Psoriatic Arthritis

Overview

Psoriasis affects about one percent of the population in North America. Psoriatic arthritis is an inflammatory arthritis seen in 4 to 6 percent of patients with psoriasis.
The exact etiology of psoriatic arthritis is unclear. Genetic, immunologic and environmental elements are thought to play a role. Psoriasis and psoriatic arthritis have a familial clustering. The disease is much more likely to occur in first-degree relatives of affected individuals than in the general population or in spouses. Psoriatic arthritis is an inflammatory disease with articular and extra-articular features. The onset of arthritis is usually insidious, but it can occur acutely. There are five general patterns of psoriatic arthritis:

  • Arthritis of the distal interphalangeal joints
  • Destructive (mutilans) arthritis
  • Symmetric polyarthritis indistinguishable from rheumatoid arthritis
  • Asymmetric oligoarthritis
  • Spondyloarthropathy

Frequently Asked Questions

What are the symptoms of Psoriatic Arthritis?
Patients usually present with pain and swelling in the affected joints. Patients with psoriatic arthritis have been found to be less tender than patients with rheumatoid arthritis. 53 percent of patients with polyarticular disease tend to demonstrate symmetry. There is no direct relation between the severity of skin lesions and the degree of joint inflammation in psoriatic arthritis.
Spondyloarthropathy develops in 20 to 40 percent of the patients, but rarely is detected at the onset of disease. It tends to affect men and older patients and begins later in the course of the disease.
Other clinical features of psoriatic arthritis include dactylitis (swelling of an entire digit), tenosynovitis (swelling of a tendon), and enthesitis (swelling of a tendon at its insertion into a bone).

How is Psoriatic Arthritis diagnosed?
No diagnostic or classification criteria for psoriatic arthritis exist. The diagnosis is usually made when a patient with psoriasis presents with features of an inflammatory arthritis.Careful history and physical and examination and Ultrasound scanning of the joint fro information can help establish the diagnosis.
How is Psoriatic Arthritis treated?
How is Psoriatic Arthritis treated?
The treatment of psoriatic arthritis is directed at controlling the inflammatory process. The skin and joint aspects of the disease need to be treated simultaneously. Initial treatment is with non-steroidal anti-inflammatory drugs. In individuals with moderate to severe disease disease modifying agents and biologic treatments are used to control disease progression and joint preservation.

Reactive Arthritis

Reactive arthritis refers to a form of peripheral arthritis often accompanied by one or more extra-articular manifestations that appears shortly after certain infections of the genitourinary or gastrointestinal tracts. The majority of affected individuals have inherited the HLA B27 gene. Cases have been observed following epidemics or sporadic outbreaks of diarrheal illnesses caused by Shigella, Salmonella, and Campylobacter microorganisms, as well as by venereally acquired genitourinary infections, usually Chlamydia trachomatis. Reactive arthritis typically begins acutely two to four weeks after venereal infections or bouts of gastroenteritis. Most venereally acquired cases of reactive arthritis occur in young men. Cases following foodborne enteric infections affect both genders equally. Whites are affected more commonly than African Americans or other racial groups that have a lower frequency of HLA-B27.

What are the symptoms of Reactive Arthritis?
Urethritis usually is the first manifestation in all forms of the disease. Mild dysuria and a purulent discharge are the most typical symptoms in men. Women may have dysuria, vaginal discharge and purulent cervicitis and/or vaginitis. Symptoms may include fever, chills, increased need to urinate, and a burning sensation when urinating. Additional Symptoms include eye information Conjunctivitis, Acute anterior uveitis (iritis) can occur and is associated with severe ocular erythema, pain and photophobia.
Joints involvement with pain and swelling typically appear last, following gastroenteritis, the bowel symptoms usually have resolved one to three weeks earlier. 50% of the patients can have low back pain and buttock pain. sacroiliitis develops in only 20% of patients.
How is reactive Arthritis treated?
Reactive arthritis runs a self-limited course of three to 12 months in the majority of patients. Relapses may occur and in about 15% of patients and continue to have chronic, often destructive and disabling arthritis or enthesitis.
How is diagnosis made and what is the treatment provided?
The diagnosis of reactive arthritis is made on clinical grounds, based on disease manifestations.
Education is a key element in the care of a person with reactive arthritis. If the reactive arthritis has been preceded by a sexually transmitted disease, safer sex practices should be employed.
In general, people with reactive arthritis experience significant improvement in joint inflammation after administration of non-steroidal anti-inflammatory drugs (NSAIDS). If the arthritis is refractory to NSAIDS, second-line agents which are more potent can be used.

Giant cell arteritis (GCA):

Giant Cell arteritis or temporal arteritis, is a systemic inflammatory vasculitis of unknown etiology that occurs in older persons and can result in a wide variety of systemic, neurologic, and ophthalmologic complications.1GCA is the most common form of systemic vasculitis in adults with typically onset at the 60 or above. GCA usually affects the superficial temporal arteries—hence the term temporal arteritis. And has shown to involve medium- and large-sized vessels. Age and female sex are established risk factors for GCA, a genetic component seems likely, and infection may have a role.

What are the Symptoms of GCA?
The signs and symptoms of GCA include visual disturbances, headache, jaw claudication, neck pain, and scalp tenderness. General symptoms like fatigue, malaise, and fever, may also be present. About 50% of the GCA patients have Polymyalgia Rheumatica.
How is the diagnosis made?
GCA should always be considered in the differential diagnosis of a new-onset headache in patients 50 years of age or older with an elevated erythrocyte sedimentation rate. Temporal artery biopsy remains the criterion standard for diagnosis of this. Ultrasound scan of the temporal arteries can show inflammation and “Halo Sign” which represents information with tin the temporal artery.
How is GCA treated?
Visual loss is one of the most significant causes of morbidity in GCA. Permanent visual impairment may occur in as many as 20% of patients. Prompt initiation of treatment may prevent blindness. Corticosteroids are the mainstay of therapy. In steroid-resistant cases, drugs such as cyclosporine, azathioprine, or methotrexate may be used as steroid-sparing agents. The typical patient with GCA remains on steroid therapy for roughly 2 years.

Polymyalgia Rheumatica:

Polymyalgia rheumatica is an inflammatory disorder that causes muscle pain and stiffness, especially in the shoulders and hip girdles. Symptoms of polymyalgia rheumatica usually begin quickly and are worse in the morning. Most people who develop polymyalgia rheumatica are older than 65. It rarely affects people under 50.
About 20 percent of people with polymyalgia rheumatica also have signs and symptoms of giant cell arteritis. About half of the people with giant cell arteritis may also have polymyalgia rheumatica.The exact cause of polymyalgia rheumatica is unknown. Genetics and environmental factors seem to play a role.

What are the The signs and symptoms of polymyalgia rheumatica?
Usual presentation is with aches and pain and stiffness in the shoulders upper arms buttocks hips and thighs. There is limited range of motion noted in the affected areas. Joint swelling and Pain can be in the hands and feet joints. Generalized symptoms of Mild fever, profound Fatigue ,Loss of appetite , unintended weight loss and Depression are also typically seen.
How is the diagnosis made?
Diagnosis is based on history , physical examination and Blood tests show indicators of inflammation — sed rate (erythrocyte sedimentation rate) and C-reactive protein to be elevated. Ultrasound scan of the temporal arteritis is typical done with the present of new onset headache and to rule out temporal arteritis. A biopsy is planned to establish diagnosis.
What is the treatment for PMR?
Polymyalgia rheumatica is usually treated with a low dose of an oral corticosteroid raging form 15 to 25 mg of prednisone per day. After the first two to four weeks of treatment, your doctor may begin to gradually decrease your dosage depending on your symptoms and the results of blood tests. The goal is to keep you on as low a dose as possible without triggering a relapse in your symptoms. Most people with polymyalgia rheumatica need to continue the corticosteroid treatment for at least a year.
People who taper off the medication too quickly are more likely to have a relapse. Thirty to 60 percent of people with polymyalgia rheumatica will have at least one relapse when tapering off the corticosteroids. Close monitoring with your Rheumatologist is needed for proper care and taper off of Corticosteroids. Steroid Sparing agents like Methotrexate or DMARDS may be used if unable to taper of of steroids after one year.