Psoriatic arthritis

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Psoriatic arthritis
Other namesArthritis psoriatica, arthropathic psoriasis, psoriatic arthropathy
Psoriatic arthritis2010.JPG
Severe psoriatic arthritis of both feet and ankles. There is also damage to the nails.
Specialty Rheumatology

Psoriatic arthritis (PsA) is a long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis. [1] [2] The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance ("sausage digit"). [3] This often happens in association with damage to the nails such as small depressions in the nail (pitting), thickening of the nails, and detachment of the nail from the nailbed. [3] Skin damage consistent with psoriasis (e.g., red, scaly, and itchy plaques) frequently occur before the onset of psoriatic arthritis but psoriatic arthritis can precede the rash in 15% of affected individuals. [3] It is classified as a type of seronegative spondyloarthropathy.

Contents

Genetics are thought to be strongly involved in the development of psoriatic arthritis. [3] Obesity and certain forms of psoriasis are thought to increase the risk. [3]

Psoriatic arthritis affects up to 30% of people with psoriasis and occurs in both children and adults. [3] Some people with PsA never get psoriasis. [4]

The condition is less common in people of Asian or African descent and affects men and women equally. [3]

Signs and symptoms

Peripheral pain

The majority of patients with PsA experience peripheral joint involvement. [5] Pain, swelling, or stiffness in one or more joints is commonly present in psoriatic arthritis. [5] Psoriatic arthritis is inflammatory, and affected joints are generally red or warm to the touch. [5] Asymmetrical oligoarthritis, defined as inflammation affecting two to four joints during the first six months of disease, is present in 70% of cases. However, in 15% of cases, the arthritis is symmetrical. The joints of the hand that is involved in psoriasis are the proximal interphalangeal, the distal interphalangeal, the metacarpophalangeal joint, and the wrist. Involvement of the distal interphalangeal joints is a characteristic feature present in many cases. [6]

Enthesitis pain can spread over a wider area around the joint. [7]

In addition to affecting the joints of the hands and wrists, psoriatic arthritis may affect the fingers, nails, and skin. Sausage-like swelling in the fingers or toes, known as dactylitis, may occur. [5]

Pain can also occur in and around the feet and ankles, especially enthesitis in the Achilles tendon (inflammation of the Achilles tendon where it inserts into the bone) or plantar fasciitis in the sole of the foot. [5]

Axial pain

Approximately 25–70% of PsA patients have axial involvement. [8] Axial pain can occur in the area of the sacrum (the lower back, above the tailbone), [5] as a result of sacroiliitis or spondylitis, which is present in 40% of cases.

Nails

Nail pitting often accompanies distal interphalangeal joint involvement and may be essential in differentiating psoriatic arthritis from other diseases. [6] Psoriasis can also cause damage to the nails, such as pitting or separation from the nail bed, [5] onycholysis, hyperkeratosis under the nails, and horizontal ridging. [9]

Psoriasis

Psoriasis classically presents with scaly skin lesions, which are most commonly seen over extensor surfaces such as the scalp, natal cleft and umbilicus.

Fatigue

Fatigue may occur, sometimes described as extreme exhaustion that does not go away with adequate rest. The exhaustion may last for days or weeks without abatement.

Complications

Rare complications are uveitis in one or both eyes, slightly higher risk of heart conditions, and increased risks of Crohn's disease and of non-alcoholic fatty liver disease (NAFLD). [7]

Pattern of activity

Psoriatic arthritis may remain mild or may progress to more destructive joint disease. Periods of active disease, or flares, will typically alternate with periods of remission. In severe forms, psoriatic arthritis may progress to arthritis mutilans [10] which on X-ray gives a "pencil-in-cup" appearance. [3]

HLA-B27

Approximately 40–50% of individuals with psoriatic arthritis have the HLA-B27 genotype. [3] Whilst incidence of psoriatic arthritis is significantly higher among people positive for HLA-B27 (compared to the overall population), the vast majority of people with HLA-B27 will not have psoriatic arthritis. [11] For instance in the US HLA-B27 incidence is 6-8%, [11] whilst psoriatic arthritis incidence has been estimated at 0.06–0.25%. [12]

Causes

Psoriatic arthritis is an inheritable polygenic disease, with many genes known or theorized to contribute to its clinical presentation (or lack thereof). When someone with the genes for psoriatic arthritis comes into contact with certain substances, these substances may induce an autoimmune reaction, causing the immune system to target normal tissues in the body. The exact strength, location, and clinical effects of this reaction depend on which genes are involved for each individual. The substance that triggers the reaction is typically not known. [3]

Genomic analysis has identified several genes involved in some patients, notably genes related to class I MHC including HLA-B*08, HLA-B*27, HLA-B*38, and HLA-B*39. Other genes relating to the immune system and central tolerance may also be involved, such as interleukin receptor genes. Thematically, these genes are often those that identify human tissues as normal and healthy, or the genes in immune cells designed to recognize those identifiers. In the case of psoriatic arthritis, the genes targeting immune cells are overexpressed, which leads to an increase in the recruitment of phagocytic neutrophils present in psoriatic skin lesions, hereby increasing inflammation and phagocytosis of healthy cells. [13] If the genes are functioning abnormally, then the immune system has a higher risk of attacking normal tissues. [3]

Bone cells such as osteoclasts are theorized to be involved in patients with psoriatic arthritis, in contrast to most people with psoriasis whose bone cells are not significantly involved in the disease. [14]

Health and environmental factors known to be associated with psoriatic arthritis include: [3]

Diagnosis

There is no definitive test to diagnose psoriatic arthritis.

Several classification criterias have been proposed, but they have wide variability. [12]

A rheumatologist (a physician specializing in autoimmune diseases) may use physical examinations, health history, blood tests and x-rays to accurately diagnose psoriatic arthritis.

Factors that contribute to a diagnosis of psoriatic arthritis include the following:

Other symptoms that are more typical of psoriatic arthritis than other forms of arthritis include enthesitis (inflammation in the Achilles tendon (at the back of the heel) or the plantar fascia (bottom of the feet)), and dactylitis (sausage-like swelling of the fingers or toes). [15]

Imaging

Magnetic resonance images of the fingers in psoriatic arthritis. Shown are T1-weighted (a) pre-contrast and (b) post-contrast coronal images. Enhancement of the synovial membrane at the third and fourth proximal interphalangeal and distal interphalangeal joints is seen, indicating active synovitis (inflammation of the synovial membrane; large arrows). There is joint space narrowing with bone proliferation at the third proximal interphalangeal joint and erosions are present at the fourth distal interphalangeal joint (white circle). Extracapsular enhancement (small arrows) is seen medial to the third and fourth proximal interphalangeal joints, indicating probable enthesitis (inflammation of a tendon insertion). Psoriatic arthritis fingers ar1934-1.gif
Magnetic resonance images of the fingers in psoriatic arthritis. Shown are T1-weighted (a) pre-contrast and (b) post-contrast coronal images. Enhancement of the synovial membrane at the third and fourth proximal interphalangeal and distal interphalangeal joints is seen, indicating active synovitis (inflammation of the synovial membrane; large arrows). There is joint space narrowing with bone proliferation at the third proximal interphalangeal joint and erosions are present at the fourth distal interphalangeal joint (white circle). Extracapsular enhancement (small arrows) is seen medial to the third and fourth proximal interphalangeal joints, indicating probable enthesitis (inflammation of a tendon insertion).
Sagittal magnetic resonance images of the ankle region in psoriatic arthritis. (a) Short tau inversion recovery (STIR) image, showing high signal intensity at the Achilles tendon insertion (enthesitis, thick arrow) and in the synovium of the ankle joint (synovitis, long thin arrow). Bone marrow edema is seen at the tendon insertion (short thin arrow). (b, c) T1 weighted images of a different section of the same patient, before (panel b) and after (panel c) intravenous contrast injection, confirm inflammation (large arrow) at the enthesis and reveal bone erosion at tendon insertion (short thin arrows). Psoriatic arthritis ankle ar1934-3.gif
Sagittal magnetic resonance images of the ankle region in psoriatic arthritis. (a) Short tau inversion recovery (STIR) image, showing high signal intensity at the Achilles tendon insertion (enthesitis, thick arrow) and in the synovium of the ankle joint (synovitis, long thin arrow). Bone marrow edema is seen at the tendon insertion (short thin arrow). (b, c) T1 weighted images of a different section of the same patient, before (panel b) and after (panel c) intravenous contrast injection, confirm inflammation (large arrow) at the enthesis and reveal bone erosion at tendon insertion (short thin arrows).

Differential diagnosis

Several conditions can mimic the clinical presentation of psoriatic arthritis including rheumatoid arthritis, osteoarthritis, reactive arthritis, gouty arthritis, systemic lupus erythematosus, and inflammatory bowel disease-associated arthritis. [3]

In contrast to psoriatic arthritis, rheumatoid arthritis tends to affect the proximal joints (e.g., the metacarpophalangeal joints), involves a greater number of joints than psoriatic arthritis, and affect them symmetrically. [3] Involvement of the spinal joints is more suggestive of psoriatic arthritis than rheumatoid arthritis. [3] Rheumatoid factor (RF) and cyclic citrullinated peptide autoantibodies are typically found in the blood of people with RA, but not, as a rule, in those with PsA. [16] [17]

Comorbities may help differential diagnosis. [17]

Osteoarthritis shares certain clinical features with psoriatic arthritis such as its tendency to affect multiple distal joints in an asymmetric pattern. [3] Unlike psoriatic arthritis, osteoarthritis does not typically involve inflammation of the sacroiliac joint. [3]

Psoriatic arthritis sometimes affects only one joint and is sometimes confused for gout or pseudogout when this happens. [3]

Classification

There are five main types of psoriatic arthritis: [3] [18]

Management and Treatments

Because prolonged inflammation can lead to joint damage, early diagnosis and treatment to slow or prevent joint damage is recommended. [19]

The underlying process in psoriatic arthritis is inflammation; therefore, treatments are directed at reducing and controlling inflammation. The first-line initial treatment for most patients is a TNF inhibitor-type biological disease-modifying anti-rheumatic drug (DMARD). [20] [6]

Biological DMARDs

Biologics (also called biological response modifiers) are a class of therapeutics developed using recombinant DNA technology. Biologic medications are derived from living cells cultured in a laboratory. Unlike traditional DMARDS that affect the entire immune system, biologics target specific parts of the immune system. They are given by injection or intravenous (IV) infusion.

Biologics prescribed for psoriatic arthritis are TNF-α inhibitors, including infliximab, etanercept, golimumab, certolizumab pegol and adalimumab, as well as the IL-12/IL-23 inhibitor ustekinumab, [3] the IL-17A inhibitor secukinumab, [21] and the IL-23 inhibitor risankizumab.

Biologics may increase the risk of minor and serious infections. [22] More rarely, they may be associated with nervous system disorders, blood disorders or certain types of cancer.[ citation needed ]

Nonsteroidal anti-inflammatory drugs

Typically the medications first prescribed for psoriatic arthritis are NSAIDs such as ibuprofen and naproxen, followed by more potent NSAIDs like diclofenac, indomethacin, and etodolac. NSAIDs can irritate the stomach and intestine, and long-term use can lead to gastrointestinal bleeding. [23] [24] Coxibs (COX-2 inhibitors) e.g. celecoxib or etoricoxib, are associated with a statistically significant 50 to 66% relative risk reduction in gastrointestinal ulcers and bleeding complications compared to traditional NSAIDs, but carry an increased rate of cardiovascular events such as myocardial infarction (MI) or heart attack, and stroke. [25] [26] Both COX-2 inhibitors and other non-selective NSAIDS have potential adverse effects that include damage to the kidneys.

Conventional synthetic disease-modifying antirheumatic drugs

Oral small molecules such as methotrexate, leflunomide, cyclosporin, azathioprine, and sulfasalazine are used in persistent symptomatic cases without exacerbation. Rather than just reducing pain and inflammation, this class of drugs helps slow down or halt the progression of the disease, and to therefore limit the amount of joint damage that occurs. Most DMARDs act slowly and may take weeks or even months to take full effect. [27] [ needs update ] According to a recent Cochrane review, low dose oral methotrexate was slightly more effective than placebos. [28] Immunosuppressant drugs can also reduce psoriasis skin symptoms but can lead to liver and kidney problems and an increased risk of serious infection.[ citation needed ]

Phosphodiesterase-4 inhibitors

A first-in-class treatment option for the management of psoriatic arthritis is apremilast, a small molecule phosphodiesterase-4 inhibitor approved for use by the FDA in 2014. By inhibiting PDE4, an enzyme which breaks down cyclic adenosine monophosphate, cAMP levels rise, resulting in the down-regulation of various pro-inflammatory factors including TNF-α, interleukin 17 and interleukin 23, as well as the up-regulation of anti-inflammatory factor interleukin 10.

It is given in tablet form and taken by mouth. Side effects include headaches, back pain, nausea, diarrhea, fatigue, nasopharyngitis and upper respiratory tract infections, as well as depression and weight loss.

It was patented in 2014 and manufactured by Celgene. There is no current generic equivalent available on the market.

JAK inhibitors

The JAK1 inhibitors tofacitinib (Xeljanz) and upadacitinib (Rinvoq) are approved for the use in active psoriatic arthritis. [29] The TYK2 inhibitor deucravacitinib (Sotyktu), which has been approved for plaque psoriasis, is currently undergoing a Phase II clinical trial to evaluate the efficacy and safety on psoriatic arthritis. The Takeda TYK2 inhibitor TAK-279 recently demonstrated a 20% improvement in signs and symptoms of disease at week 12 as compared to placebo in a Phase II clinical trial. [30] Takeda also plans to initiate a Phase III clinical trial to evaluate the efficacy and safety of TAK-279. [30]

Other treatments

A review found tentative evidence of benefit of low level laser therapy and concluded that it could be considered for relief of pain and stiffness associated RA. [31]

Photochemotherapy with methoxsalen and long-wave ultraviolet light (PUVA therapy) are used for severe skin lesions. Doctors may use joint injections with corticosteroids in cases where one joint is severely affected. In psoriatic arthritis patients with severe joint damage orthopedic surgery may be implemented to correct joint destruction, usually with the use of a joint replacement. Surgery is effective for pain alleviation, correcting joint disfigurement, and reinforcing joint usefulness and strength.

Epidemiology

Reviews have found psoriatic arthritis incidence globally of 0.11%, with incidence in the USA of 0.06–0.25% [12] and in Europe of 0.19% (95% CI 0.16–0.32). [32] Other studies found an overall prevalence rate of 0.1-0.2%, affecting men and women equally, and an incidence rate of 0.006% annually, [11]

70% of people who develop psoriatic arthritis first show signs of psoriasis on the skin, 15% develop skin psoriasis and arthritis at the same time, and 15% develop skin psoriasis following the onset of psoriatic arthritis. [33] Some people with PsA never get psoriasis. [4]

Psoriatic arthritis can develop in people who have any level severity of psoriatic skin disease, ranging from mild to very severe. [34] Studies have found that obesity is a significant risk factor and predictor of disease outcome. [35] Other risk factors associated with an increase risk of developing psoriatic arthritis include severe psoriasis, nail psoriasis, scalp psoriasis, inverse psoriasis, and having a first-degree relative with psoriatic arthritis. [30]

Psoriatic arthritis tends to appear about 10 years after the first signs of psoriasis. [3] For the majority of people, this is between the ages of 30 and 55, but the disease can also affect children. The onset of psoriatic arthritis symptoms before symptoms of skin psoriasis is more common in children than adults. [36]

More than 80% of patients with psoriatic arthritis will have psoriatic nail lesions characterized by nail pitting, separation of the nail from the underlying nail bed, ridging and cracking, or more extremely, loss of the nail itself (onycholysis). [36] [12]

Enthesitis is observed in 30 to 50% of patients and most commonly involves the plantar fascia and Achilles’ tendon, but it may cause pain around the patella, iliac crest, epicondyles, and supraspinatus insertions [37]

Men and women are equally affected by this condition. [3] Like psoriasis, psoriatic arthritis is more common among Caucasians than African or Asian people. [3]

Prevention

Some focus has been made on attempting to prevent patients with psoriasis developing psoriatic arthritis. However once psoriatic arthritis is established, the inflammatory burden of psoriatic disease might not be susceptible to modulation in many patients. [38]

See also

Related Research Articles

<span class="mw-page-title-main">Arthritis</span> Type of joint disorder

Arthritis is a term often used to mean any disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, swelling, and decreased range of motion of the affected joints. In some types of arthritis, other organs are also affected. Onset can be gradual or sudden.

<span class="mw-page-title-main">Rheumatoid arthritis</span> Type of autoimmune arthritis

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involved, with the same joints typically involved on both sides of the body. The disease may also affect other parts of the body, including skin, eyes, lungs, heart, nerves, and blood. This may result in a low red blood cell count, inflammation around the lungs, and inflammation around the heart. Fever and low energy may also be present. Often, symptoms come on gradually over weeks to months.

<span class="mw-page-title-main">Psoriasis</span> Non-contagious skin disease

Psoriasis is a long-lasting, noncontagious autoimmune disease characterized by patches of abnormal skin. These areas are red, pink, or purple, dry, itchy, and scaly. Psoriasis varies in severity from small localized patches to complete body coverage. Injury to the skin can trigger psoriatic skin changes at that spot, which is known as the Koebner phenomenon.

<span class="mw-page-title-main">Ankylosing spondylitis</span> Type of arthritis of the spine

Ankylosing spondylitis (AS) is a type of arthritis from the disease spectrum of axial spondyloarthritis. It is characterized by long-term inflammation of the joints of the spine, typically where the spine joins the pelvis. With AS, eye and bowel problems—as well as back pain—may occur. Joint mobility in the affected areas sometimes worsens over time. Ankylosing spondylitis is believed to involve a combination of genetic and environmental factors. More than 90% of people affected in the UK have a specific human leukocyte antigen known as the HLA-B27 antigen. The underlying mechanism is believed to be autoimmune or autoinflammatory. Diagnosis is based on symptoms with support from medical imaging and blood tests. AS is a type of seronegative spondyloarthropathy, meaning that tests show no presence of rheumatoid factor (RF) antibodies.

Spondyloarthritis (SpA), also known as spondyloarthropathy, is a collection of clinical syndromes that are connected by genetic predisposition and clinical manifestations. The best-known clinical subtypes are enteropathic arthritis (EA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), and reactive arthritis (ReA). Spondyloarthritis typically presents with inflammatory back pain and asymmetrical arthritis, primarily affecting the lower limbs, and enthesitis, inflammation at bone-adhering ligaments, tendons, or joint capsules.

<span class="mw-page-title-main">Monoarthritis</span> Medical condition

Monoarthritis, or monoarticular arthritis, is inflammation (arthritis) of one joint at a time. It is usually caused by trauma, infection, or crystalline arthritis.

<span class="mw-page-title-main">Reactive arthritis</span> Inflammatory arthritis triggered by infection elsewhere in the body

Reactive arthritis, previously known as Reiter's syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infection can trigger the disease. By the time a person presents with symptoms, the "trigger" infection has often been cured or is in remission in chronic cases, thus making determination of the initial cause difficult.

<span class="mw-page-title-main">Sacroiliitis</span> Inflammation of the sacroiliac joint of the pelvis

Sacroiliitis is inflammation within the sacroiliac joint. It is a feature of spondyloarthropathies, such as axial spondyloarthritis, psoriatic arthritis, reactive arthritis or arthritis related to inflammatory bowel diseases, including ulcerative colitis or Crohn's disease. It is also the most common presentation of arthritis from brucellosis.

A TNF inhibitor is a pharmaceutical drug that suppresses the physiologic response to tumor necrosis factor (TNF), which is part of the inflammatory response. TNF is involved in autoimmune and immune-mediated disorders such as rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel disease, psoriasis, hidradenitis suppurativa and refractory asthma, so TNF inhibitors may be used in their treatment. The important side effects of TNF inhibitors include lymphomas, infections, congestive heart failure, demyelinating disease, a lupus-like syndrome, induction of auto-antibodies, injection site reactions, and systemic side effects.

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<span class="mw-page-title-main">Childhood arthritis</span> Medical condition

Childhood arthritis is an umbrella term used to describe any rheumatic disease or chronic arthritis-related condition which affects individuals under the age of 16. There are several subtypes that differentiate themselves via prognosis, complications, and treatments. Most types are autoimmune disorders, where an individual's immune system may attack its own healthy tissues and cells.

Interleukin 20 receptors (IL20R) belong to the IL-10 family. IL20R are involved in both pro-inflammatory and anti-inflammatory immune response. There are two types of IL20R: Type I and Type II.

<span class="mw-page-title-main">Arthritis mutilans</span> Medical condition

Arthritis mutilans is a rare medical condition involving severe inflammation damaging the joints of the hands and feet, and resulting in deformation and problems with moving the affected areas; it can also affect the spine. As an uncommon arthropathy, arthritis mutilans was originally described as affecting the hands, feet, fingers, and/or toes, but can refer in general to severe derangement of any joint damaged by arthropathy. First described in modern medical literature by Marie and Leri in 1913, in the hands, arthritis mutilans is also known as opera glass hand, or chronic absorptive arthritis. Sometimes there is foot involvement in which toes shorten and on which painful calluses develop in a condition known as opera glass foot, or pied en lorgnette.

A Janus kinase inhibitor, also known as JAK inhibitor or jakinib, is a type of immune modulating medication, which inhibits the activity of one or more of the Janus kinase family of enzymes, thereby interfering with the JAK-STAT signaling pathway in lymphocytes.

<span class="mw-page-title-main">Enteropathic arthropathy</span> Medical condition

Enteropathic arthropathy commonly referred to as enteropathic arthritis, is a type of arthritis linked to Crohn's disease, ulcerative colitis, and chronic inflammatory bowel diseases.

<span class="mw-page-title-main">Secukinumab</span> Monoclonal antibody against IL-17

Secukinumab, sold under the brand name Cosentyx among others, is a human IgG1κ monoclonal antibody used for the treatment of psoriasis, ankylosing spondylitis, and psoriatic arthritis. It binds to the protein interleukin (IL)-17A and is marketed by Novartis.

<span class="mw-page-title-main">Axial spondyloarthritis</span> Medical condition

Axial spondyloarthritis is a chronic, immune-mediated disease predominantly affecting the axial skeleton. The term itself is an umbrella term characterizing a diverse disease family united by shared clinical and genetic features, such as the involvement of the axial skeleton. The 2009 introduced term axial spondyloarthritis is a preferred term nowadays and substitutes the old term ankylosing spondylitis.

<span class="mw-page-title-main">Antiarthritics</span> Drug class

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Epigenetics of autoimmune disorders is the role that epigenetics play in autoimmune diseases. Autoimmune disorders are a diverse class of diseases that share a common origin. These diseases originate when the immune system becomes dysregulated and mistakenly attacks healthy tissue rather than foreign invaders. These diseases are classified as either local or systemic based upon whether they affect a single body system or if they cause systemic damage.

Acquired hand deformity refers to the structural or functional abnormalities that develop in the hand. There are multiple varying causes of acquired hand deformity, triggering significant consequences and complications. Trauma, including blunt force, penetrating injuries, burns, and sports-related incidents, is a primary cause of acquired hand deformities. Inflammatory conditions such as rheumatoid arthritis, gouty arthritis, and systemic lupus erythematosus can also contribute to hand deformities by affecting the joints. Degenerative arthritis, specifically osteoarthritis, functions to evoke impaired hand function due to the gradual deterioration of cartilage. Neurological disorders like cerebral palsy can result in hand contractures due to increased muscle tone and stiffness. There are different types of acquired hand deformities, each with distinct characteristics and underlying causes, such as boutonnière deformity, Dupuytren's contracture, gamekeeper's thumb, hand osteoarthritis deformity, mallet finger, swan-neck deformity, ulnar claw hand, among many others.

References

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