diagnosis and Treatment of Ankylosing Spondylitis

 

ALSO SEE

Psoriatic Arthritis

 

References

https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Spondyloarthritis

https://www.uptodate.com/contents/clinical-manifestations-of-axial-spondyloarthritis-ankylosing-spondylitis-and-nonradiographic-axial-spondyloarthritis-in-adults?search=ankylosing+spondylits&source=search_result&selectedTitle=2%7E150

https://www.spondylitis.org/Ankylosing-Spondylitis

https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808

Categories: