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Mayo Clinic Q and A: With psoriatic arthritis, the sooner therapy is started, the better
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DEAR MAYO CLINIC: I was recently diagnosed with psoriatic arthritis and am confused about all of the treatment options. What do you recommend for your patients?
ANSWER: Psoriatic arthritis is a type of arthritis that develops in some people who have psoriasis — a chronic skin condition characterized by thickened, reddish patches of skin that are often flecked with dry, white scales. It can cause painful, swollen joints — similar to rheumatoid arthritis. Any joint can be affected, and the pain can range from mild to severe. In both psoriasis and psoriatic arthritis, you may find that symptoms flare up, recede and then flare up again.
People with psoriatic arthritis often feel worn down by the chronic itching and pain that accompany the two diseases. Although there’s no cure, there are effective treatments that can help relieve the symptoms and even help prevent further joint damage. The sooner therapy is started, the less time the disease has to progress and cause permanent damage to your joints.
A number of medications used for rheumatoid arthritis can also be used for psoriatic arthritis, and some of them are also effective for psoriasis. Which ones you use and for how long depend on how bothersome your symptoms are, how well the medication works, and the potential side effects. You may have to try several different drugs but most people are able to find one that works.
NSAIDs — If your symptoms are mild, nonsteroidal anti-inflammatory drugs (NSAIDs) may be sufficient to relieve pain and reduce inflammation. Nonprescription NSAIDs include ibuprofen and naproxen sodium, and stronger NSAIDs are available by prescription.
Disease-modifying antirheumatic drugs (DMARDs) — These drugs can relieve pain as well as slow the progression of psoriatic arthritis and save joints and other tissues from permanent damage.
Immunosuppressants — These medications act to tame your immune system, which is out of control in psoriatic arthritis.
Tumor necrosis factor-alpha (TNF-alpha) inhibitors — TNF-alpha is an inflammatory substance produced by your body. TNF-alpha inhibitors block this substance and help reduce pain, stiffness and swollen joints.
If established medications don’t help or become less effective over time, there are two newly approved drugs your doctor may try. Ustekinumab (Stelara) works by blocking interleukin (IL)-12 and IL-23, a set of immune system proteins that research suggests may be involved in promoting psoriatic arthritis. The medication is injected under the skin. Apremilast (Otezla) inhibits the activity of an enzyme involved in promoting inflammation and may help joint pain and skin inflammation, including hard-to-treat areas such as nails and scalp. It’s available as a pill. During clinical trials, side effects were mild to moderate and didn’t increase the risk of serious infection, as can happen with DMARDs, TNF-alpha inhibitors and immunosuppressants.
In addition, the drug secukinumab (Cosentyx) has been approved for psoriasis, and phase III trials have shown that it may be effective for psoriatic arthritis as well.
For joints that become very swollen due to psoriatic arthritis, a steroid injected directly into the joint can rapidly relieve inflammation. If a joint is severely damaged, surgery to replace it with an artificial joint may be an option. Topical medications can be quite effective in lessening the itching associated with psoriasis and decreasing the thickened skin plaques.
It’s also important to consider other measures to help you cope with psoriatic arthritis. Increasing physical activity can help your body release “feel-good” endorphins. Regular exercise promotes relaxation and can keep your joints flexible and maintain your overall health. Walking, swimming, stretching, yoga and stationary bicycling are all good activities.
Stress and anxiety may worsen psoriasis and complicate chronic pain. Taking measures to relieve stress — such as visualization therapy, biofeedback or meditation — may help you cope with day-to-day variations in symptoms of both conditions, such as itching and pain levels. Reducing stress may also help your treatment work better. Smoking is associated with an increased risk for developing psoriasis, so consider smoking cessation for the psoriasis and your general health. Drinking alcohol can worsen the skin and decrease the effectiveness of treatment, so limiting your alcohol use may be another way to help manage the psoriasis.
Finally, do what you can to protect your joints. Changing the way you carry out everyday tasks can make a big difference in how you feel. For example, you can avoid straining your finger joints by using gadgets such as jar openers to twist the lids from jars, by lifting heavy pans or other objects with both hands, and by pushing doors open with your whole body instead of just your fingers. — April Chang-Miller, M.D., Rheumatology, Mayo Clinic, Scottsdale, Ariz.
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