Among the millions of psoriatics, a small but significant number suffer with a double jeopardy – psoriasis combined with arthritis. Although the clinical features resemble other forms of arthritis, particularly rheumatoid, serological tests have a positive rheumatoid factor in rheumatoid arthritis but not necessarily in psoriatic arthritis.
Experts cannot agree on the correlation between the incidence of psoriasis and arthritis. The fact remains that the combination of the two problems, on the skin and in the joints, can create havoc with the individual and can, in the severe cases, lead to invalidism. Fortunately, these cases number relatively few among psoriatics, but they do occur.
Psoriatic arthritis requires more work, patience, and discipline than any other form of psoriasis. For one thing, the person probably began this disease process many years before starting treatment. It has been estimated that some patients have had skin lesions for twenty or thirty years before they started experiencing joint disease.
Psoriatic arthropathy is probably much more common than previously thought as one study that examined people with psoriasis and took X-rays of their joints showed changes recognized as being due to arthropathy in half of them. Most of these people had absolutely no symptoms, so the percentage of people who really suffer from the condition is closer to 15%. It can be wrongly diagnosed as being due to other causes of arthritis, especially as it can occur before there are any signs of psoriasis on the skin. The arthritis can affect one or more joints as well as the bones in the spine and can cause painful local swelling and stiffness. One form can be quite destructive to the joint, causing severe disability.
Psoriatic arthropathy can be classified into five different types, so the answer is ‘Yes’! Although it is easy to write down the differences between these different types, things are not so clear-cut in real life as one person may have features that fit several types, and there is progression from one type to another.
• The most common presentation is probably with swelling of one or two large joints on one side of the body. This is called asymmetrical oligoarthritis and accounts for 70% of cases. It often progresses to affect more joints on both sides of the body – referred to as symmetrical polyarthritis.
• Symmetrical polyarthritis is thought to make up 15% of cases and is the type that most closely resembles rheumatoid arthritis. The blood test that is positive in rheumatoid arthritis will be negative here, however. The condition affects many joints at the same time and can be found in both large and small joints. This can be a very troublesome form of the disease as about half of people with this type will experience slow worsening with more and more damage to their joints.
• Another pattern just picks out the small joints in the fingers, especially where there are nail changes as well.
• The spine can also be affected, as can the parts of the body where large tendons join strong muscles on to bone, for example the Achilles tendon where it attaches to the heel, and around the pelvis. This leads to pain and stiffness, which is particularly bad in the lower back.
• Finally, one form of arthropathy is very destructive – hence the name ‘arthritis mutilans’. It is very severe and affects the small joints of the hands as well as the feet and spine. The joint destruction can leads to loss of use and great disability.
Psoriatic arthritis has been recognized for about a hundred years, and even in this form, there are different classifications. For instance, there is asymmetric oligoarthritis, which affects the majority of psoriatic arthritics (70 percent). Oligo refers to “few” or “little” joints, especially those in the hands near the knuckles. Then there is symmetric polyarthritis, which closely resembles rheumatoid arthritis, but a blood test does not show a positive rheumatoid factor. This constitutes about 15 percent of those afflicted. Polyarthritis is a third form (about 5 percent) in which many joints are affected, usually near the fingertips and also in the feet. This type is considered the classic type of psoriatic arthritis. A fourth type is psoriatic spondylitis (also about 5 percent). In psoriatic spondylitis, the vertebrae are involved, to a greater or lesser degree, and should be of prime interest to the chiropractor or osteopath. The fifth type is arthritis mutilans. Again, only 5 percent of psoriatic arthritics are affected by it, but it is the most destructive type. In this type there is bone destruction and deformity.
About Arthritis
Arthritis can strike anyone; it 1S no respecter of age. Its proportions range from minor aches and pains to complete incapacitation. Unless the cause is related directly to trauma or infection, its origin is largely unknown, but the one certainty common to most forms is inflamed joints.
The word arthritis is derived from the Greek prefix artbron, meaning “pertaining to a joint,” and the Greek suffix itis, meaning “inflammation .. ” Them are about a hundred forms of the disease, but the most common forms by far are rheumatoid arthritis (RA) and osteoarthritis (DJD-degenerative joint disease).
Approximately 36 million Americans are afflicted with arthritis, with a million new cases occurring each year. Over 7 million arthritics have some disability, and about 3 million are seriously impaired. There are 8 million people crippled with RA. Estimates show that three times more women than men contract this most serious form, even in childhood. Although the explanation for this discrimination is unknown, researchers are now questioning hormonal factors. Psoriatic arthritis, however, is found equally in men and women.
Research reveals a close similarity in managing both of these conditions – psoriasis and rheumatoid arthritis . Common sense dictates that a combination of the therapeutic regimens for psoriasis and rheumatoid arthritis is the best and most reasonable course to follow-
1. Follow the psoriasis regimen.
2. Add the following measures derived from the discourses on rheumatoid arthritis.
• Have a full-body peanut-oil massage twice a week, if possible. Leave the oil on for at least a half hour or overnight after the massage before washing it off. Shower down, but do not use soap.
• Take a peanut-oil tub bath. To a tub of comfortably hot water, add one cup of cold-pressed peanut oil. Submerge up to the neck and remain in the water at least a half hour. As the water cools, add additional hot water, (Caution: Peanutoil baths leave the tub very slippery. The patient must be sure to have help getting into and out of the tub. After the bath, the patient pats himself dry, leaving the light coating of peanut oil on overnight. Clearly it’s best to do this just before bed time.)
• Add Jerusalem artichokes (sunchokes) to the diet, once a week.
• Avoid bananas and strawberries and too many fruits in general.
• Eat all kinds of raw vegetables (except cabbage, which can cause constipation) in Knox gelatin. These may include watercress, chard, mustard greens, kale, carrots, celery, and lettuce (leaf or romaine). These vegetables must be prepared within the gelatin-as a gelatin salad. As mentioned in chapter 6, gelatin has been called a catalyst in the body, helping it to better absorb the vitamins and other nutrients of fruits and vegetables.
• Cleanse the colon by using high colonic irrigations or high enemas, as these playa significant role in alleviating arthritis. Colonies or high enemas should be used approximately every ten days, from the beginning of therapy, for at least two months, Thereafter, once a month until all symptoms subside, then about four times a year, at the change of seasons. This pattern may vary with individual patients.
• Avoid alcoholic drinks.
Since rheumatoid arthritis is so closely tied to psoriatic arthritis, the same precautionary measures apply. Do not disturb the body too greatly, and expect the regimen to take more time. The course to follow in psoriatic arthritic cases is the slow, gentle approach.
Treatments for psoriatic arthropathy (arthritis)
This depends on how badly affected you are. The aim of treatment is to improve your quality of life, deal with any inflammation in the joints and try to prevent any permanent damage to your joints. The first type of treatment to try is a non-steroidal anti-inflammatory drug (NSAID).
This may sound complicated but is in fact the first type of tablet to try in lots of different types of arthritis. One example is readily available, both on prescription and over the counter – ibuprofen (Nurofen).
In general, the treatments are the same as for other sorts of arthritis and can be divided into first-line and second-line, as with treatment of the skin. The first-line treatments can be started by your GP without the need for specialist advice. In the early stages, it does not matter very much if the diagnosis has not been confirmed because the treatment will be the same for any person with joint pains.
Physiotherapy is often forgotten or used only at later stages of the disease, but it can be very useful both to treat pain and stiffness and to educate you about exercises, correct lifting techniques and other simple things that can help to prevent further problems. It is a shame that there are often long waiting times to see NHS physiotherapists when all that might be needed is this simple advice. The Psoriatic Arthropathy Alliance (PAA) is a useful patient support group to contact for advice.
As with psoriasis on the skin, this is where second-line treatments are used. Doctors talk about ‘disease-modifying anti-rheumatic drugs’ (DMARDs) as this indicates that the drugs alter the disease itself rather than dealing with the symptoms (e.g. pain) or the effects of the disease (inflammation). These drugs are not specific to psoriatic arthropathy but are used for many different types of arthritis:
• Methotrexate is also used for other types of arthritis, so it fits in well if you have skin and joint psoriasis. It has been dealt with earlier in this chapter, where the dosages and precautions are discussed. It is taken as a small weekly dose and needs careful monitoring.
• Steroids are powerful anti-inflammatory drugs so can have a dramatic effect in treating an acute flare-up of arthritis. In some cases, they are also used long term in low doses to try to keep a balance between the benefits and the potential side-effects listed in the section on ‘Steroids’ in Chapter 4. If steroids are used in high doses, careful monitoring of any psoriasis on the skin is essential because rapid changes in steroid dose can cause problems, with dramatic worsening of the skin, sometimes to the point of pustular psoriasis or erythroderma, which are medical emergencies.
• Sulfasalazine (Salazopyrin) is being used increasingly often in psoriatic arthritis. It is another type of antiinflammatory drug that was used mainly for inflammatory gut diseases such as ulcerative colitis. People with ulcerative colitis can get a type of arthritis affecting the lower back, and they noticed that this as well as their gut problems improved when taking sulfasalazine. It was tried in other forms of arthritis and does seem to work well in psoriatic cases. Some rheumatologists now use it as a first-choice tablet treatment and then add in methotrexate if needed.
Get a free trial of Dermasis psoriasis cream. and Read the Quick Action Plan to cure psoriasisOther agents. Immunosuppressive drugs such as azathioprine and ciclosporin are sometimes used but seem less effective for the arthritis than they can be for the skin.
• Gold injections are used less often than they were in the past for all forms of arthritis. They were only rarely used for psoriatic arthropathy because one of the common side-effects is a skin rash! They worked well in a few patients so might be considered as a last resort if nothing else has worked.
• Leflunomide is a tablet treatment that is used mainly in rheumatoid arthritis but can be useful in some other types of arthritis. It is a DMARD. It should be compared with existing treatments to decide exactly where it should fit into the range of different drugs.
• Patients should be involved to help to decide whether it is an easy treatment to use and produces a real improvement in quality of life.
• It should undergo a ‘health economic analysis’ to make sure it is affordable and that the extra money would not help more people if spent on other drugs or treatment resources.
• It should be studied long term to try to identify all the possible side-effects.
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