Psoriatic Arthritis

Curated by Claudia Shannon / Research Scientist / Honayst

What is psoriatic arthritis?

It usually affects people who already have the skin condition psoriasis (sur- ry- a-sis). This causes patches of red, raised skin, with white and silvery flakes. Sometimes people have arthritis symptoms before the psoriasis. In rare cases, people have psoriatic arthritis and never have any noticeable patches of psoriasis.

Psoriatic arthritis and psoriasis are autoimmune conditions. Our immune system protects us against illness and infection. In autoimmune conditions, the immune system becomes confused and attacks healthy parts of the body.

Both conditions can affect people of any age. It’s estimated that around one in five people with psoriasis will develop psoriatic arthritis. People with psoriasis are as likely as anyone else to get other types of arthritis, such as osteoarthritis or rheumatoid arthritis. These conditions are not linked to psoriasis. Psoriatic arthritis is a type of spondyloarthritis. These are a group of conditions with some similar symptoms.

Symptoms

Psoriatic arthritis can cause a number of symptoms around the body. People will often have two or more of these symptoms, and they can range from mild to severe. One of the main symptoms is pain, swelling and stiffness because of inflammation inside a joint. This is known as inflammatory arthritis.

Inflammation is normally a useful tool of a healthy immune system. The body sends fluid, mainly blood, to a part of the body to fight off infection. But when someone has a type of inflammatory arthritis, inflammation can cause pain, swelling and stiffness in joints.

Any joint can be affected in this way. The most commonly affected joints are the:

    neck back
  • shoulders
  • elbows
  • wrists
  • fingers
  • knees
  • ankles
  • toes.

Joint stiffness is usually worse first thing in the morning, and it can last for more than 30 minutes. You may also feel stiff after you’ve been resting.

Psoriatic arthritis can cause connective tissue called entheses (en-thee-seas) to become inflamed. Entheses attach tendons and ligaments to bones. When they become inflamed it’s known as enthesitis.

Enthesitis pain can spread over a wider area rather than just inside a joint. Affected areas can feel tender if you touch them or if there’s just a small amount of pressure on them.

It commonly occurs in the feet. This can happen at the back of the heel or on the bottom of the foot near the heel. In some cases, this pain can make standing or walking difficult.

The knees, hips, elbows and chest can also be affected by enthesitis.

People with psoriatic arthritis can have swollen fingers or toes. This is known as dactylitis (dak-till-eye-tus), or sausage digit, to describe how whole fingers or toes swell up. It most commonly affects one or two fingers or toes at a time.

It can also cause fatigue, which is severe and persistent tiredness that can’t be cured with rest.

What are the symptoms of psoriasis?

There are different types of psoriasis. The most common is chronic plaque psoriasis. This causes patches of red, raised skin, with white and silvery flakes.

It can occur anywhere on the skin, but most commonly at the elbows, knees, back, buttocks and scalp. Psoriasis can cause small round dents in finger and toe nails, this is known as pitting. Nails can also change colour, become thicker and the nail may lift away from your finger.

Can psoriatic arthritis affect other parts of the body?

Having psoriatic arthritis can put you at risk of developing other conditions and complications around the body. The chances of getting one of these are rare. But it’s worth knowing about them and talking to your doctor if you have any concerns. Eyes Seek urgent medical attention if one or both of your eyes are red and painful, particularly if you have a change in your vision. You could go to your GP, an eye hospital, or your local A&E department. These symptoms could be caused by a condition called uveitis, which is also known as iritis. It involves inflammation at the front of the eye. This can permanently damage your eyesight if left untreated. Other symptoms are:

  • blurred or cloudy vision
  • sensitivity to light
  • not being able to see things at the side of your field of vision – known as a loss of peripheral vision
  • small shapes moving across your field of vision.

These symptoms can come on suddenly, or gradually over a few days. It can affect one or both eyes. It can be treated effectively with steroids.

Heart Psoriatic arthritis can put you at a slightly higher risk of having a heart condition. You can reduce your risk by:

  • not smoking
  • staying at a healthy weight
  • exercising regularly
  • eating a healthy diet, that’s low in fat, sugar and salt
  • not drinking too much alcohol.

These positive lifestyle choices can help to improve your arthritis and skin symptoms. Talk to your doctor if you have any concerns about your heart health. Crohn’s disease Crohn’s disease is a condition in which parts of the digestive system become inflamed. See a doctor if you have any of these symptoms, particularly if you have two or more and they don’t go away:

  • blood in your poo
  • diarrhoea for more than seven days
  • regular pain, aches or cramps in your stomach
  • fevers
  • a general feeling of being unwell
  • unexplained weight loss.

Non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is a term used to describe some conditions where there is a build-up of fat in the liver. This doesn’t cause problems in the early stages. But it can lead to cirrhosis (sir-oh-sis), which is when the liver becomes scarred and may stop working properly.

See a doctor if you have:

  • extreme tiredness
  • pain in the top right of the tummy, which can be dull or aching
  • unexplained weight loss
  • yellowing of the skin and eyes, which is known as jaundice
  • itchy skin
  • swelling in the legs, ankles, feet or tummy.

Causes

The genes you inherit from your parents and grandparents can make you more likely to develop psoriatic arthritis. If you have genes that put you at risk of this condition, the following may then trigger it:

  • an infection
  • an accident or injury
  • being overweight
  • smoking.

There is also an element of chance, and it might not be possible to say for certain what caused your condition. Psoriasis and psoriatic arthritis are not contagious, so people can’t catch it from one another.

How will psoriatic arthritis affect me?

Starting the right treatment as soon as possible will give you the best chance of keeping your arthritis under control and minimise damage to your body. Psoriatic arthritis can vary a great deal between different people. This makes it difficult to offer advice on what you should expect. It will usually have some effect on your ability to get around and your quality of life, but treatment will reduce the effect it has. Psoriatic arthritis can cause long-term damage to joints, bones and other tissues in the body, especially if it isn’t treated.

Diagnosis

If your GP thinks you have psoriatic arthritis, you’ll need to see a rheumatologist. These are doctors with special knowledge of the condition. There’s no specific test to diagnose psoriatic arthritis, so a diagnosis will be made based on your symptoms and a physical examination by your doctor. Tell your doctor if you have any history of psoriasis or psoriatic arthritis in your family. If you’ve developed psoriasis in the past few years, and symptoms of arthritis have started more recently, this could suggest it’s psoriatic arthritis. But it doesn’t always follow this pattern. It can sometimes be difficult to tell the difference between psoriatic arthritis and some other conditions, including rheumatoid arthritis, osteoarthritis and gout.

Blood tests such as those for rheumatoid factor and the anti-CCP antibody can help. People with psoriatic arthritis tend not to have these antibodies in their blood. People who have rheumatoid arthritis are more likely to test positive for them – especially if they’ve had rheumatoid arthritis for a while. These tests won’t say for certain if someone has psoriatic arthritis, but they can help when taking everything else into account.

X-rays of your back, hands and feet may help because psoriatic arthritis can affect these parts of the body in a different way to other conditions. Other types of imaging, such as ultrasound scans and magnetic resonance imaging (MRI), may help to confirm the diagnosis.

Who will be responsible for my healthcare?

You’re likely to see a team of healthcare professionals.

Your doctor, usually a rheumatologist, will be responsible for your overall care. And a specialist nurse may help monitor your condition and treatments. A skin specialist called a dermatologist may be responsible for the treatment of your psoriasis.

You may also see:

  • a physiotherapist, who can advise on exercises to help maintain your mobility
  • an occupational therapist, who can help you protect your joints, for example, by using splints for the wrist or knee braces. You may be advised to change the way you do some tasks to reduce the strain on your joints.
  • a podiatrist, who can assess your footcare needs and offer advice on special insoles and good supportive footwear.

Treatment

Because there are several features of psoriatic arthritis, there are different treatment options. Some of these are just for symptoms, such as pain and swelling, while some can treat the condition itself and reduce its symptoms. People react differently to specific treatments, so you may need to try a few options to find what works for you.

Types of treatments

For the arthritis:

  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • steroid injections into affected joints
  • disease modifying anti-rheumatic drugs (DMARDs)
  • biological therapies.

For the psoriasis:

  • creams and ointments
  • retinoid tablets
  • ultraviolet light therapy, also known as phototherapy
  • some DMARDs and biological therapies used for arthritis can also help the psoriasis.
Treatments for the arthritis

Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs can reduce pain and stiffness, but they might not be enough to treat symptoms of psoriatic arthritis for everyone. Some people find that NSAIDs work well at first but become less effective after a few weeks. If this happens, it might help to try a different NSAID. There are about 20 available, including:

  • ibuprofen
  • etoricoxib
  • etodolac
  • naproxen.

Like all drugs, NSAIDs can have side effects. Your doctor will reduce the risk of these, by prescribing the lowest effective dose for the shortest possible period of time. NSAIDs can sometimes cause digestive problems, such as stomach upsets, indigestion or damage to the lining of the stomach. You should also be prescribed a drug called a proton pump inhibitor (PPI), such as omeprazole or lansoprazole, to help protect the stomach. For some people, NSAIDs can increase the risk of heart attacks or strokes. Although this increased risk is small, your doctor will be cautious about prescribing NSAIDs if there are other factors that may increase your overall risk, for example, smoking, circulation problems, high blood pressure, high cholesterol or diabetes. Some people have found that taking NSAIDs made their psoriasis worse. Tell your doctor if this happens to you. Steroid treatment Steroid injections into a joint can reduce pain and swelling, but the effects do wear off. Having too many steroid injections into the same joint can cause some damage to the surrounding area, so your doctor will be careful not to give you too many. Steroid tablets or a steroid injection into a muscle can be useful if lots of joints are painful and swollen. But there’s a risk that psoriasis can get worse when these types of steroid treatments wear off. If used over the long term, steroid tablets can cause side effects, such as weight gain and osteoporosis (oss-tee-o-pur-oh-sis). This is a condition that can weaken bones and cause them to break more easily. Disease- modifying anti-rheumatic drugs (DMARDs) There are drugs that can slow your condition down and reduce the amount of inflammation it causes. This in turn can help prevent damage to your joints. These are called disease-modifying anti- rheumatic drugs (DMARDs) (dee-mards). Many DMARDs will treat both psoriasis and psoriatic arthritis. Because they treat the cause of your condition rather than the symptoms, it can take several weeks or even up to three months before you feel an effect.

You’ll need to keep taking them even if they don’t seem to be working at first. It’s also important to keep taking them once they do take effect. People will usually take DMARDs for many years, sometimes all their life.

The decision to use a DMARD, and which one, will depend on several factors, including what your symptoms are like and the likelihood of joint damage. You may need to take more than one DMARD at a time. You can take NSAIDs and painkillers at the same time as DMARDs. Like all drugs, DMARDs can have some side effects. But it’s important to remember that not treating psoriatic arthritis effectively could lead to permanent bone and joint damage. When taking a DMARD you’ll need regular blood tests, blood pressure checks, and in some cases a urine test. These tests allow your doctor to monitor the effects of the drug on your condition but also check for possible side effects.

There are different groups of DMARDs and they work slightly differently. DMARDs are normally taken as tablets you swallow, though methotrexate can be injected too. They reduce the activity of the immune system.

The following DMARDs can be used at early stage after diagnosis:

  • methotrexate
  • sulfasalazine
  • leflunomide.

You may be able to try some newer DMARDs, if other treatments haven’t worked. These newer DMARDs work on specific parts of the immune system to reduce inflammation. They’re taken as tablets you swallow. The following can treat psoriatic arthritis:

  • apremilast
  • tofacitinib

Both drugs may be prescribed alongside methotrexate. Biological therapies Biological therapies are drugs that target key parts of the immune system to reduce inflammation. You might be able to try them if other drugs haven’t worked for you. Two groups of biological therapies are used to treat psoriatic arthritis – anti- TNF drugs and interleukin inhibitors. Anti-TNF drugs target a protein called tumour necrosis factor (TNF). Interleukin inhibitors target interleukin proteins. The body’s immune system produces both TNF and interleukin proteins to act as messenger cells to help create inflammation. Blocking TNF or interleukin messengers can reduce inflammation and prevent damage to the body. A biological therapy may be prescribed on its own, or at the same time as a DMARD, such as methotrexate. The following anti-TNF drugs can treat psoriatic arthritis:

  • adalimumab
  • infliximab
  • etanercept
  • golimumab
  • certolizumab pegol.

The following interleukin inhibitors can treat psoriatic arthritis:

  • ustekinumab
  • secukinumab
  • ixekizumab.

Biological therapies can take up to three months to fully take effect.

The psoriatic arthritis treatment pathway

There are now several excellent long-term treatments for psoriatic arthritis. It’s important to find the right one for you as soon as possible, to improve your quality of life and prevent this condition damaging your body. See our diagram of the psoriatic treatment pathway (PDF, 1.2 MB) to find out the order in which these drugs may be taken.

Treatments for your skin

If your psoriasis is affecting your quality of life, or your treatment is not working, you may be referred to a dermatologist. There are a number of treatment options for psoriasis. Ointments, creams and gels that can be applied to the skin include:

  • ointments made from a medicine called dithranol
  • steroid-based creams and lotions
  • vitamin D-like ointments such as calcipotriol and tacalcitol
  • vitamin A-like (retinoid) gels such as tazarotene
  • salicylic acid
  • tar-based ointments.

Surgery

People don’t often need joint surgery because of psoriatic arthritis. Very occasionally a damaged tendon may need to be repaired with surgery. And sometimes, after many years of psoriatic arthritis, a joint that has been damaged by inflammation may need joint replacement surgery.

If your psoriasis is bad around an affected joint when you have surgery, your surgeon may recommend a course of antibiotic tablets to help prevent infection. Sometimes psoriasis can appear along the scar left by an operation, but this can be treated in the usual way.

Managing symptoms

There are some things you can do, alongside taking prescribed medication, that may help to ease your symptoms.

Staying active

Keeping active is one of the best things you can do to feel better physically and improve your mood. It can help reduce pain and stiffness in joints. Being inactive can lead to muscles becoming weak, which can make symptoms worse. Exercise won’t make your psoriatic arthritis worse. However, if your condition is making certain activities difficult, you might need to change the way you exercise.

It’s ok to take it easy if your symptoms are bad, and you’ll need to find the right balance between rest and exercise. There are simple exercises you can do when sitting or lying down to keep your joints moving. Every little movement and step really does help in the long-term.

Starting off slowly, and gradually increasing the amount you do can be a good way to start exercising. If you have psoriatic arthritis, you can still be very active – though you may need to build up to this. Swimming can be a great way to exercise as it doesn’t put strain on your joints. It improves stamina, strength and flexibility, which are three important areas of fitness. There are many good ways to exercise and the key is to find something you enjoy as this will help you to keep doing it. You may find that exercising with your partner, a friend or a relative helps as you can support one another. Group fitness classes can be good fun, if you find the right one for you. Keeping active is good for your emotional well-being and confidence, as well as making you feel better physically. If you’re struggling to exercise, your doctor or a physiotherapist can give you support and advice.

Healthy eating

There aren’t any diets that can cure psoriatic arthritis. Having a diet that’s healthy, balanced, nutritious and low in fat, salt and sugar is good for your overall health and well-being. This is particularly important if you have psoriatic arthritis. Being overweight will put extra strain on your joints, such as your hips, knees and back. A healthy diet is also good for your heart health. Eating plenty of fresh fruit and vegetables, and drinking around two litres of water a day is also good for your health. Talk to your doctor, a dietitian or visit the NHS Eatwell Guide website if you need more information.

Getting some sunshine

The right amount of sunshine can make psoriasis better, at least in the short term. Too much sun and sunburn though can make psoriasis worse. For this reason, it’s a good idea to talk to your doctor if you’re planning to go abroad.

Giving up smoking

Smoking can make psoriasis worse. It can also increase the likelihood of some of the potential complications – such as heart problems. If you smoke your doctor can give you advice and support to help you stop, or you can visit the NHS Smokefree website.

Complementary treatments

Some people with psoriatic arthritis find complementary treatments are helpful, but you should always talk to your doctor first if you want to try them. Complementary treatments come from a variety of cultural and historical backgrounds. They’re different to mainstream or conventional medication and therapies that you’ll get from GPs, rheumatology teams or physiotherapists. Examples of complementary therapies include:

  • acupuncture – fine needles are inserted at different points around the body to stimulate nerves and produce natural pain-relieving substances in the body known as endorphins.
  • The Alexander Technique – based on the principle of having improved posture and movement through a good understanding and awareness of the body. People who teach it say it releases tension in the body.

And there are alternative medicines that can be taken as pills or applied as creams. These can include:

  • fish body oil – they contain fatty acids, known as omega-3, that are thought to have health benefits, including reducing inflammation. Though some evidence suggests it’s much better to get these from eating fish like salmon, sardines and mackerel, rather than taking pills.
  • glucosamine – this is an important building block of cartilage, which is the substance that lines the ends of bones in joints to protect them. It’s thought that taking glucosamine sulfate may protect the joints, by slowing down the breakdown of cartilage and replacing lost cartilage.

There can be risks associated with some complementary treatments, so it’s important to go to a legally registered therapist, or one who has a set ethical code and is fully insured. If you decide to try therapies or supplements, you should be critical of what they’re doing for you, basing your decision to continue on whether or not you notice any improvement.

Aids and adaptations

You could be offered aids that help with everyday tasks, as well as minor adaptations to your home, to help you get around. This support is available only to people in England who have a physical or mental condition that means they’re unable to do basic tasks and activities, such as:

  • cooking
  • washing
  • going to the toilet
  • getting dressed
  • cleaning
  • working
  • developing and maintaining family and social relationships.