Approach to Diagnosing Psoriatic Arthritis:
Psoriatic arthritis is a specific type of arthritis that develops in approximately 23percent of people who have psoriasis. The disease can be difficult to diagnose, particularly in its milder forms.

The cause of psoriatic arthritis is unknown. Doctors suspect that genetic, environmental and immune factors play a role in the condition. It is classified in the group of diseases called Seronegative Spondyloarthropathies (Other diseases in this group include Behcet's disease, Reiter's syndrome, ankylosing sponylitis, Marie-Strumpell arthritis, Rheumatoid spondylitis, psoriatic arthritis, and inflammatory bowel disease.) Approximately 40 percent of people who develop psoriatic arthritis have a family member with either psoriasis or arthritis.

Psoriatic arthritis can start slowly with mild symptoms, or it can develop quickly. Left untreated, psoriatic arthritis can be a progressively disabling disease.

Symptoms include:

Joints commonly affected by psoriatic arthritis are the wrists, knees, ankles, lower back and neck. Psoriatic arthritis can develop any time, but for most people it appears between the ages of 30 and 50, and it affects men and women equally.

Approach to Therapy of Psoriatic Arthritis:
Current therapy for psoriatic arthritis (PA) can relieve pain, reduce swelling, help keep joints working properly and possibly prevent further tissue damage. Physicians will choose treatments based on the type of PA, its severity and an individual's reaction to treatment.

Some cases of PA cause deterioration of the spine and deformity of the joints, leading to disability. It is important for people who seem to be developing severe psoriatic arthritis to begin appropriate treatment before irreversible changes occur.
Early treatment can help slow the disease and preserve function and range of motion. Some early indicators of severe disease include onset at a young age, spinal involvement and the results of certain blood studies.

Categories of Treatment
Drugs for the treatment of PA can be divided into two categories:

Corticosteroids play a helpful role in some cases. Heat, warm water soaks, exercise programs and physical therapy also are used in the treatment of PA. The following treatments are not listed in an ascending order of importance. A physician must evaluate each PA case individually.

Step 1: Treating the Symptoms

Aspirin & NSAIDs
Aspirin is often less effective for PA than for rheumatoid arthritis, even though it can help reduce pain, swelling and stiffness. Aspirin can cause bleeding in the stomach, ulcers and easy bruising.

Prescription and nonprescription NSAIDs are effective for many people with PA in controlling swelling, pain and morning stiffness, and in improving range of motion to joints. They can help reduce the limitations to daily activities often caused by arthritis.

Many different brands of NSAIDs are available. The specific drug to be used is determined between the individual person with PA and his or her physician. It may take some experimentation before the NSAID with the right combination of good results and low side effects is found. NSAIDs and aspirin generally do not significantly alter psoriasis skin lesions, although certain NSAIDs have been reported to trigger flares of psoriasis.

NSAIDs and/or aspirin are sufficient treatment for many people over time. Acetaminophen (Tylenol) may be added for pain relief. A physician considers stronger medications when NSAIDs and aspirin fail to work and progression of the disease is evident.

Some NSAIDs, when taken in high doses or over long periods of time, carry a risk of causing stomach problems, including ulcers and gastrointestinal bleeding. The risk depends on the strength of the NSAID and how long it is taken, and many people with PA do not have problems with NSAID side effects.

For those who have had stomach problems or are at a higher risk for them, a new type of NSAID called a COX-2 inhibitor is now on the market. It has been developed to be safer for the stomach than other NSAIDs. The COX-2 inhibitor celecoxib (brandname Celebrex) has been approved for treating the symptoms of rheumatoid arthritis and osteoarthritis, while rofecoxib (brandname Vioxx) is indicated for symptoms of osteoarthritis and for acute pain.

Celecoxib and rofecoxib are not necessarily more effective at relieving pain and inflammation than regular NSAIDs. They are more expensive and have their own risks. People with PA who are interested in trying a new COX-2 inhibitor should talk to their physician.

Step 2: Slowing the Disease

Methotrexate
Methotrexate is a drug used widely and successfully for treating PA and rheumatoid arthritis. Available by pill or injection, it is effective at relieving the symptoms associated with PA, and it may retard the destruction caused by certain forms of PA.
Methotrexate usually is well tolerated in low doses. It does, however, have a number of side effects and the long-term potential of damaging the liver. With careful management and dosage, the drug can be used safely for years by selected individuals. A person taking methotrexate should follow a physician's instructions carefully.

Cyclosporine
Cyclosporine is a drug that suppresses the immune system and is used for preventing rejection of transplanted organs. It is approved for treating psoriasis, and it has produced improvement in the skin and in joint disease. Use of cyclosporine has increased recently, and it may be combined with methotrexate in certain individuals. Frequent blood tests are required due to the possibility of kidney damage.

Sulfasalazine
Sulfasalazine, a sulfa drug developed to treat inflammatory bowel diseases, has been increasingly used for PA as well as rheumatoid arthritis. Approximately one-third of PA patients respond rapidly to this therapy (usually within four to eight weeks), which may also induce more sustained remissions of the disease.
This drug has less dangerous side effects than some other systemic psoriasis and psoriatic arthritis treatments, including methotrexate, so a trial of sulfasalazine may be worthwhile for some. However, many people cannot tolerate sulfasalazine because of side effects, including nausea, vomiting and loss of appetite.

Antimalarials
Antimalarial therapy, commonly used with success in rheumatoid arthritis, has sometimes been used to treat PA. However, certain antimalarials can cause skin psoriasis to get much worse in some people. Some experts think antimalarials should not be used at all for PA.

On the other hand, it has been reported that the antimalarial hydroxychloroquine (Plaquenil) is less likely to cause a psoriatic flare than quinacrine or chloroquine, if a person needs to take an antimalarial in order to travel. A health care provider should be consulted about the available antimalarial treatments and alternatives.

Retinoids
Acitretin (brandname Soriatane in the U.S.), a systemic vitamin A derivative (retinoid) approved for severe skin psoriasis, may be effective for some PA patients. Oral retinoids carry with them the risk of birth defects and the possibility of producing skeletal side effects with long-term use.

PUVA
The administration of a photosensitizing drug called psoralen with ultraviolet light A (PUVA) may sometimes improve PA affecting the limbs. Generally it is used in combination with other medications. It is not helpful in treating PA of the spine.
It has few short-term side effects, but it has the long-term potential to increase the risk of certain skin cancers. The amount of risk is based on several factors, including the individual's skin type, the number of treatments and the total "dose" administered.

Gold (chrysotherapy)
Injection of gold salts and administration of gold capsules by mouth have both been reported to be effective in treating arthritis affecting the limbs, but not for treating arthritis of the spine. Though some people report that it causes a rash which makes psoriasis worse, others say it seems to improve their psoriasis lesions. Blood and urine samples are required to prevent kidney damage.

Use of gold has declined somewhat in recent years as new therapies have been developed.

Azathioprine
Azathioprine (brandname Imuran) is a drug that suppresses the immune system, and it is approved for use in certain types of arthritis. It has potent anti-inflammatory effects. Blood tests must be performed frequently because the drug can cause life-threatening effects on the bone marrow. Azathioprine increases the risk of malignancies in later years.

Corticosteroids
Steroid medications taken orally (by mouth) are not generally recommended for long-term treatment of PA, although in some circumstances they may be needed for relief of acute, severe joint inflammation and swelling. For the most part, large doses of steroids injected into muscles should be avoided-psoriasis of the skin may become much worse when treatment with systemic steroids is stopped.

Occasionally, severe forms of psoriasis, such as pustular psoriasis, may be provoked by the use of systemic steroids. However, selective low-dose steroid injections to inflamed joints, tendons and the area around joints can improve range of motion and limit contraction.

New Therapies Being Developed
Several new therapies approved by the U.S. Food and Drug Administration for treating rheumatoid arthritis are proving beneficial for psoriatic arthritis as well. These therapies, called "biologic response modifiers," target the immune system response that leads to inflammation. They represent an exciting and promising area of research for the treatment of inflammatory forms of arthritis, including PA.

In small studies and in anecdotal reports, etanercept (brandname Enbrel) has shown very good results in improving the symptoms of PA. There are very few side effects, although there can be an increased risk of infections. Large-scale testing of this drug in PA patients was underway in 2000, in preparation for application to the FDA for approval. In the meantime, many physicians are already prescribing etanercept "off label" for their PA patients. Etanercept is given through a self-administered injection.

Infliximab (brandname Remicade) is another biologic response modifier that is being used "off label" for PA in limited cases. This drug is approved for rheumatoid arthritis and Crohn's disease, an inflammatory bowel condition. Several small studies of the effectiveness of infliximab for treating PA and psoriasis are ongoing. Infliximab is administered by injection in a doctor's office.

A third new rheumatoid arthritis drug is leflunomide (brandname Arava). It is similar to methotrexate. Leflunomide, which comes in a pill, is proving beneficial to some people with PA, according to anecdotal reports.

People with PA who are interested in trying one of these new medications should talk to their physician; a rheumatologist is most likely to be familiar with them. These drugs may be very expensive (up to $1,000 per month), and insurance companies may not cover them because they are not FDA approved specifically for PA.

Other Approaches:

Diet and Climate
Manipulating the diet has not been found to be useful for PA. However, a warm, stable climate may have some influence on the disease symptoms.

Surgery
Surgery can help people whose joint destruction limits motion and function despite medical therapy. (Skin affected by psoriasis does not appear to cause any special problems with infection during surgery.)

Aspirin and NSAIDs must be stopped five days before surgery because they can cause more bleeding. Some dermatologists recommend that methotrexate also be stopped for a week before and a week after surgery to minimize the risk to healing tissues.

Rehabilitation
Physical therapy and rehabilitation are used to maximize the function of an arthritic joint.

Exercise
Exercise is essential to preserve strength and maintain range of motion. Isometric exercise is often prescribed because it appears to be less damaging to inflamed joints. A range of motion program should be coupled with a stretching program.

Pain lasting for two hours after exercise is a sign of overdoing it or of choosing the wrong exercise. Stretching exercises are part of the treatment and are especially useful for spinal arthritis.

Splints
In addition to exercise and local pain therapy, a splint may be used to support a joint in a position to improve function and relieve pain and swelling.

Other
Heat, cold and rest are used to relieve pain. Immobilizing an inflamed swollen area while using cold packs can reduce the swelling and improve range of motion.

Osteoporosis may occur with arthritis, especially with psoriatic spondylitis, and fractures from minor trauma may occur. Calcium supplements along with vitamin D help prevent it in affected individuals. In addition, calcitonin and biphosphonates (prescription drugs that affect calcium metabolism and bone formation) may be used. Prolonged bed rest should be avoided, unless directed by a physician.