Psoriatic arthritis - signs and treatment of joint inflammation

Psoriatic arthritis

is a secondary inflammatory disease of the joints with a chronic course. It appears in every 4th patient with psoriasis as a consequence of the underlying disease. Often the inflammatory process affects not only the peripheral joints, but also spreads to the spine, involving ligaments and tendons.

Psoriatic arthritis is a chronic inflammation of the joints, a consequence of psoriasis.

Usually the disease makes itself felt at the age of 25-50 years, but an earlier, juvenile form

, in which the onset of the disease occurs at the age of 9-11 years. By a slight margin, women are more susceptible to psoriatic arthritis.

Although the disease is usually mild to moderate, approximately 10-15% of patients suffer from a disabling form

General information

Psoriatic arthritis (PsA) or psoriatic arthropathy is a chronic systemic disease of the musculoskeletal system associated with psoriasis, that is, concomitant with it. Codes for the International Classification of Diseases, 10th revision (ICD-10) - L 40.5, M07.0 - M07.3.

According to statistics, the incidence of PsA is 3–8 per 100,000 population. Inflammatory processes in the joints with psoriasis more often appear in people against the background of existing skin rashes (70% of all patients). But it also happens the other way around, when psoriatic arthritis is the only manifestation of the disease, which significantly complicates timely diagnosis. There are about 15% of such patients; the same number of patients had both skin and joint symptoms.

In children

In childhood, pathology usually occurs in the form of psoriatic erythroderma , more often observed in girls. Doctors identify a separate juvenile form of the disease, its peak occurs during puberty - age 10-12 years. Manifestations of arthritis are preceded by psoriasis, without fever, hepatolienal syndrome or lymphadenopathy . The prognosis is usually favorable: in children in 20-50% of cases there is a stable remission, in 25-30% there is a sluggish progression of chronic polyarthritis , and only in 10-15% of children the pathology leads to disability.

Why and how the disease develops

The causes of psoriasis have not been fully established. It is believed that the immune system and hereditary predisposition play a major role in the development of psoriatic arthritis. It has been established that about 40% of patients with PsA have close relatives suffering from psoriasis.

Under the influence of any trigger factors (nervous stress, infection, hypothermia, alcohol abuse, etc.), genetically predisposed individuals experience a malfunction of the immune system. Normally, immune cells produce information molecules—cytokines—that regulate inflammatory reactions. A malfunction of the immune system leads to the fact that the normal ratio of cytokines that support and suppress inflammation is disrupted, a cytokine storm develops, and inflammation becomes uncontrollable.

Genetic predisposition manifests itself in the presence of certain antigens in the body. Thus, in the presence of the B38 antigen, psoriatic arthritis rapidly progresses with the development of a destructive process that destroys the articular surface. The presence of B17 and Cw6 antigens indicates the possible involvement of a small number of joints in the process, and the B57 antigen indicates multiple lesions.

The pathogenesis of the disease is associated with the production of antibodies to antigens. Antigen-antibody complexes are deposited in the synovium, causing an inflammatory process that is maintained for a long time by a cytokine storm. Long-term psoriatic arthritis destroys cartilage tissue, causes thinning of bone tissue (osteoporosis) and its proliferation with the development of joint deformation, immobility (ankylosis) and loss of function.

Pathogenesis

The pathology is based on a pathological process - synovitis , which manifests itself in the form of an increase in volume and accumulation of effusion (biological fluid) in the cavities of the joints. Articular syndrome is a thickening of the synovial membrane of the joints, an increase in periarticular intermuscular joints and the proliferation of intra-articular fatty tissues.

Destructive changes in joints usually occur under the influence of tumor necrosis factor , an extracellular protein called TNF-α , which activates endothelial cells and stimulates the proliferation of fibroblasts. This causes the expression of matrix metalloproteinase , stimulation of the synthesis of collagenase and prostaglandin PGE2 , activation of osteoclasts and regulation of the production of certain chemokines . An important role is also played by the formation of interaction of immunocompetent cells with keratinocytes, synovial membrane cells, cytokines , disruption of immunoregulation processes, activation of inducers of inflammation and tissue destruction.

Arthropathy and psoriatic disease in general cause alterative changes in the basic substance of the vascular walls, depolymerization of the fibrillar components of the connective tissue, while the accumulation of perivascular cellular infiltrates occurs, as well as reversible and irreversible changes in neurons.

Clinical forms of psoriatic arthritis

The following types of PsA are distinguished:

Distal. The end joints of the fingers are involved in the pathological process. Occurs in 5% of cases.
Asymmetrical damage to one or more (no more than four) large joints, as well as proximal (located closer to the limb) joints of the fingers. Occurs in two thirds of patients.
Symmetrical lesions (rheumatoid-like form) occur in a fifth of patients.
Osteolytic. It manifests itself as dissolution (lysis) of bone joint tissue with a decrease in length and subluxation of the fingers. Osteolysis is possible in all forms of psoriatic arthritis.
Spondyloarthritic. The sacroiliac joints and spinal joints are affected. Occurs in half of the cases. The combination with psoriatic arthritis of the joints of the extremities develops much less frequently.

Any form of arthritis has serious complications, so you should not delay treatment.
See how easily the disease can be cured in 10-12 sessions.

Prevention

The etiology of arthropathic psoriasis has not yet been clarified, which makes it impossible to prevent the development of the disease. Therefore, secondary prevention methods are most often used to reduce the damage to the health of patients after the manifestation of the disease, maintain the functionality of the joints and slow down the rate of progression of the pathology. It is important to listen to these recommendations:

stop smoking;
lead an active lifestyle;
normalize body weight;
regularly engage in physical therapy;
follow a special diet.

Symptoms of psoriatic arthritis

Signs of psoriatic arthritis depend on the nature of its course.

First signs

Psoriatic arthritis begins on average 6 years after the appearance of changes on the skin. But in recent years, PsA has increasingly preceded skin rashes.

The disease usually begins with the onset of fever, malaise, redness and swelling of the distal interphalangeal joints of the fingers and toes with the development of radish-shaped deformities of the fingertips. Damage to several interphalangeal joints of the finger involving soft tissues is called dactylitis (inflammation of the finger). The finger swells, becomes reddish-bluish in color and looks like a sausage. All this is accompanied by severe pain.

Swelling, redness of the joint and fever are the first signs of psoriatic arthritis

Much less often, the first symptoms of psoriatic arthritis appear in one or two large joints. The lesions are asymmetrical, most often the ankles are affected, and then the inflammation rises like a ladder with the knee affected. Characterized by morning stiffness of movement, which goes away after a while. Less commonly, symmetrical damage to large joints occurs, most often the knees - a rheumatoid-like form.

When the first symptoms of psoriatic arthritis appear, you should immediately consult a doctor to stop the progression of the disease as quickly as possible.

Obvious symptoms

Characteristic signs of psoriatic arthritis include:

distal lesions of the fingers with simultaneous lesions of the nails; development of dactylitis with sausage-shaped fingers;
asymmetrical damage to 2 – 3 large joints with the formation of mono- and oligoarthritis (damages of one or more joints) and enthesitis (inflammation of the tendon attachment site); pain in psoriatic arthritis intensifies in the morning and decreases after the start of physical activity; The joints of the lower extremities (knees, ankles) are especially often involved in the pathological process; sometimes the inflammation spreads to multiple joints;
the process also involves the joints of the lumbosacral spine and sacroiliac joints; this is accompanied by pain and movement disorders: the back does not straighten;
the course of the disease is undulating: exacerbations alternate with partial (less often complete) remissions; often psoriatic arthritis worsens against the background of progression of skin symptoms of psoriasis.

If obvious symptoms of psoriatic arthritis appear, it is not too late to seek medical help: you can help the patient in any case.

Dangerous symptoms, recommendations

You should consult a doctor immediately if:

many joints become inflamed at once - a sign of generalization of the process;
pain appears in the lower back - a symptom of psoriatic arthritis of the spinal joints;
the appearance of joint dislocations and subluxations.

These symptoms of psoriatic arthritis indicate an unfavorable course of the disease and require immediate medical attention.

Appealing the decision

If the patient is not satisfied with the results of the medical examination, he has the right to appeal such a decision. To do this, you need to send an application to the bureau that reviewed the application for disability. Having received a complaint, representatives of the bureau must send it, along with all documents, to representatives of the main department within 3 days. There a decision is made to schedule another MSEC. If the newly obtained results of the commission do not satisfy the patient, he has the right to appeal them by submitting an application to the main bureau, which will be sent along with the attached documentation to the federal department.

Sometimes the MES refuses to limit the ability to work for patients

A secondary examination, in addition to confirming a predetermined disability, is necessary to adjust the rehabilitation program and monitor the dynamics of possible changes in the patient’s health status.

The intervals for re-examination may vary and depend on the patient’s disability group:

for disabled people of group 3, passing the commission is mandatory once a year;
patients belonging to disability group 2 must undergo re-examination once a year;
passing the commission twice a year is a mandatory procedure for disabled people of group 1;
children who are disabled of any group must undergo examination before the end of the period for which the disability was assigned.

In cases where disability is established for an indefinite period, that is, it is indefinite, re-examination can also be completed by first writing an application.

Why is PsA dangerous?

Psoriatic arthritis occurs in different ways. But even an imperceptible course can lead over time to permanent loss of ability to work. To find out the degree of danger of the disease, you need to undergo an examination.

Degrees of psoriatic arthritis

During the course of the disease, the following degrees of activity are distinguished:

Minor.
It manifests itself as slight pain in the affected joints during physical activity. Stiffness in movements in the morning after sleep lasts no more than half an hour or is completely absent. There is no fever, laboratory signs of the inflammatory process are minimal: ESR is not higher than 20 mm/hour.
Average.
During exacerbations, a slight fever appears, the joints may swell slightly, the pain is moderate, and appears at rest and during movement. Stiffness after sleep lasts up to three hours and goes away with physical activity. Laboratory parameters changed significantly: ESR up to 40 mm/hour, increased number of leukocytes.
Expressed.
Severe fever during an exacerbation, joints swell, the skin over them turns red, the pain is very strong and constant. Stiffness after sleep lasts more than three hours. Laboratory indicators indicate the presence of a severe inflammatory reaction.

Chondroprotectors: what are they, how to choose, how effective are they?

Joint pain at rest

Possible complications

Untreated psoriatic arthritis can progress and lead to complete loss of joint function and disability. During an exacerbation, in some cases the following complications occur:

the occurrence of articular subluxations and dislocations;
melting (lysis) of the distal ends of the bones of the fingers and toes;
generalization of the process - a severe progressive course with multiple joint lesions;
ankylosis - complete loss of joint function, impaired mobility of the limb.

What to do during an exacerbation of psoriatic arthritis

In case of exacerbation, accompanied by high fever, swelling, redness, joint pain, the following recommendations must be followed:

take orally a tablet of medication from the group of non-steroidal anti-inflammatory drugs (NSAIDs) - Nise, Diclofenac, Meloxicam, Celebrex;
apply a gel or cream with the same products to sore joints several times a day;
to reduce swelling, you can take an antihistamine - Claritin, Zodak, etc.;
call a doctor at home.

If the disease worsens, you can take the anti-inflammatory drugs Nise, Diclofenac, Meloxicam, Celebrex, as well as the antihistamine Claritin or Zodak

Receiving a bypass sheet

A referral to MSEC can be made either by a general practitioner or another specialized specialist who supervises the patient’s treatment, for example, a rheumatologist or orthopedist. The list of doctors who will have to give an opinion to the patient is quite extensive. In addition to a general practitioner, dermatologist, rheumatologist and orthopedist, it may include an ophthalmologist, surgeon, neurologist, ENT specialist, and cardiologist. Based on objective indications, the patient may be referred for an appointment with other doctors whose competence is to determine the level of disability. The doctor directs the patient to undergo all tests, including blood, urine and fluorography. After collecting all the reports, the patient again goes to the attending physician to receive a final report, in which the doctor refers to the opinion of his colleagues.

Before appearing to the strict members of the ITU commission, the patient must appear before the medical commission working in the clinic at his place of residence. The main task of the commission is to determine the correctness of medical credentials so that the pension applicant does not turn out to be a malingerer. The composition includes the chief physician of a medical institution or his deputy and several multidisciplinary specialists. This procedure is usually formal, but the difficulty lies in the fact that the commission usually meets for only one hour and on a certain day.

Possible localizations of the inflammatory process

Psoriatic arthritis can affect different joints:

Arthritis of the lower extremities
– the most common localization. Joints affected:
knee - of the large articular joints, it is most often affected; lesions are often asymmetrical and appear either immediately in one knee, or develop after primary psoriatic arthritis of the joints of the foot (staircase sign);
ankle - very often the lesion begins with it; severe inflammation and swelling is accompanied by severe pain and impaired movement;
heel - in the heel area with ankle arthritis, enthesitis develops - inflammation at the internal site of attachment to the heel bone of the Achilles tendon and plantar aponeurosis; there is a slight swelling and severe pain in the heel area;
interphalangeal joints – several on one or more fingers may be affected primarily; dactylitis develops - inflammation of the finger, and it takes on the appearance of a sausage; Damage to the terminal sections of the fingers and nails is also typical.
Arthritis of the upper extremities
- also occurs frequently. Joints affected:
ulnar - most often affected after the small joints of the hand (staircase symptom); enthesitis often develops in the elbow area, increasing pain;
small joints of the hand and fingers - psoriatic arthritis of the finger joints affects several of them on one finger at once, and they take on the appearance of sausages; the distal ends of the fingers and nail plates are also affected;
Lumbosacral arthritis
– affects the joints of the lumbosacral spine. Pain appears in the lower back and buttocks, the function of the spine is disrupted - flexion and extension are first impossible due to pain, and then due to the development of ankylosis.
Sacroiliac arthritis
- develops quite often, is asymmetrical in nature, manifested by pain in one side of the back, radiating to the groin area.

Read all about arthritis and its symptoms here.

Further work activity after registration of disability

If a patient has received group 3 disability, this does not mean that he should end his work activity. According to the Law, an employer cannot fire an employee who has been assigned a 2nd or 3rd disability group. Some business managers use a trick, because the law can be circumvented by dismissing an employee on the basis of staff reduction. Moreover, the reduction may well be fictitious. In any case, the director must warn the employee 2 months before the proposed layoff.

How to establish the correct diagnosis?

Ultrasound and x-rays are often used to diagnose psoriatic arthritis.

Diagnosis of psoriatic arthritis is carried out according to anamnesis (patient survey) and characteristic signs of the disease. The diagnosis is confirmed by laboratory and instrumental studies:

Laboratory.
Blood tests are carried out - general clinical, biochemical, genetic - to identify signs of the inflammatory process, the presence or absence of rheumatoid factor (to exclude rheumatoid arthritis), antigens that support the inflammatory process.
Instrumental diagnostics:
Ultrasound – determination of the volume of joint fluid and enthesitis;
MRI – for early detection of articular changes in the spine and sacroiliac joints.

Treatment of psoriatic arthritis

After the final diagnosis is established, psoriatic arthritis is treated. It must be comprehensive and selected individually for each patient. Goal of treatment:

suppression of inflammation activity and disease progression;
prevention of destruction of articular joints and loss of their function.

It is impossible to completely cure psoriatic arthritis. But modern medicine has the ability to control and manage this disease, provided that treatment is carried out as prescribed and under the supervision of the attending physician. A significant increase in the duration of remission is quite possible.

Drug and non-drug methods are used to treat psoriatic arthritis. If necessary, use folk remedies and surgical methods.

Crunching in joints - when to worry

Intra-articular injections of hyaluronic acid

Drug therapy

Complex drug therapy for psoriatic arthritis includes the following medications:

Medicines from the NSAID group are prescribed during an exacerbation to suppress inflammation, swelling, pain, and also as an antipyretic. Diclofencac, Ibuprfen, Nimesulide and other drugs are prescribed in the form of tablets for oral administration, intramuscular injections, ointments and gels for external use.
Glucocorticoid hormones are used for severe inflammation, swelling and pain that is not relieved by NSAIDs. Hormones (Prednisolone, Dexamethasone, Betamethasone, etc.) are taken orally, administered in the form of intramuscular and intra-articular injections.
Basic drugs that suppress the activity of the immune system (immunosuppressants) - Methotrexate, Cyclosporine, Sulfasalazine, Leflunomide are prescribed in long courses under laboratory and radiological control.
Genetically engineered biological drugs that contain antibodies, cytokines and other biologically active substances that take part in immune reactions and suppress the activity of pro-inflammatory cytokines - Rituximab, Ustekinumab. Effective modern therapy for PsA.

Correctly prescribed drug therapy allows you to completely control the course of the disease.

Non-drug treatments

Treatment of psoriatic arthritis should be comprehensive and necessarily include therapeutic exercises, reflexology and physiotherapeutic procedures

Complex therapy also includes treatment of psoriatic arthritis using non-drug methods:

Mode.
During an exacerbation - the most gentle regimen, with a severe exacerbation - bed rest. During remission, a gradual increase in physical activity is recommended.
Nutrition.
There is no special diet, but it is recommended to adhere to the principles of a healthy diet with the exception of fatty, fried, spicy, smoked foods, sweets, baked goods and alcohol.
Physiotherapeutic procedures.
The procedures that are most suitable for the patient’s condition are selected: those that relieve inflammation and pain, restore joint function, eliminate the effects of stress, etc.
Physiotherapy.
Specially selected exercises relieve morning stiffness and reduce pain. During remission, it is recommended to gradually increase the load.
Reflexology.
Acupuncture sessions and other oriental techniques eliminate pain, inflammation, and restore joint function.

General clinical recommendations

All patients suffering from PsA are recommended to:

during an exacerbation, strictly follow all doctor’s instructions and do not self-medicate;
during remission, conduct courses of anti-relapse treatment; regularly perform complexes of therapeutic exercises; It is useful to carry out sanatorium-resort treatment once a year in the sanatoriums of Zheleznovodsk, Pyatigorsk, Kislovodsk, Matsesta, etc.;
promptly treat all existing concomitant diseases and foci of infection, avoid stress and heavy physical activity;
eat properly and in a timely manner, lose excess weight;
get rid of bad habits: smoking and alcohol abuse.

We combine proven techniques of the East and innovative methods of Western medicine.
Read more about our unique method of treating arthritis

Frequently asked questions about the disease

Is it possible to get disability?

If there is a dysfunction of the joint, then yes, it is possible.

Which doctor treats you?

Two doctors treat: a dermatovenerologist and a rheumatologist, but the main one is a rheumatologist.

What prognosis do doctors usually give?

It all depends on the clinical form of the disease and the rate of its progression. But in any case, the disease can be brought under control.

Psoriatic arthritis is not a death sentence; it can and should be treated at any stage of the disease. It is quite possible to relieve the patient from exacerbations, joint pain and progressive decline in function for a long time (sometimes until the end of life). Doctors at the Paramita clinic have extensive experience in treating this disease, please contact us!

Literature:

Kungurov N.V. et al. Genetic factors in the etiology and pathogenesis of psoriasis // Bulletin of Dermatology and Venereology. 2011. No. 1. pp. 23–27.
Yusupova L. A., Filatova M. A. Current state of the problem of psoriatic arthritis // Practical Medicine. 2013. No. 3. pp. 24–28.
Korotaeva T.V. Standards for the treatment of psoriatic arthritis // Scientific and practical rheumatology. 2009. No. 3. P. 29–38.
Haroon M., Gallagher P., FitzGerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2015;74(6):1045–1050. DOI: 10.1136/annrheumdis-2013-204858.

Themes

Arthritis, Joints, Pain, Treatment without surgery Date of publication: 04.11.2020 Date of update: 14.12.2020

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What must be done to obtain disability?

The procedure for completing documents, as well as familiarizing the medical commission with the medical history will take a lot of time - 3-4 months. Such a long period is explained by the need to examine a sick person by many doctors. You will need to consult an ophthalmologist, surgeon, ENT specialist, cardiologist and neurologist. In addition, it is necessary to conduct an ultrasound examination of the joints and internal organs, as well as an X-ray scan. This is necessary to make sure that psoriatic lesions are absent or present, in addition to joints, in other tissues and organs.

The prerequisite for receiving government support is the patient’s loss of ability to work.