Medical Care: The treatment of psoriatic arthritis is directed at controlling the inflammatory process. Although no clear correlation exists between the skin and joint inflammation in every patient, the skin and joint aspects of the disease often must be treated simultaneously.
Initial treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs) for joint disease and topical therapies for the skin. In many patients, this approach is sufficient to control disease manifestations, although some patients have a worsening of psoriasis with NSAIDs. In these patients, a drug belonging to a different family of NSAIDs should be used.
" Intra-articular injection of entheses or single inflamed joints with corticosteroids may be particularly effective in some patients.
o Use disease-modifying drugs in individuals whose arthritis is persistent. If the skin disease is well controlled with topical medication, the joint disease can be treated with a variety of second-line or cytotoxic drugs.
o Intramuscular administration of gold has been used in the past but has been supplanted by newer disease-modifying antirheumatic drugs.
" In patients with severe skin inflammation, medications such as methotrexate (MTX), retinoic-acid derivatives, and psoralen plus UV light should be considered. These medications have been shown to work for both skin and joint manifestations.
" Sulfasalazine and cyclosporine are 2 second-line agents that have received particular attention in the management of psoriatic arthritis. Although these drugs may control the acute inflammation in persons with psoriatic arthritis, they have not been helpful in arresting the progression of clinical and radiologic damage. Thus, the disease must be treated earlier or better drugs are necessary to prevent the damage that may ensue as a result of psoriatic arthritis.
o Cyclosporine appears to be an effective agent for the treatment of psoriasis and psoriatic arthritis.
o The major concern with cyclosporine is its toxicity, especially nephrotoxicity and hypertension. Combination therapy (eg, MTX/sulfasalazine, MTX/cyclosporine) may be more efficacious in some patients.
" The use of biologic response modifiers that target TNF and other cytokines represents an advance in the treatment of several diseases involving autoimmune mechanisms. Several such agents have been developed, in the form of either soluble fusion proteins (eg, etanercept) or monoclonal antibodies (eg, infliximab, adalimumab), which have shown considerable efficacy in the treatment of RA and other autoimmune diseases.
" Etanercept is approved by the US Food and Drug Administration for (1) treating adult patients (age >18 y) with chronic, moderate-to-severe plaque psoriasis; (2) reducing the symptoms and signs of moderate-to-severe polyarticular-course juvenile RA and ankylosing spondylitis; and (3) reducing the signs and symptoms and inhibiting the progression of structural damage associated with psoriatic arthritis. Therefore, etanercept may be an effective and safe alternative monotherapy for the treatment of psoriatic arthritis.
" Infliximab (Remicade) is another TNF-neutralizing agent that has been approved for the treatment of Crohn disease, ulcerative colitis, RA (in combination with MTX), ankylosing spondylitis, and psoriatic arthritis. It has shown successful results in reducing the signs and symptoms of psoriatic arthritis. However, the Food and Drug Administration issued safety warnings for infliximab concerning worsening heart failure in patients with moderate-to-severe congestive heart failure and opportunistic infections such as tuberculosis, histoplasmosis, listeriosis, and pneumocystosis.
" The effects of other anti-TNF medications on psoriasis and psoriatic arthritis are being studied.
" Several other modalities have been tried in persons with psoriatic arthritis, including vitamin-D3, bromocriptine, peptide T, and fish oils, but their efficacy remains to be proven.
" Antimalarials, particularly hydroxychloroquine (Plaquenil), are usually avoided in patients with psoriasis for fear of precipitating exfoliative dermatitis or exacerbating psoriasis. Two studies showed that these reactions did not occur in patients treated with hydroxychloroquine; therefore, it is occasionally used to treat psoriatic arthritis.
" Systemic corticosteroids are usually avoided because of possible rebound of the skin disease upon withdrawal.
Surgical Care: Arthroscopic synovectomy has been effective in treating severe chronic monoarticular synovitis. Because of the enhanced tendency for fibrosis associated with this therapy, anti-inflammatory and physical therapy measures aimed at improving range of motion are important adjuncts to this intervention. Joint replacement and forms of reconstructive therapy are occasionally necessary.
Diet: For people who have morning stiffness, the optimal time for taking an NSAID might be after the evening meal and again upon awakening. Taking NSAIDs with food can reduce stomach discomfort. Any NSAID can damage the mucous layer and cause ulcers and GI bleeding when taken for long periods. Cyclooxygenase (COX)-2 selective inhibitors are associated with a lower prevalence of gastric ulcer formation.
Activity:
" Exercise
o Exercise is an important part of the total treatment to limit the pain and swelling of arthritis, which can make joints stiff and hard to move.
o A directed exercise program can improve movement, strengthen muscles to stabilize joints, improve sleep, strengthen the heart, increase stamina, reduce weight, and improve physical appearance.
" Rest
o Generally, a normal amount of rest and sleep is sufficient to decrease fatigue and reduce joint inflammation.
o In a very few people, psoriatic arthritis may cause extreme fatigue.