Psoriatic arthritis is a long-term inflammatory arthritis that occurs in people affected by autoimmune disease psoriasis. The classic feature of psoriatic arthritis is swelling of all fingers and toes with a sausage-like appearance. This often occurs in relation to changes in the nail such as small depression in the nail (pitting), thickening of the nails, and nail removal of the nail. Skin changes consistent with psoriasis (eg, red, scaly, and itchy plaques) often occur before the onset of psoriatic arthritis but psoriatic arthritis can precede rash in 15% of affected individuals. It is classified as a seronegative type of spondyloarthropathy.
Genetics is thought to be heavily involved in the development of psoriasis arthritis. Obesity and certain forms of psoriasis are considered to increase the risk.
Psoriatic arthritis affects up to 30% of people with psoriasis and occurs in children and adults. Approximately 40-50% of individuals with psoriasis arthritis have the HLA-B27 genotype. This condition is less common in people of Asian or African descent and affects men and women alike.
Video Psoriatic arthritis
Classification
There are five main types of psoriatic arthritis:
- Oligoarticular: This type affects about 70% of patients and is generally mild. This type does not occur in the same joints on both sides of the body and usually involves only less than 3 joints.
- Polyarticular: This type accounts for about 25% of cases, and affects five or more joints on both sides of the body simultaneously. This type is most similar to rheumatoid arthritis and paralyzes about 50% of all cases.
- Arthritis mutilans (M07.1): results in less than 5% of patients and is a severe, deform and destructive arthritis. This condition can last for months or years causing severe joint damage. Arthritis mutilans have also been called chronic absorption arthritis, and can be seen in rheumatoid arthritis as well. Spondyloarthritis (M07.2): This type is characterized by stiffness of the spine sacroiliac neck or joint, but can also affect the hands and feet, in a manner similar to symmetrical arthritis.
- Distal interphalangeal predominant (M07.0): This type of psoriatic arthritis is found in about 5% of patients, and is characterized by inflammation and stiffness in joints closest to the fingertips and toes. Nail changes are often flagged.
Maps Psoriatic arthritis
Signs and symptoms
Pain, swelling, or stiffness in one or more joints is usually present in psoriatic arthritis. Psoriatic arthritis is inflammatory, and the affected joint is usually red or warm to the touch. Asymmetric Oligoarthritis, defined as an inflammation that affects one to four joints during the first six months of the disease, is present in 70% of cases. However, in 15% of cases, arthritis is symmetrical. Hand joints involved in psoriasis are proximal interphalangeal (PIP), interphalangeal distal (DIP), metacarpophalangeal (MCP), and wrist. The involvement of the distal interphalangeal joint (DIP) is a characteristic feature and is present in 15% of cases.
In addition to affecting the joints of the hands and wrists, psoriatic arthritis can affect the fingers, nails, and skin. Sausage swelling in the fingers or toes, known as dactylitis, can occur. Psoriasis may also cause changes in the nail, such as pitting or separation from the base of the nail, onycholysis, hyperkeratosis under the nail, and removal horizontally. Psoriasis is classically present with scaly skin lesions, most commonly seen on extensor surfaces such as scalp, chestnut and umbilicus.
In psoriatic arthritis, pain can occur in the sacrum area (lower back, above the coccyx), as a result of sacroiliitis or spondylitis, which is present in 40% of cases. Pain may occur around the feet and ankles, especially the entesitis in the Achilles tendon (inflammation of the Achilles tendon where it is inserted into the bone) or plantar fasciitis in the sole of the foot.
Along with the pain and inflammation noted above, there is extreme fatigue that does not go away with adequate rest. Fatigue may last for days or weeks without subtraction. Psoriasis arthritis may remain mild or may progress to more destructive joint disease. The period of active disease, or flares, will usually alternate with the remission period. In severe form, psoriatic arthritis can develop into mutilans arthritis which on X-rays gives the appearance of "pencil-in-cup".
Because prolonged inflammation can cause joint damage, early diagnosis and treatment to slow or prevent joint damage is recommended.
Cause
The exact cause is unknown, but a number of genetic associations have been identified in the study of genome associations of psoriasis and psoriasis arthritis including HLA-B27.
Diagnosis
There is no definitive test to diagnose arthritis psoriasis. Symptoms of psoriatic arthritis may be very similar to other diseases, including rheumatoid arthritis. A rheumatologist can use physical examination, medical history, blood tests and x-rays to accurately diagnose psoriatic arthritis.
Factors that contribute to the diagnosis of psoriatic arthritis include the following:
- Psoriasis in the patient, or family history of psoriasis or psoriatic arthritis.
- Negative test results for rheumatoid factor, blood factor associated with rheumatoid arthritis.
- Symptoms of arthritis of distal interphalangeal articulation of the hands (joints closest to the fingertips). This is not a characteristic of rheumatoid arthritis.
- Projection or pitting of nails or toenails (onycholysis), associated with psoriasis and psoriatic arthritis.
- Radiologic features showing degenerative joint changes.
Other symptoms more typical of psoriatic arthritis than other forms of arthritis include enthesitis (inflammation of the Achilles tendon (at the back of the heel) or plantar fascia (lower leg)), and dactylitis (swelling of sausages such as fingers or toes).
Differential diagnosis
Some conditions may resemble clinical presentation of psoriasis arthritis including rheumatoid arthritis, osteoarthritis, reactive arthritis, gouty arthritis, systemic lupus erythematosus, and associated gastrointestinal arthritis. In contrast to psoriatic arthritis, rheumatoid arthritis tends to affect the proximal joint (eg the metacarpophalangeal joint), involving more joints than psoriatic arthritis, and affecting them symmetrically. Spinal joint involvement is more suggestive of psoriatic arthritis than rheumatoid arthritis. Osteoarthritis shares certain clinical features with psoriatic arthritis such as its tendency to affect multiple distal joints in asymmetric patterns. Unlike psoriatic arthritis, osteoarthritis usually does not involve inflammation of the sacroiliac joint. Arthritis psoriasis sometimes affects only one joint and is sometimes confused for gout or pseudogout when this happens.
Treatment
The underlying process in psoriatic arthritis is inflammation; Therefore, the treatment is directed to reduce and control the inflammation. Lighter cases of arthritis psoriasis may be treated with NSAID alone; However, there is a trend toward prior use of antirheumatic drugs that modify disease or biological response modifiers to prevent irreversible joint damage.
Nonsteroidal anti-inflammatory drugs
Usually the first drugs prescribed for psoriatic arthritis are NSAIDs such as ibuprofen and naproxen, followed by stronger NSAIDs such as diclofenac, indomethacin, and etodolac. NSAIDs can irritate the stomach and intestines, and long-term use can cause gastrointestinal bleeding. Coxibs (COX-2 inhibitors) eg. Celecoxib or Etoricoxib, is associated with a relative risk reduction of 50 to 66% in gastrointestinal ulcers and bleeding complications compared with traditional NSAIDs, but carries an increased incidence of cardiovascular events such as myocardial infarction (MI) or heart attacks, and stroke. Both COX-2 and other non-selective NSAID inhibitors have adverse effects including damage to the kidneys.
An antirheumatic drug that modifies the disease
It is used in persistent symptomatic cases without exacerbations. Instead of just reducing pain and inflammation, this class of drugs helps limit the amount of joint damage that occurs in psoriasis arthritis. Most DMARDs act slowly and may take weeks or even months to get the full effect. Drugs such as methotrexate or leflunomide are commonly prescribed; Other DMARDS used to treat psoriatic arthritis include cyclosporin, azathioprine, and sulfasalazine. These immunosuppressant medications can also reduce psoriasis skin symptoms but can cause liver and kidney problems and an increased risk of serious infections.
Biological response modifiers
The latest class of treatment called biological or biological response modifiers has been developed using recombinant DNA technology. Biological drugs come from living cells that are cultivated in the laboratory. Unlike traditional DMARDs that affect the entire immune system, biology targets specific parts of the immune system. They are administered by intravenous injection or IV (IV).
Biologic prescribed for psoriatic arthritis is TNF-? inhibitors, including infliximab, etanercept, golimumab, certolizumab pegol and adalimumab, as well as IL-12/IL-23 ustekinumab inhibitors.
Biologically may increase the risk of mild and serious infections. Less commonly, they may be associated with a disorder of the nervous system, blood disorders or certain types of cancer.
Phosphodiesterase-4 inhibitor
The first classroom treatment option for the management of psoriatic arthritis, apremilast is a small molecule phosphodiesterase-4 inhibitor approved for use by the FDA in 2014. By inhibiting PDE4, the enzyme that breaks the cyclic adenosine monophosphate, the cAMP level increases, resulting in decreased regulation of various pro- inflammation including TNF-, interleukin 17 and interleukin 23, and increased regulation of interleukin anti-inflammatory factor 10.
It was given in tablet form and drunk. Side effects include headache, backache, nausea, diarrhea, fatigue, nasopharyngitis and upper respiratory tract infections, as well as depression and weight loss.
Patented in 2014 and produced by Celgene, no common equivalent is currently available in the market.
Other treatments
A review finds tentative evidence about the benefits of low-level laser therapy and concludes that it can be considered for relief of pain and associated RA stiffness.
Retinoid etretinate is effective for arthritis and skin lesions. Photo phototherapy with psoralen metoxy and ultraviolet wavelength (PUVA) are used for severe skin lesions. Doctors may use injections along with corticosteroids in cases where one joint is severely affected. In patients with psoriatic arthritis with severe joint damage, orthopedic surgery can be done to repair joint damage, usually by using joint replacement. Effective surgery to relieve pain, repair joint damage, and strengthen the utility and strength of the joints.
Epidemiology
Seventy percent of people with psoriatic arthritis first showed signs of psoriasis on the skin, 15 percent developed skin psoriasis and arthritis at the same time, and 15 percent developed skin psoriasis after the onset of psoriatic arthritis.
Arthritis of psoriasis can develop in people who have the severity of psoriasis skin disease, ranging from mild to very severe.
Psoriatic arthritis tends to appear about 10 years after the first signs of psoriasis. For most people, this is between the ages of 30 and 55, but this disease can also affect children. The onset of psoriatic arthritis symptoms before the symptoms of skin psoriasis is more common in children than adults.
More than 80% of patients with psoriatic arthritis will have psoriatic nail lesions characterized by nail pitting, nail separation from underlying, jagged and cracked nail bed, or worse, nail loss itself (onycholysis).
Enthesitis is observed in 30 to 50% of patients and most often involves the plantar fascia and Achilles tendon, but can cause pain around the patella, iliac crest, epicondyl,
and supraspinatus insertion
Men and women are equally affected by this condition. Like psoriasis, psoriatic arthritis is more common among Caucasians than Africans or Asians.
References
External links
- Psoriatic Arthritis at Patient.info
- National Psoriasis Foundation
- The Arthritis Foundation
- Treatment guidelines for the management of psoriasis and psoriatic arthritis - National Guideline Clearinghouse
- Psoriasis and Allergy Psoriatic Arthritis
- National Institute of Arthritis and Musculoskeletal Diseases and Skin
Source of the article : Wikipedia
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