psoriatic arthritis

Psoriasic arthritis

Its causes, diagnosis and treatments

Psoriatic arthritis is a major joint disorder that occurs most often in people affected with chronic skin disease called psoriasis. Many of those who have psoriasis do not realize the risk of psoriatic arthritis. Even individuals with mild psoriasis or even those with relatives with psoriasis may develop psoriatic arthritis.

       If you have psoriasis and have joint pain or some other symptom of those mentioned here, talk to your doctor as soon as possible.

What is psoriasis?

Approximately 7.5 million people in the US they have psoriasis, a chronic autoimmune disease (where the body's defense system attacks its own structures).

    In psoriasis, the defense system, called immune, sends altered signals that accelerate the growth cycle of skin cells.
    The most common symptom of psoriasis are painful red patches on the skin that cause itching and a whitish silvery buildup of dead epidermal cells.
    Although psoriasis most often appears on the knees, elbows and scalp, it can occur on any part of the body, even on the nails of the fingers and toes.
    Psoriasis is not contagious, however, it is more than a skin disease. People with psoriasis are more likely to develop other serious health conditions, such as arthritis, diabetes, heart problems, and depression.

What is psoriatic arthritis?

Psoriatic arthritis is a disorder that causes pain and inflammation in the joints. It occurs in people with psoriasis, which is a chronic (long-term) skin disease that is characterized by the presence of a dry, scaly, itchy skin rash. This rash is more common on the elbows, knees and scalp. Psoriasis can cause changes in the nails of the fingers and toes as small depressions that resemble dots on the surface of the nails, called fovea.

Not everyone who has psoriasis has psoriatic arthritis. From 10 to 30% of people with psoriasis develop psoriatic arthritis. Joint pain caused by psoriatic arthritis is usually associated with swelling and redness of the joints, particularly in the knees, ankles, and fingers and toes. Some individuals with psoriatic arthritis also have pain and stiff neck and / or back, which may limit movement. People who develop psoriatic arthritis may first present either skin or joint symptoms, but more often skin manifestations appear before joint pain. Both symptoms may show at the same time and fluctuate with episodes of exacerbation. Psoriatic arthritis affects both men and women. It usually develops between 30 and 55 years of age.

Although psoriatic arthritis can damage joints and other body systems, its effects can often be reduced if diagnosed and treated early.

What is the cause of psoriatic arthritis?

The cause of the disease is still unknown. It is believed that genetic factors (hereditary), a malfunction of the body's immune system, inflammation in the joints and the environment, play a role in the development of the disease. In the inflammatory types of arthritis, such as psoriatic arthritis, the body's defense system mistakenly attacks the lining of the joints, causing pain and inflammation.

What are the symptoms?

The common symptoms of psoriatic arthritis are:

Pain and swelling in one or more joints, usually in the wrists, knees, ankles and / or joints at the end of the fingers and toes (called distal).
    Swelling of the fingers and / or toes that gives them the appearance of a sausage.
    Ailments where the tendons and ligaments are attached to the bones, especially in the heel (Achilles tendon) or the sole of the foot.
    Pain in the lower back, neck or in the buttocks.
    Dry and scaly patches of silver or gray color that peel off the skin, located on the scalp, on the elbows, on the knees and / or on the lower end of the spine.
    Fovea, characterized by minute depressions in the nails of the fingers and / or toes, and / or detachment of the nails.

The course of psoriatic arthritis varies. The constant presence of heat and swelling in the membrane that covers the joint, called synovium, could cause damage and deformity in the joint. With the right treatment, most people lead a normal life.

Which joints can be affected?

Psoriatic arthritis affects the peripheral joints such as the knees, fingers and feet. In most cases, more than five joints are affected. This is known as polyarthritis.

            When the peripheral joints are affected, psoriatic arthritis can occur in the same joints on both sides of the body (symmetric arthritis). For example, the right and left knees may have arthritis. At the beginning of the disease, however, it is more common to occur in diverse joints on both sides of the body (asymmetric arthritis). For example, the right hand and the left knee may be affected.

           There are those who only have inflammation in the distal joints of the fingers and toes. In addition, the whole finger can swell and cause pain, which is called a digit in "sausage".

            Approximately 5% of people with psoriatic arthritis have arthritis only in the joints of the spine. This is known as spondylitis. This form of psoriatic arthritis usually affects the sacroiliac joints and the joints of the lower back and neck regions. This generates pain and stiffness in the buttocks, in the lower back, in the neck and along the spine. This can lead to a restriction in the movements of the back. Some people with psoriatic arthritis have compromised the spine and peripheral joints or limbs.

How is it diagnosed?

To find out if you have psoriatic arthritis, your doctor will ask about your symptoms and perform a physical examination. The latter can detect abnormalities in the joints such as sensitivity, inflammation, pain when moving the joints, or inability to move them in their entirety. In addition, your doctor will look for evidence of psoriasis on the skin or changes in the nails. Also, they will do some of the following tests:

    X-rays, magnetic resonance imaging or ultrasound to detect changes in bones, joint tissues and cartilage.
    Blood tests to rule out other diseases, such as rheumatoid arthritis.
    Joint fluid tests to rule out gout or infectious arthritis.

Treatment of two diseases

As most people with psoriatic arthritis also have psoriasis, medical care must be carefully coordinated between the attending physician, the dermatologist and the rheumatologist.

    Some treatments work for both diseases, while others are only used for skin psoriasis or arthritis.
    It is possible that taking some medications together produces an adverse reaction. Talk with the medical staff about all the drugs, with and without prescription, and the dietary supplements or herbalists that you are taking for these or other symptoms.
    What works for you may be different from what works for another person to control psoriasis or psoriatic arthritis. Take the medications as directed by the doctor and the pharmacist.

Treatment for psoriasis

There are many free shelf and prescription treatments for cutaneous psoriasis. If you have psoriasis, talk to your dermatologist about the following options:

    Topical medications applied directly to the skin.
    Treatments by means of solar light or special ultraviolet light.
    Drugs orally to improve the skin.
    Drugs orally directed to the immune system.

Treatment for psoriatic atritis

If left untreated, the inflammation that accompanies psoriatic arthritis can result in joint damage. Controlling inflammation can delay or prevent joint damage.

The treatment of psoriatic arthritis focuses on several goals:

    Reduce inflammation
    Ease the pain.
    Retain the function of the joints.

Drugs to control psoriatic arthritis

To achieve early and aggressive treatment of psoriatic arthritis requires a category of drugs called disease modifying antirheumatics or DMARDs, which include traditional DMARDs and a new subcategory known as biological response modifiers (MRB). Traditional DMARDs stop the disease in several ways, many of which are not fully understood.

       MBRs, also called simply biological, are genetically engineered drugs designed from the genes of a living organism. Some attack cytokines (blood proteins that cause inflammation), others inhibit the cells that help to release them. Like other DMARDs, biologics decrease the activity of the disease, postpone the progress of psoriatic arthritis, and prevent or delay joint damage. These medications work more quickly than other DMARDs (some may start to take effect in one to two weeks).

       Before taking any DMARDs, blood tests should be done to rule out hepatitis, because certain medications such as methotrexate can damage the liver. The flu shot may be recommended. Before starting biologic therapy, you can have a tuberculin skin test and x-ray exams to rule out tuberculosis.

ANTIRREUMATIC DRUGS MODIFIERS OF THE TRADITIONAL DISEASE (DMARDS)

Methotrexate

Methotrexate (Rheumatrex, Trexall) has been used for cancer management for many years, but when used for the treatment of arthritis it is done in much smaller doses, with fewer side effects. Methotrexate helps relieve pain, stiffness and inflammation of many types of arthritis, including psoriatic arthritis, and improve skin symptoms. The medication is administered weekly, orally as a liquid, pill or by injection. Adverse effects are nausea, vomiting, mouth sores, diarrhea, low white blood cell count, abnormal liver function and pneumonia. Taking folic acid can reduce some of the side effects. You should avoid getting pregnant, because the drug can cause harm to the fetus or miscarriages, so women of childbearing age should have an effective method of contraception. Also, you should not drink alcohol if you are taking methotrexate.

Leflunomide

Some clinical studies suggest that the action of leflunomide (Arava) is comparable to methotrexate in terms of improving the symptoms of psoriatic arthritis. The possible side effects are nausea, diarrhea, rashes, liver toxicity, hypertension, hair loss (alopecia) and headaches (headaches). It is known that leflunomide causes congenital defects. Both men and women must take effective contraceptive measures while they are under the medication and continue them for three months after they have stopped using it.


Sulfasalazine

Clinical studies have revealed that sulfasalazine (Azulfidine, Azulfidine EN-Tabs) can relieve joint pain and swelling in people with psoriatic arthritis. However, those who are allergic to medications containing sulfa drugs can not take such medication. Side effects may include gastrointestinal problems, inappetence, skin rashes, increased sensitivity to sunlight, dizziness, headaches, liver abnormalities, a low count of low lobules and sperm.

Ciclosporin

Cyclosporin (Neoral) is used for the treatment of skin and joint problems in psoriatic arthritis. Blood pressure should be carefully monitored and blood tests performed to check liver and kidney function. The side effects are nausea, vomiting, diarrhea, inflammation of the gums (gingivitis), hypertension, itching, excessive hair growth ((hirsutism) and abnormalities of liver and kidney function. Cyclosporine can also cause congenital defects if taken during pregnancy, so women of childbearing age should use effective contraception during treatment with this drug.

Azathioprine

Azathioprine (Imuran) also suppresses the action of the immune system and can relieve joint pain, stiffness and swelling of psoriatic arthritis. Adverse effects of the medication include irritation of the stomach, inflammation of the pancreas, rash, and a low count of blood cells. Regular blood tests are required. Azathioprine can cause congenital defects if taken during pregnancy, so that women of childbearing age should use an effective method of contraception while taking the medication.

MODIFIERS OF THE BIOLOGICAL RESPONSE (MRB) / BIOLOGICAL

These medications suppress the immune system, so you may become more vulnerable to other diseases and infections.

    If you are taking a biological medication, it is important to contact your doctor if you develop symptoms of infection (fever, sore throat, chills, cough).
    You should also do the tuberculin test before starting a biological medicine and avoid any live virus vaccine.
    With certain biologics there is a risk of an allergic reaction. In general it is recommended to avoid pregnancy during the course of treatment.

Biologics are used when a moderate to severe disease can not be controlled with the treatment of first choice. Evidence suggests that biologics may be the appropriate first choice treatment for some patients with psoriatic arthritis. They can be used alone, but usually alternate with methotrexate and other DMARDs. Two biologicals should not be used together.

       All biologicals are injected. Some are put under the skin and can be administered by the patient himself. Others require intravenous infusion to be done in the office or clinic.

       As with any drug, taking biologics carries risks. Since these medications suppress the immune system, it can increase the risk of infections and cancer. If the drug is injected, you may also experience pain and irritation at the injection site. If it is administered intravenously, it may present a reaction to the infusion.

Biologics attack specific parts of the immune system to help block or slow the factors responsible for inflammation. There are several types of biologicals in different steps of the inflammatory process. Anti-Tumor Necrosis Factor (TNF) agents (which block a chemical signal of inflammation) etanercept (Enbrel), adalimumab (Humira) and infliximab (Remicade) are approved by the FDA to reduce the symptoms of active psoriasis and Psoriatic arthritis in adult patients.


Golimumab (Simponi) is approved to treat adults with psoriatic arthritis (not so for psoriasis). Ustekinumab (Stelara), which inhibits an inflammatory compound called interleukin and alefacept (Amevive), against the T lymphocytes involved in inflammation, are the two other drugs used to treat moderate to severe psoriasis.

In 2014, the FDA approved apremilast (Otezla, its trade name), a class of drugs classified as a selective inhibitor of the enzyme phosphodiesterase 4, which is involved in inflammation. Studies show that apremilast can be as potent as the biological agents available to treat psoriatic arthritis, apparently with less risk of infection. It was also accepted more recently the use of secukinumab (Cosentyx), another type of biological, directed against interleukin 17-A (IL 17-A) promoter of inflammation; both drugs were initially used for psoriasis.

Drugs to treat the symptoms of psoriatic arthritis

NON-STEROID ANTI-INFLAMMATORY MEDICINES (NSAIDs)

Nonsteroidal anti-inflammatory drugs or NSAIDs can help reduce pain and inflammation of the joints. They work by inhibiting the production of substances called prostaglandins at the site of inflammation. You may have to take NSAIDs for a few days, weeks, or maybe much longer, depending on your situation. Over-the-counter or non-prescription NSAID medications include aspirin, ibuprofen, and naproxen. Some of them are only issued with a prescription. Over-the-counter medications are often available in lower-strength doses than those prescribed and can control pain, but at these lower doses they may not control inflammation. Check with your doctor if it is advisable to take over-the-counter medications in addition to those you have prescribed.

            Prolonged use of these drugs carries the risk of creating stomach problems, a fall in kidney function, and heart attacks or strokes. Talk to your doctor to understand the risks. One type of NSAID called COX-2 selective inhibitor, celecoxib (Celebrex), was designed to be softer to the stomach, but may pose an increased risk of heart attack and stroke. Check with your doctor about the possible risks and to decide which drugs are right for you.

CORTICOSTEROIDS

Corticosteroids are synthetic forms of cortisol, a hormone produced by the body. Your doctor may prescribe corticosteroid pills or creams or inject the medicine directly into the inflamed muscles or joints. Oral corticosteroids, such as prednisone, may be necessary to control the swelling, stiffness and pain associated with joint inflammation. However, they have less potential to affect the course of psoriatic arthritis.

Doctors use them in two ways:

    Short-term oral therapy. In high doses, pills can help decrease inflammation and symptoms in a person with onset of severe psoriatic arthritis. A moderate dose of corticosteroids may be prescribed at the beginning of DMARD therapy to control symptoms. Once the DMARDs begin to work, the corticosteroid dose is reduced and eventually discontinued. At that time, therapy with DMARDs can be adjusted to better control the disease.
    Injection during an acute episode or exacerbation. If the episode occurs in a single joint, it can be injected directly. In these cases, the existing treatment regimen for psoriatic arthritis is not altered.
    Low-dose long-term therapy. A small daily dose of corticosteroids can be combined with one or more DMARDs. However, most rheumatologists try to avoid continuous treatment with corticosteroids, if possible.

The prolonged use of oral corticosteroids is not highly recommended in psoriatic arthritis due to its adverse effects: hypertension, osteoporosis, Cushing's syndrome (weight gain, roundness and "face of the moon" facial redness,

thinning of the skin, muscle weakness and fragile bones), cataracts, predisposition to infections, sudden mood swings, increased appetite and the risk of developing stomach ulcers. To reduce these effects, the lowest possible dose of the medication should be used for the shortest possible period of time.

When should a surgery be considered?

Most people with psoriatic arthritis may never require surgery to replace the joints. However, if your joints are seriously damaged by the disease or when other treatments do not diminish the pain, your doctor may recommend surgery, in which the joints damaged by psoriatic arthritis are replaced with artificial joints. The benefits include less pain and improvement in joint function.

Living with psoriatic arthritis

Self-care techniques

One of the best ways to deal with a chronic illness is to play an active role in your own treatment and, consequently, your own life - a process called self-care.

       First, make a conscious decision to maintain a positive attitude and lead a healthy lifestyle by eating well, doing physical activity and finding a way to overcome any emotional problems related to your diagnosis. Learn as much as you can about your illness, your doctor or the medical staff that sees you, and any reliable sources, such as the Arthritis Foundation (www.arthritis.org/espanol).

       Keep an open line of communication with your doctor and keep a record of your symptoms, pharmacological regimens, side effects, pain level, etc. Consider seeing an occupational therapist, who can teach you how to reduce joint tension and provide assistive devices such as splints or splints that help you relax your joints and decrease pain, swelling and stiffness. Finally, develop a network of friends, family and even co-workers that you can count on for emotional support.

LIFESTYLE CHANGES THAT CAN HELP YOU

Rest and physical activity

Rest is important when psoriatic arthritis is active and the joints hurt, are stiff or inflamed. Rest helps decrease fatigue and inflammation during acute episodes. When the activity of the disease is low, physical activity is essential. Your exercise program should emphasize low-impact aerobic movements, muscle strengthening and flexibility. A physiotherapist can help you design, and maintain, an exercise program that is right for you.

Nutrition

Eating a balanced diet, according to the FDA (Administration of Drugs and Foods) of the United States, is based on foods of vegetable origin. Approximately two-thirds of the diet should come from fruits, vegetables and whole grains. The remaining part includes low or no fat products and sources of lean protein.

Stress management

It has been shown that stress exerts a crucial impact on psoriasis, and is linked to inflammation. Some ways to reduce stress are:

    The regular exercise
    Practices such as yoga, tai chi and meditation.
    Spend time with family and friends.

Other things you can do to manage psoriatic arthritis

Facing the pain generated by psoriatic arthritis may seem impossible at the time of diagnosis. Your doctor will probably prescribe medicines, but there are other ways to control pain and improve your quality of life. Try any of the following options:

Heat and cold treatments. In general they are applied directly on the painful part, the heat can be more useful for chronic pain and cold for acute pain. You can use bags of frozen chopped vegetables, which mold very well to the body or fomentations of hot water.
    Relaxation techniques. Train the muscles to relax and decelerate the thoughts with deep breathing techniques, guided images and visualization, among others.
    Massages Research shows that massage can help relieve arthritis pain, improve joint function and reduce stress and anxiety.
    Topical treatments They are applied directly on the skin over the painful joint or muscle, may contain salicylates or capsaicin, decreasing sensitivity to pain or also some non-steroidal anti-inflammatory drugs.
    Acupuncture. Acupuncture is the practice of inserting fine needles into the body on special points called "meridians" to relieve pain