Who Will Be Responsible For My Healthcare
Youre 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 onspecial insoles and good supportive footwear.
Up To 30 Percent Of People With Psoriasis Will Go On To Develop Psa And 85 Percent Of People With Psa Also Have Skin Psoriasis
Writing and reporting by Susan Jara and Steven Newmark
Psoriasis and psoriatic arthritis are distinct conditions, but they are connected. In fact, data show that up to 30 percent of people with psoriasis will go on to develop PsA and 85 percent of people with PsA also have skin psoriasis.
Although people can be diagnosed with PsA without having any skin involvement, most often they will have a family member with skin psoriasis, says Rebecca Haberman, MD, a rheumatologist at NYU Langone Health in New York City.
Psoriasis is an inflammatory condition of the skin, while psoriatic arthritis also includes inflammation of the joints and entheses , .
Read on to find out the different symptoms of psoriasis vs. PsA, how they are diagnosed and treated, and what you need know about the link between these health conditions.
Work And Psoriatic Arthritis
Having psoriatic arthritis may make some aspects of working life more challenging. But, if youre on the right treatment, its certainly possible to continue working.
Help and support is available, and you have rights and options.
The Government scheme Access to Work is a grant that can pay for equipment to help you with activities such as answering the phone, going to meetings, and getting to and from work.
The 2010 Equality Act, and the Disability Discrimination Act in Northern Ireland makes it unlawful for employers to treat anyone with a disability less favourably than anyone else.
Psoriatic arthritis can be classed as a disability if it:
- makes daily tasks difficult
- lasts for more than 12 months.
Your employer may need to make adjustments to your working environment, so you can do your job comfortably and safely.
You might be able to change some aspects of your job or working arrangements, or train for a different role.
In order to get the support youre entitled to, youll need to tell your employer about your condition. Your manager or HR department might be a good place to start.
Other available support might include:
- your workplace occupational health department, if there is one
- an occupational therapist. You could be referred to one by your GP or you could see one privately
- disability employment advisors, or other staff, at your local JobCentre Plus
- a Citizens Advice bureau particularly if you feel youre not getting the support youre entitled to.
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Role Of Tnf In Psoriasis And Psoriatic Arthritis
TNF is a key proinflammatory cytokine capable of driving inflammation in a number of different clinical settings. That TNF plays an important role in psoriasis and PsA has been demonstrated in a number of ways. Firstly, the TNF protein and message in skin and synovial tissue has been well documented. Secondly, TNF gene polymorphism analysis also suggests a role for TNF if not in disease initiation quite likely in disease severity. Thirdly, evidence from clinical trials strongly supports a role for TNF inhibition, as a high degree of clinical benefit in both skin and joint disease has been demonstrated.
What Causes Psoriatic Arthritis
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:
- being overweight
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 cant catch it from one another.
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What Are The Treatment Options For Psoriatic Arthritis
The aim of treatment for psoriatic arthritis is to control the disease and relieve symptoms. Treatment may include any combination of the following:
Choice of medications depends on disease severity, number of joints involved, and associated skin symptoms. During the early stages of the disease, mild inflammation may respond to nonsteroidal anti-inflammatory drugs . Cortisone injections may be used to treat ongoing inflammation in a single joint. Oral steroids, if used to treat a psoriatic arthritis flare, can temporarily worsen psoriasis. Long-term use of oral steroids should be avoided when possible due to the negative effects on the body over time.
DMARDs are used when NSAIDs fail to work and for patients with persistent and/or erosive disease. DMARDs that are effective in treating psoriatic arthritis include: methotrexate, sulfasalazine, and cyclosporine.
Biologic agents are an important consideration when disease control is not being achieved with NSAIDS or DMARDs. Biologics have been utilized for the treatment of psoriatic arthritis since 2005 and are highly effective at slowing and preventing progression of joint damage. Your healthcare provider will complete additional laboratory tests and review safety considerations before initiating a medication regimen. Gaining good control of psoriatic arthritis and psoriasis is important to avoid increased systemic risks, particularly heart disease.
Exercise
Heat and cold therapy
Joint protection and energy conservation
Does The Severity Of Skin Or Nail Psoriasis Matter
- Nail changes are found in 2 out of 5 individuals with psoriatic arthritis, compared with around half in those with psoriasis alone.
- Nail changes include pitting and discolouration of the nail due to abnormalities in the growth of tissue in the nailbed.
- The risk of developing psoriatic arthritis is greater in individuals with severe psoriasis, yet severe psoriatic arthritis may occur with minimal skin disease.
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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 ascalcipotriol and tacalcitol
- vitamin A-like gels such astazarotene
- tar-based ointments.
For more information about the benefits and disadvantages of any of these talk to your GP, dermatologist, or pharmacist.
If the creams and ointments dont help, your doctor may suggest light therapy, also known as phototherapy. This involves being exposed to short spells of strong ultraviolet light in hospital.
Once this treatment has started, youll need to have it regularly and stick to the appointments youve been given, for it to be successful. This treatment is not suitable for people at high risk of skin cancer or for children. For some people, this treatment can make their psoriasis worse.
Retinoid tablets, such as acitretin, are made from substances related to vitamin A. These can be useful if your psoriasis isnt responding to other treatments. However, they can cause dry skin and you may not be able to take them if you have diabetes.
Some DMARDs used for psoriatic arthritis will also help with psoriasis.
How To Prevent Psoriasis And Psa Flare
The symptoms of psoriatic disease cant be completely stopped, but they can usually be controlled with treatment.
Identifying what triggers your psoriasis and PsA flares is key to treating the condition. Because PsA is a result of psoriasis, both conditions may be triggered by the same environmental factors.
For some people, stress can be a major trigger for a psoriasis flare. Learning breathing exercises, practicing yoga, and using other coping mechanisms for stress may help stop stressful situations from making your psoriasis symptoms worse.
The biggest lifestyle change that might ease the symptoms of psoriatic disease is diet. Looking at your diet to identify things that trigger your psoriasis symptoms could mean removing some foods as a form of treatment.
Obesity is known to contribute to psoriasis symptoms. Maintaining a healthy diet is essential to being in a healthy weight range. If you can avoid carrying extra pounds, studies indicate that your symptoms will be less severe.
Drinking alcohol and smoking can also trigger flares, so limiting or eliminating these factors entirely can be beneficial.
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Early Symptoms Of Psoriatic Arthritis
Here are some common first signs of PsA. If you experience any of these, talk to your primary care provider. Early detection and treatment of the disease can help prevent future joint damage.
How Do Psoriasis And Psa Overlap
For every 10 patients who walk in the door with psoriasis, about three or four of them will eventually get PsA, says Elaine Husni, MD, MPH, vice chair of the department of rheumatic & immunologic diseases at the Cleveland Clinic in Ohio. Most cases almost always start with the skin condition and then within seven to 10 years later, joint pain symptoms start to develop.
However, skin and joint symptoms can develop at the same time and, more rarely, joint symptoms can appear before skin involvement, says Dr. Haberman. While estimates vary, one study showed that up to 3 percent of patients developed joint disease before skin disease, she notes.
In some cases, there may have been skin involvement that went unnoticed or undiagnosed. For example, psoriasis can be sneaky and show up in hidden or private areas like the scalp, intergluteal cleft , belly button, and inside the ear, explains Dr. Husni. Since people dont really examine their scalp or buttocks very often, small psoriasis patches can get missed and delay diagnosis, she says.
Adds Dr. Haberman: You might have a small fleck in your scalp that you just think of as dandruff that is actually psoriasis.
Whats more, people with psoriasis in some of these hidden areas may actually be more prone to PsA. Studies have shown that you may be at higher risk of developing PsA if you have scalp, nail, or inverse psoriasis, says Dr. Haberman.
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Genetic Markers Of Psoriatic Arthritis
In the last 3 years, significant progress has been made toward identifying genetic markers associated with psoriatic arthritis. However, most of these markers are also associated with psoriasis, and thus a major remaining challenge is to identify genetic risk factors that are specific to psoriatic arthritis.
HLA locus
The HLA locus contains many genes responsible for immunologic function in humans. Psoriasis and psoriatic arthritis demonstrate human leukocyte antigen associations, most frequently with HLA-Cw6.29,6769 However, the HLA region may potentially harbor multiple genes that are associated with psoriasis and psoriatic arthritis. For psoriasis, Feng et al.70 recently identified three independent signals near the HLA locus that contribute to psoriasis risk: HLA-Cw6, c6orf10, and the region between HLA-B and MICA.
Although psoriatic arthritis is most strongly associated with HLA-Cw6, other HLA markers have also been associated with it. The frequency of HLA-B27 is reportedly higher among patients with psoriatic arthritis.28,71,72 Gladmann and Farewell71 performed a univariate analysis of psoriatic arthritis patients and showed that HLA-B27, HLA-B39, and HLA-DQw3 antigens were associated with psoriatic arthritis disease progression, whereas HLA-DR7 was protective. Additionally, the presence of HLA-B39 suggested early progression in psoriatic arthritis.
MICA locus
Other genetic loci
Inflammation Is Behind Ps And Psa
Although there is no known cause for psoriasis, it is an auto-immune disease and is tied to inflammation.
With plaque psoriasis, the skin cells renew faster than they should. This causes plaques to form on the skin.
With psoriatic arthritis, joint inflammation occurs, leading to stiffness, swelling, and pain.
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Symptoms Of Psoriatic Arthritis
The severity of the condition can vary considerably from person to person. Some people may have severe problems affecting many joints, whereas others may only notice mild symptoms in 1 or 2 joints.
There may be times when your symptoms improve and periods when they get worse .
Relapses can be very difficult to predict, but can often be managed with medicine when they do occur.
The Impact Of Comorbidities
Some comorbidities can affect your health and quality of life with PsA more than others. If you do have any of these underlying health conditions, it is important to speak with your doctor about how to manage and treat them. Addressing these conditions can help you lead a healthier, more comfortable life.
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How Is Psoriatic Arthritis Diagnosed
Psoriatic arthritis is easier to confirm if you already have psoriasis. If you donthave the skin symptoms, diagnosis is more difficult. The process starts with a healthhistory and a physical exam. Your healthcare provider will ask about your symptoms. Youmay have blood tests to check the following:
- Erythrocyte sedimentation rate . This test looks at how quickly red blood cells fall to the bottom of a test tube. When swelling and inflammation are present, the bloods proteins clump together and become heavier than normal. They fall and settle faster at the bottom of the test tube. The faster the blood cells fall, the more severe the inflammation.
- Uric acid. High blood uric acid levels can be seen in psoriatic arthritis but are not used for diagnosis or monitoring.
- Imaging. X-rays, CT scans, ultrasound, MRI, and skin biopsies may all be used to help diagnosis.
Diagnosing Psoriasis And Psa
Unfortunately, theres no one simple diagnostic test to check for psoriasis or psoriatic arthritis. This means your doctor will need to make a clinical diagnosis, which requires taking into account your symptoms, risk factors, as well as the results of bloodwork and X-rays or other imaging scans to assess any joint involvement.
During the physical exam, your doctor might look for signs of psoriasis on the elbows and knees as well as less visible places like the scalp, belly button, intergluteal cleft, palms of hands, and soles of feet. Theyll also check for any fingernail or toenail abnormalities, like pitting or ridging, as well as swollen fingers or toes .
The presence of dactylitis and finger and toenail changes are evidence of psoriasis that can be used to aid in the diagnosis of psoriatic arthritis if there is no evidence of skin disease, says Dr. Haberman.
Here are some common steps used to diagnose psoriasis and PsA:
- A medical exam to discuss family history, risk factors, and symptoms
- Blood tests to check for markers of inflammation and antibodies , which can help rule out other types of arthritis, including rheumatoid arthritis
- Imaging tests to detect any joint damage, dislocation of small or large joints, disfiguration , new bone formation, and inflammation in the enthesis
- Skin biopsy of a skin plaque, if you have previously undiagnosed psoriasis
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Treatment Options For Both Psoriasis And Psa
Drugs to suppress immune system activity are among the most effective treatments for psoriasis and PsA.
Systemic, immune-suppressing drugs often provide relief for both conditions. However, your risk of secondary infections and other side effects is greater when using these drugs.
If you have severe psoriasis and are diagnosed with PsA, your doctor may prescribe the anti-inflammatory and immune-suppressant drug methotrexate . This medication aims to slow down the cells in your body that are reproducing too quickly and causing psoriasis flares.
Common side effects of methotrexate include:
A newer class of drugs called biologics, in particular TNF blockers, targets specific parts of the immune system more precisely. Because of this, your doctor may be more likely to recommend them over methotrexate.
Biologics reduce inflammation and psoriasis outbreaks in most people who take them. There are a number of brands of biologics approved for treatment of psoriasis in the United States.
Biologics need to be injected. Some need to be administered more often than others. Common side effects include:
- allergic reaction
When To Seek Medical Advice
You should speak to your GP if you experience constant pain, swelling or stiffness in your joints even if you haven’t been diagnosed with psoriasis.
If you have been diagnosed with psoriasis, you should have check-ups at least once a year to monitor your condition. Make sure you let your doctor know if you’re experiencing any problems with your joints.
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Management Of Psoriatic Arthritis
PsA can be treated with a variety of strategies and, depending on the severity, chronicity, and other comorbidities, low remission or low disease activity should be the target.11 The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis , the European League Against Rheumatism , and the American College of Rheumatology and the National Psoriasis Foundation in collaboration have all published and revised psoriatic arthritis treatment recommendations.1
Figure 3: Suggested treatment algorithm for patients with psoriasis and/or psoriatic arthritis.15