Psoriatic arthritis: causes, symptoms and treatment in an article by endocrinologist M. Yu. Babintsev.

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

Causes of psoriatic arthritis

The exact causes of psoriatic arthritis have not yet been established by science. It is assumed that it can be triggered by the combined action of such factors as:

hereditary predisposition to diseases of the musculoskeletal system (currently the leading cause of psoriatic arthritis, according to rheumatologists);
severe emotional shocks, stress, work associated with high psychological stress;
recent viral and infectious diseases;
carriage of streptococcal infection, the presence of foci of chronic inflammation in the body;
unfavorable environmental situation in the region of residence;
various injuries (including those received in the distant past);
bad habits;
unhealthy lifestyle, especially unbalanced diet;
overweight;
long-term use of certain medications;
immunodeficiency states;
depression;
intense physical activity;
recent childbirth, menopause, disruption of the endocrine glands and age-related hormonal changes.

Most often, psoriatic arthritis affects middle-aged patients with autoimmune nail lesions and plaques characteristic of psoriasis. There is a relationship between the manifestation of arthritis and the state of the nervous system - loose nerves and increased excitability can trigger the onset of the disease

It has also been noted that women more often suffer from symmetrical psoriatic arthritis, and men are treated with inflammation of the vertebral joints and interphalangeal joints of the extremities.

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.

Types of psoriatic arthritis

Over ⅔ of patients with psoriatic arthritis have lesions in large joints

— in this case, the disease can spread only to one joint or affect several at once. Most often, the knee and ankle joints are affected, and a little less often the hip joints. As with rheumatoid arthritis, the disease can affect absolutely any joint. In 15% of patients, oligoarthritis occurs, in which inflammation begins in 3 or more joints.

Rheumatologists distinguish 5 conventional forms of psoriatic arthritis. It should be borne in mind that these forms can be combined, be in an intermediate state, and even transform into one another in the same patient.

Symmetrical polyarthritis
- its manifestations resemble rheumatoid arthritis (accompanied by pain, inflammation, swelling, stiffness in the morning). This form is characterized by a relatively mild course and practically does not lead to noticeable deformations of the joints or the formation of nodules. Most often it affects the peripheral joints.
Asymmetric oligoarthritis
- affects 2-4 joints (usually the joints of the fingers and toes). It is often accompanied by dactylitis, an inflammation of the joints that leads to swelling of the fingers (the so-called “sausage fingers.” The pain with asymmetric oligoarthritis is quite intense, and the limitation of mobility is pronounced.
Arthritis involving the distal joints of the fingers
(i.e., those closest to the nail). Unlike rheumatoid arthritis, psoriatic arthritis can affect all joints of the finger, as a result of which fusion of the articular surfaces can form, leading to complete immobility of the finger. It is characterized by diffuse (edematous) swelling and redness of the skin over the joints. This form of psoriatic arthritis can affect the joints of the toes and hands, either individually or together.
Axial (axial) form
- it is characterized by inflammation of the intervertebral and sacroiliac (located in the lumbar region, in the back of the pelvis) joints. It is more often observed in men (up to 40% of those suffering from psoriatic arthritis). Accompanied by inflammatory back pain, moderate limitation of mobility when bending forward, backward and to the sides. The axial form of psoriatic arthritis is diagnosed in patients who complain of lumbar pain lasting over 3 months, which appeared before the age of 45.
Mutilating form
- this type of psoriatic arthritis occurs in approximately 5% of patients and is accompanied by disfigurement and deformation of the joints. Its characteristic feature is considered to be the so-called. telescopic fingers. This pathology is caused by the resorption of bone tissue in the terminal phalanges of the fingers and the heads of the metacarpal bones. As a result, the fingers become shortened and become swollen at the base and narrowed at the tips (cone-shaped). The fingertips become thinned and pointed. The pathology has not only aesthetic consequences: due to the curvature of the fingers, patients suffer from their subluxations and immobility of the joints, various contractures (persistent restrictions on mobility), and disruption of the normal axes of movement. Changes are almost always asymmetrical.

Rarely and exclusively in men, a malignant form of psoriatic arthritis can occur. It occurs against the background of atypical psoriasis and is accompanied by fever, chills, and severe pain that cannot be relieved with conventional analgesics. Patients rapidly lose weight, complain of the formation of ulcers, hair loss, enlarged and painful lymph nodes. Severe articular syndrome is accompanied by disturbances in the functioning of the heart, kidneys, and sometimes the brain

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.

Symptoms of psoriatic arthritis

Symptoms of psoriatic arthritis are almost always preceded by dermatological manifestations of psoriasis. In this case, plaques, ulcers, and peeling of the skin can appear several years or 2-3 months before joint pain. This development of pathology is observed in at least 6 out of 7 patients; in others, the articular syndrome may be primary. Approximately 15% of patients notice symptoms of psoriatic arthritis within the first year after skin lesions.

The progression of the disease usually parallels the progression of psoriasis, but there is no direct correlation between the growth of psoriasis lesions and the complication of arthritis

Common nonspecific symptoms of psoriatic arthritis include:

pain and swelling in the joints
(usually peripheral);
feeling of stiffness in the morning, which may progress
(to permanent stiffness or partial limitation of mobility) or remain in place;
enthesopathy - pain when palpating or squeezing the joints at the sites of tendon attachment
(these areas are especially susceptible to the inflammatory process in psoriatic arthritis).

Symptoms of psoriatic arthritis may be accompanied by ulcers, thimble syndrome (deformation of the nails with the formation of indentations) and other signs of psoriasis.

Specific symptoms of psoriatic arthritis (PsA) include:

inflammation of the finger joints and their swelling in a spindle-shaped manner (dactylitis);
swelling, which is accompanied by cyanosis and purplishness of the skin;
stiffness of movements in the spine (in the case of psoriatic spondylitis or unilateral sacroiliitis);
pathological change in the shape of the joints with pinkness of the skin over them;
decreased elasticity of ligaments, tendons and muscles, which leads to discomfort during movements, dislocations and subluxations;
increased stiffness in the second half of the night and upon waking up in the morning, as well as its gradual attenuation during everyday activities or warm-up;
noticeable attempts by the patient to protect the affected joints and transfer the load from them to healthy ones;
in some forms of PA - shortening of the fingers.

It is important to consider that in arthritis of psoriatic origin, rheumatoid nodules characteristic of rheumatoid arthritis are absent

Psoriatic arthritis often has an unpredictable course with periodic exacerbations and subsequent remission. More often it has a hidden beginning; remissions occur faster, more completely and easier than with rheumatoid arthritis. The aggressive course of the disease with rare remissions has a poor prognosis

If left untreated or with a malignant course, the symptoms of psoriatic arthritis can increase until the patient becomes disabled

Diagnosis of psoriatic arthritis

Psoriasis is a long-term, chronically relapsing skin disease that affects 1-3% of the world's population. One of the most severe disabling manifestations of this disease is damage to the joints—psoriatic arthritis (PsA), which, according to various sources, ranges from 6 to 42% of cases of simultaneous damage to the skin and joints [1, 2].

According to generalized data from European and American studies, patients with severe forms of psoriasis (PsA, psoriatic erythroderma) make up about 1/3 of all patients with psoriasis and are the main group of patients who consult a doctor [3].

PsA can develop at any age, including in childhood, but most often occurs between 30-50 years. Men and women get sick equally often, but in women the disease usually begins at an earlier age [4, 5].

Clinical manifestations of psoriatic arthritis

PsA is a chronic inflammatory seronegative spondyloarthropathy with predominant damage to the distal interphalangeal joints of the hands, metatarsophalangeal joints of the feet, and the spine in combination with skin manifestations of psoriasis [6, 7]. PsA is characterized by stiffness, pain, fever, and swelling of the joints and surrounding ligaments and tendons. PsA can manifest itself as asymmetric progressive joint damage and occur in the form of oligo- or polyarthritis [8]. Any joints are affected, including peripheral (eg, distal interphalangeal) and/or axial (axial) joints (spine, sacroiliac joint). In PsA, damage to the periarticular structures is also possible, manifested by tenosynovitis (inflammation of the synovial membrane of the tendon sheath), dactylitis, or thickening of the fingers like sausages (inflammation of the entire finger), and enthesopathy (inflammation at the sites of attachment of tendons to the bones) [9].

PsA symptoms can range from mild to very severe. The severity of the skin process and arthritis usually do not correlate with each other. PsA can start slowly, with mild symptoms.

The spectrum of inflammatory changes in joints is very large: from axial to peripheral lesions, inflammation of synovial and underlying tissues, enthesitis, osteitis, impaired bone formation, severe osteolysis.

In cases of PsA, as well as in relation to other seronegative spondyloarthropathies, extra-articular manifestations are known: inflammation of the eyes, mucous membranes, urinary and cardiovascular systems (iritis, conjunctivitis, aortic aneurysm, urethritis) [10].

The course of PsA is variable and unpredictable, ranging from mild non-destructive to severe disabling arthropathy. In cases of early onset of the disease, skin lesions are more widespread, there is an unstable course, a tendency to relapse, as well as a more frequent development of guttate psoriasis and nail lesions. Patients with a late onset have a more stable course of the disease and a frequent tendency to develop palmoplantar pustulosis [11, 12]. Erosive deforming arthritis occurs in 40-60% of patients with PsA (data from rheumatology centers) and can progress in the first year. The course of PsA is characterized by constant exacerbations and remissions [3].

Most patients with PsA have mild or moderate skin manifestations, 80-90% of them suffer from nail damage [13]. Moreover, in 46% of patients with psoriasis (without joint damage), the nails are involved in the pathological process. The severity of skin and joint manifestations closely correlates with nail damage; this relationship is more often found in arthrosis of the distal interphalangeal joints as part of PsA [14, 15].

The nature of the course of the disease can vary, significantly complicating the diagnosis. In approximately 75-80% of patients with psoriasis, skin manifestations occur 5-10 years before joint damage. Exacerbation of arthritis can be combined with psoriasis or occur independently of it [9, 16].

Without treatment, a patient with PsA experiences persistent inflammation, progressive joint damage, severe limitations in physical activity, disability, and increased mortality.

Classification of psoriatic arthritis

There are several classifications of PsA, the most common of which is the clinical classification of J. Moll and V. Wright (Table 1).

It is sometimes difficult to recognize PsA among other inflammatory joint diseases because the clinical manifestations may overlap. PsA is differentiated primarily from rheumatoid arthritis (RA), reactive arthritis, inflammatory bowel disease (IBD), and ankylosing spondylitis.

Peripheral polyarthritis in PsA may have common features with RA (Table 2).

Clinical features are very important to differentiate seronegative RA with concomitant psoriasis from peripheral PsA. The presence of psoriatic plaques or psoriatic nail lesions helps in making the diagnosis of PsA. The affected joints in PsA are usually less painful and swollen, and the location is less symmetrical than in RA. However, 20% of patients with PsA, especially women, have a symmetrical inflammatory polyarthritis similar to RA, which is differentiated by the presence of clinical manifestations on the skin and nails. Dactylitis, enthesitis, and damage to the distal interphalangeal joints are typical for PsA and not typical for RA.

In patients with psoriasis with joint symptoms, it is very important to carry out a differential diagnosis with osteoarthritis. Damage to the distal interphalangeal joints is noted in both PsA and osteoarthritis, but classic Heberden's nodes (associated with lesions of the distal interphalangeal joints) in osteoarthritis are bony outgrowths (exostoses), while in PsA, lesions of the distal interphalangeal joints are represented by inflammatory changes in the joints . Morning stiffness or stiffness after prolonged immobility (for example, while traveling by plane or in a car) is typical for PsA; in osteoarthritis, stiffness often occurs during active movement. PsA occurs equally often in men and women; osteoarthritis of the hands and feet develops more often in women. Enthesitis (inflammation where tendons attach to bones), dactylitis (inflammation of the entire finger or toe), and sacroiliitis (inflammation of the sacroiliac joint) are not usually found in patients with osteoarthritis.

According to those presented in table. 2 data, the clinical picture in PsA with axial lesions (psoriatic spondylitis) may be similar to that in ankylosing spondylitis (AS), which mainly affects the joints of the spine and sacroiliac joints. However, in patients with PsA, symptoms are often less severe, the lesions are asymmetrical, and the course of the disease is less severe. In addition, psoriatic plaques or nail changes characteristic of patients with psoriasis are absent in AS. Although axial involvement in most patients with PsA is a secondary feature of predominantly peripheral arthritis, axial PsA can also present as sacroiliitis (usually asymmetric and asymptomatic) or spondylitis, affecting any level of the spine. Compared to AS, PsA rarely affects mobility or develops ankylosis (complete immobility of the joint).

Other rheumatological diseases, such as osteoarthritis, rheumatic soft tissue disease, septic arthritis, and true RA, can also be combined with psoriasis, which makes diagnosis much more difficult. In addition, psoriasis occurs more often in patients with inflammatory bowel disease and ankylosing spondylitis [17–19].

The presence of such difficulties in diagnosis emphasizes the need for a thorough history and examination of the patient, including serological, radiological and, possibly, genetic studies.

There are several classification criteria for PsA. The Classification criteria for Psoriatic Arthritis (CASPAR) are the newest criteria in the diagnosis of PsA. They are easy to use, have high specificity (98.7%) and sensitivity (91.4%) in the diagnosis of PsA [20].

According to the CASPAR criteria, a diagnosis of PsA is made when inflammatory joint lesions (prolonged morning or immobility-induced joint stiffness, tenderness and swelling) are combined with 3 or more of the 5 criteria listed below.

1. A history of psoriasis or a family history of psoriasis (relatives in the first and second generations). Psoriasis is characterized by lesions of the skin or scalp.

2. Psoriatic lesions of the nails: onycholysis, pinpoint impressions, hyperkeratosis, observed at the time of examination.

3. Absence of rheumatoid factor (except for the latex agglutination reaction).

4. Dactylitis in history or at the moment, confirmed by a rheumatologist.

5. X-ray confirmation of extra-articular osteogenesis (bone proliferation), manifested by paravertebral ossification (excluding the formation of osteophytes), detected on a regular radiograph of the hands or feet.

Based on these criteria and the main clinical features, when examining each new patient with psoriasis, it is necessary to collect anamnesis, objective examination, laboratory tests and analysis of management tactics.

History of the disease

- History of psoriasis or current psoriasis or hereditary history of psoriasis.

- Inflammatory changes in joints.

- Pain and weakness in the joints.

— Morning stiffness for more than 30 minutes.

— Functionality in performing everyday household duties (decreased performance and quality of life), etc.

Diagnosis of psoriatic arthritis

In addition to clinical and anamnestic criteria, it is necessary to conduct additional laboratory and radiological studies. Basic laboratory tests should include a complete blood count (hemogram), erythrocyte sedimentation rate, C-reactive protein, Rh factor, standard liver and kidney function tests.

Recently, qualitative and quantitative studies of cytokine reactions in synovial fluid have been introduced into clinical practice, which helps to assess the activity of the disease and the effectiveness of therapy.

Structural damage in PsA can be assessed by standard radiographs and is an important baseline in determining the effectiveness of therapy. Plain radiographs may be normal in the early stages of the disease, but paravertebral ossification, periarticular osteopenia, and erosive joint damage are possible. The most commonly affected joints are the hands and wrists, followed by the joints of the feet, ankles, knees, shoulders, and distal interphalangeal joints, combined with asymmetrical lesions, which are characteristic features of PsA.

Radiological signs of PsA can be divided into destructive and proliferative. Erosions are typical destructive manifestations, most often starting at the edges of the joints, spreading to the center. Ulcerations combined with increased bone production (bone formation) are typical of PsA, and their spread can lead to widening of the joint space. Spread of erosive changes can lead to characteristic pencil-in-a-cup changes (protrusion of one articular surface into the base of an articular surface) in later stages. In severe cases, severe osteolysis with complete destruction of the phalanges may be observed. In addition, joint ankylosis is possible [21].

Modern principles of treatment and prognosis

The mild form of PsA, accounting for 50% of all cases of this disease, can be successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular injections of glucocorticosteroids (GCS) [22]. Patients with moderate and severe forms require more intensive therapy and the use of disease-modifying antirheumatic drugs (DMARDs). This group of drugs includes methotrexate, sulfasalazine, leflunomide, cyclosporine and gold preparations. Evidence supporting the effectiveness of methotrexate in the treatment of PsA includes two randomized, placebo-controlled trials.

The first study, conducted in 1964, evaluated the effectiveness of treatment in 21 patients with PsA who received 3 intramuscular injections of methotrexate 10 days apart. This therapy resulted in a decrease in joint tenderness, swelling, and erythrocyte sedimentation rate [23]. In the second study, 37 patients received methotrexate (7.5 to 15 mg per week) or placebo. After 12 weeks, the group of patients taking methotrexate achieved higher rates of improvement in arthritis compared to the placebo group [24]. Despite the scarce clinical data, methotrexate is often used as the main MBAP for PsA, since it combines high efficiency in the treatment of skin processes and joint lesions, as well as low cost.

Sulfasalazine was associated with moderate improvement in a study of 221 patients with PsA. After 38 weeks of treatment, 58% of patients receiving sulfasalazine achieved significant improvement compared with 45% of the placebo group [25].

Leflunomide (a selective pyrimidine synthesis inhibitor) was studied in a randomized, double-blind, placebo-controlled trial in 188 patients with active PsA. At 6 months, 59% of patients receiving leflunomide achieved improvement compared with 30% of patients receiving placebo [26]. Other MBAs, including antimalarials, cyclosporine and gold, are used less frequently because data on their effectiveness are insufficient [22].

Recently, the treatment options for PsA have expanded due to the introduction of biological drugs—tumor necrosis factor (TNF) inhibitors. The important role of TNF-α in the pathophysiology of PsA is proven by the fact that increased levels of TNF-α are observed in the synovium, joint fluid and skin of patients with PsA. The effectiveness of TNF-α inhibition in the treatment of PsA has been demonstrated in several clinical trials [27–29]. Three TNF-α antagonists (adalimumab, etanercept, infliximab) are currently registered for the treatment of PsA in most countries of the world.

Methotrexate, TNF inhibitors, or a combination of these drugs are considered first-line treatments for patients with moderate to severe forms of PsA. However, the use of methotrexate and TNF inhibitors is not always necessary; good results are observed when treating patients with moderate PsA with NSAIDs or intra-articular injections of corticosteroids [3, 30].

In the treatment of skin and joint manifestations of PsA, it is necessary to take into account all aspects of this disease. Treatment can be aimed at eliminating each pathological manifestation independently of the others, but at the same time improving the condition as a whole. Treatment options that benefit both skin and joint manifestations include the following approaches.

1. Traditional systemic therapy:

— Cyclosporine (orally 3-5 mg/kg/day).

- Methotrexate (dose varies from 15-25 mg orally or intramuscularly weekly).

2. Anti-cytokine therapy:

— Etanercept (50 mg subcutaneously 2 times a week).

- Infliximab (initial dose is 5 mg/kg, then the drug is administered at the same dose 2 weeks and 6 weeks after the first administration, after that - every 8 weeks).

- Adalimumab (40 mg subcutaneously every 2 weeks).

A large number of medications for the treatment of PsA may not have the best effect on the skin manifestations of psoriasis. Among such drugs are gold preparations, systemic corticosteroids, hydroxychloroquine (plaquenil). In addition, some medications intended to treat skin manifestations can worsen arthritis; these include acitretin and efalizumab [31].

Most dermatologists avoid the use of systemic corticosteroids in the treatment of patients with psoriasis due to the potential risk of exacerbation of erythroderma and pustulosis during their withdrawal. Nevertheless, rheumatologists often use systemic corticosteroids in short- and long-term treatment of PsA, but in much lower doses (5-10 mg/day) than dermatologists traditionally use for chronic dermatoses. About 10–20% of patients participating in the central clinical trial of adalimumab, etanercept and infliximab for PsA received systemic corticosteroids with minimal side effects [32–34]. Worsening of the skin process after initiation of NSAID therapy was observed with the use of both nonspecific NSAIDs and specific cyclooxygenase-2 inhibitors. In contrast, treatment with methotrexate and TNF-α inhibitors has a beneficial effect on both the skin process and the joint manifestations of PsA.

Since the course of PsA can vary widely from monoarthritis with a favorable prognosis to erosive and destructive polyarticular lesions with a poor prognosis, comparable to a similar form in patients with RA, it is most often impossible to predict in which case disabling PsA will develop. Thus, to prevent erosive and deforming lesions in the evolution of PsA, early use of adequate therapy becomes imperative [35].

We present our clinical observation of a combined variant of psoriatic arthritis (osteolytic variant) and psoriatic partial erythroderma.

Patient S., 24 years old, was admitted to the Clinical Clinical Hospital of the First Moscow State Medical University named after. THEM. Sechenov in March 2009 with complaints of rashes all over the skin, accompanied by intense itching. He has been ill since the age of 10 (for 14 years), when he first noticed the appearance of a psoriatic plaque in the area of the left knee joint. The patient went to the Lakinsk hospital in the Vladimir region, where he lived at that time. Therapy with B vitamins, intravenous injections of calcium chloride, and topical salicylic ointment were administered, with improvement. By summer, the rashes had completely regressed.

Over the course of 4 years, the process was limited in nature in the form of regular plaques on the knees with complete regression of the rashes in the summer. At the age of 14 years, after severe rubella, the process became widespread with the addition of inflammatory changes and pain in the small joints of the feet, which made movement and walking very difficult. He was hospitalized in the same hospital where treatment was carried out, the same as during the previous hospitalization, without effect, but by the summer there was an improvement with complete regression of the articular syndrome. Since then, exacerbations have become annual with a gradual increase in the arthropathic component: inflammatory changes and pain in the knee joints and joints of the hands. In connection with this, he was treated in the hospital of the regional KVD in Vladimir, therapy was carried out using conventional methods without effect.

At the age of 18, after moving to Moscow, he received treatment from a private dermatologist with intramuscular injections of a systemic steroid drug, the name and frequency of administration of which the patient does not remember. The remission continued for a year. From the age of 19, he was treated in various dermatological institutions in Moscow, including being hospitalized twice in City Clinical Hospital No. 52, where he received sessions of plasmapheresis, hemosorption, and vitamin therapy without effect. From the age of 20, for 4 years (2003-2008), he was treated independently with unconventional methods: herbal medicine, turpentine baths, psychics, traditional healers, with temporary improvement. The process progressed steadily with transformation into erythroderma and deformation of the joints, mainly of the hands and feet. In this regard, to register his disability, he applied to the Department of Internal Affairs at his place of residence, from where he was sent for consultation to an arthrology hospital. There he underwent an examination, after which he was sent to the clinic of skin diseases at Perm State Medical University named after. THEM. Sechenov with recommendations for treatment with Remicade.

Local status.

The entire skin is affected, with especially pronounced manifestations of the disease on the skin of the face, torso, upper and lower extremities (PASI score 26 points at admission). The skin has a reddish-bluish color with a stagnant component, especially in the area of the distal extremities (see figure, a).

Figure 1. Partial psoriatic erythroderma, psoriatic arthritis in patient S., 24 years old.
a — total damage to the skin; the skin has a reddish-bluish color with a stagnant component, is significantly thickened, infiltrated, and difficult to fold; There is abundant large-plate peeling throughout the skin in the form of easily detachable grayish-yellow scales, which fall off abundantly from the skin when the patient undresses; b — severe deformation and osteolysis of the distal interphalangeal joints of the hands and feet, limited mobility of the affected joints, dactylitis (thickening of the fingers like “sausages”); c — plain X-ray of the hands in a direct projection: mutilating arthritis, multiple intra-articular osteolysis of the distal and proximal interphalangeal joints, complete bony ankylosis of the wrist joints, multiple subluxations of the joints. In the area of the trunk, upper and lower extremities, the skin is significantly infiltrated, thickened, hot to the touch, and difficult to fold. There is abundant large-plate peeling throughout the entire skin in the form of easily detachable grayish-yellow scales, which fall off abundantly from the skin when the patient undresses. There is severe deformation and osteolysis of the distal interphalangeal joints of the hands and feet, limited mobility of the affected joints, and dactylitis (thickening of the fingers like sausages; see figure, b). There is separation of the plate from the nail bed in the distal and lateral sections. Subjectively, there is a feeling of burning, tightness, and pain in the area of the affected joints. Laboratory results.

In the general blood test, general urine test, HbsAg, serological reactions, no significant deviations were detected, with the exception of high ESR (42 mm/h with a norm of 3-10 mm/h), leukocytosis (10.19 109/l with a norm of 4- 9·109/l), thrombocytosis (578.3·109/l with a norm of 180–320·109/l) and increased levels of C-reactive protein (6.34 mg/dl with a norm of 0–0.8 mg/dl ).

General X-ray of the hands in direct projection

(see figure, c): mutilating arthritis, multiple intra-articular osteolysis of the distal and proximal interphalangeal joints, complete bony ankylosis of the wrist joints, multiple subluxations of the joints.

Diagnosis: partial psoriatic erythroderma, psoriatic arthritis.

Therapy carried out:

methotrexate intramuscularly 25 mg per week (4 injections were given), voltaren in rectal suppositories 100 mg once a day, suprastin 2.0 ml intramuscularly at night; tavegil 0.001 g, 1 tablet 3 times a day. Locally Unna cream, celestoderm ointment.

During treatment, positive dynamics were observed in the form of regression of erythroderma, disappearance of edema and a significant reduction in infiltration, peeling, itching, burning, as well as a decrease in joint pain (PASI on the 21st day of therapy 10.8 points). A decrease in ESR to 15 mm/h was achieved.

The patient was recommended to continue injections of methotrexate 25 mg intramuscularly once a week on an outpatient basis (in the clinical hospital at the place of residence) under the strict supervision of clinical and biochemical blood tests before each injection, as well as re-hospitalization to the clinic of skin and venereal diseases of the First Moscow State Medical University named after. THEM. Sechenov for complex therapy, including a course of methotrexate injections. In addition, the patient was sent to the city clinical hospital No. 14 named after. V.G. Korolenko with recommendations for treatment with Remicade.

Discussion.

In the described case, the juvenile onset of psoriasis and the lack of adequate systemic therapy caused both the steady progression of the skin symptom (psoriatic erythroderma) and the addition and active progression of the articular syndrome. Disabling manifestations of PsA in the form of osteolysis and deformation of the distal interphalangeal joints, limited mobility, and pain led to complete disability.

This clinical observation fully corresponds to the picture of PsA. The course of the disease is typical, skin manifestations preceded the symptoms of arthropathy (as mentioned above, a similar course is observed in 75-80% of patients). In the described patient, the early onset of the disease subsequently became widespread, with an unstable course, a tendency to relapse, and the development of nail lesions. In addition, the anamnestic data, clinical picture and examination data meet the CASPAR criteria for PsA: the presence of psoriasis in the history and at the time of examination, psoriatic lesions of the nails, dactylitis at the time of examination and x-ray confirmation of joint damage.

Thus, this observation confirms the modern concept that classifies PsA as an independent pathology, often accompanying psoriasis (comorbidity).

Since 84% of most PsA patients develop psoriasis approximately 12 years before the development of joint symptoms, dermatologists are able to be the first to detect PsA. Therefore, there is a strong recommendation to exercise a high degree of suspicion for signs and symptoms of PsA at every examination. Once PsA is diagnosed, treatment should be aimed at relieving the signs and symptoms of PsA, preventing structural damage, and maximizing quality of life.

Timely diagnosis and treatment of PsA is the most important task, since early detection and immediate treatment can prevent the progression of damage and favorably affect the prognosis of the disease.

Diagnosis of psoriatic arthritis

Diagnosis of psoriatic arthritis includes an oral interview, examination of the patient and palpation of the affected joints, as well as laboratory instrumental research methods.

a clinical (general) blood test when diagnosing psoriatic arthritis may show an increase in ESR;
a biochemical blood test shows increased titers of C-reactive protein (the more intense the manifestations of PA, the higher this indicator);
In a blood test for rheumatic factor in psoriatic arthritis, rheumatic factor is usually absent. If a rheumatic factor is nevertheless detected, an anti-CCP test will help make the correct diagnosis.

Also, studies may show signs of damage to internal organs and eyes. Patients often also experience arterial hypertension.

Among hardware studies, the most informative for diagnosing psoriatic arthritis are:

X-ray examination
(allows to detect destruction of the distal phalanges, the presence of deformities and subluxations);
magnetic resonance imaging
(MRI);
Ultrasound examination of joints
(ultrasound).

Additionally, a consultation with a dermatologist and skin scraping tests may be required. In case of damage to internal organs and eyes, other specialists are involved in the diagnostic process

Being secondary to an autoimmune disease, PsA shares many features with rheumatoid arthritis.

(also autoimmune etiology).
Therefore, during the diagnosis of psoriatic arthritis, it is important to differentiate these two diagnoses from each other
.
The separation of rheumatoid and psoriatic arthritis also complicates the similarity of clinical pictures: for example, ankylosing spondylitis in psoriasis and ankylosing spondylitis, Reiter's disease and psoriatic lesions of the mucous membrane of the eyes, mouth, and genital organs can only be distinguished with the help of special diagnoses
.

Self-diagnosis plays an important role in the early detection of symptoms of psoriatic arthritis. For this purpose, patients with arthritis are recommended to undergo a special screening questionnaire annually.

You should immediately consult a doctor if the patient has 4 or more signs from the list below:

joint pain began before reaching 40 years of age;
the pain syndrome had a hidden onset (it was not preceded by injury or another obvious cause);
discomfort disappears after moderate physical activity;
pain persists or even intensifies at rest;
pain is especially annoying at night, and by the middle of the day it noticeably subsides;
there is a rash on the body, separation and deformation of the nails.

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

Treatment for psoriatic arthritis involves suppressing the body's faulty immune response.

,
relieving pain and inflammation
,
restoring synovial cartilage and other structural elements of the joint
. Taking control of psoriatic arthritis symptoms also helps prevent further joint destruction. A wide range of means are used for this: drug treatment, diet, therapeutic exercises and physiotherapy (magnetic therapy, medicinal electrophoresis, ultrasound with hydrocortisone, massage, paraffin baths, hydrogen sulfide baths, kinesiotherapy). Educating the patient on the orthopedic regimen is also advisable.

Surgical treatment of psoriatic arthritis is performed extremely rarely - when complex therapy for the disease is ineffective.

Diet for psoriatic arthritis

The diet for psoriatic arthritis involves a ratio of alkali-forming foods to acidic foods of at least 3:1.

Not recommended for patients:

nightshades (tomatoes, potatoes, eggplants, bell peppers);
an abundance of meat products and grains in the diet.

You should limit your consumption:

legumes;
oils;
Sahara;
starch-rich foods;
sour berries, citrus fruits;
adding vinegar to dishes.

It is advisable to completely exclude

from the diet:

semi-finished products and fast food;
sausages and confectionery products;
snacks, chocolate;
carbonated drinks;
crustacean dishes and offal;
fried food.

Apples should only be consumed baked. Lean poultry and boiled fish should be eaten 4 to 7 times a week; include eggs in your diet 2-4 times a week. Remember to eat reduced-fat dairy products. You should also drink 6 to 8 glasses of water (not drinks!) every day!

Exercise therapy for psoriatic arthritis

A set of exercises for the treatment of psoriatic arthritis is created by a physical therapy instructor. This takes into account which joints are affected, what level of athletic training the patient has, whether he has injuries and constitutional features, as well as what age he is. In addition to therapeutic exercises, walking, swimming, and water aerobics are recommended for patients with psoriatic arthritis. You should avoid traumatic sports, running

Therapeutic gymnastics exercises should be spent at least 30-40 minutes a day: this time should be divided into 2-3 sessions of 15-20 minutes each.

Exercises for damage to the joints of the hand

clench and unclench your fingers at a fast pace;
holding your hands at chest level, perform rotations in the wrist joints, first in one direction, then in the other;
try to tilt your hands with straight palms as far as possible to the left and right, and then forward and backward (do not help yourself with the other hand);
take an apple, a small ball or other round object and start squeezing it with your fingers;
You can also perform exercises with a special wrist expander or knead plasticine.

Gymnastics for elbow joints

relax your shoulders so that your arms hang freely along your body, swing them freely;
Without changing position, try to gently rub the tissue around the elbow joint with your other hand, repeat on both sides;
Raise your arms so that your elbows are at shoulder level. Freely swing your forearms like a ball-jointed doll;
rotate your arms at the elbow joints, avoiding sudden, violent movements;
take a tennis ball and roll it on the table away from you, towards you and in other directions;
Place your elbows on the table so that your wrists are perpendicular to the tabletop. Rotate your brushes first in one direction, then in the other.

Exercises for the shoulder joints

lower your arms freely, and then rotate your arms in front of you, first clockwise, then counterclockwise (alternately);
place your elbow on a support (for example, a tabletop) and rotate your shoulder forward and backward;
bend perpendicular to the floor, hanging your arms freely, and swing from side to side so that your arms swing like a “pendulum”;
stand up straight and, keeping your elbows straight, “climb” your palms up the door frame.

Exercises for psoriatic arthritis of the feet

pull the sock towards you, slightly swaying it from side to side (exercises can be performed standing, sitting or lying down);
stomp on the spot or walk forward, shifting from foot to foot - first on the outer surface of the feet, then on the inner, then on the toes and on the heels;
rotate your feet clockwise and counterclockwise.

Warm-up for knee joints

stand up straight and try to spring on your feet, slightly bending and straightening your knees. At the same time, strain the leg muscles so that the load falls on them and not on the joints;
sit on a chair and, holding your leg under your kneecap, gently pull your knee towards your chest;
standing straight, cross your legs and begin bending, trying to reach the floor with your fingertips;
stand up straight and place your hands on your waist, then move your legs to the side.

Gymnastics for the hip joints

standing straight and holding your hands on your belt, move your straight leg to the side, slightly swinging it and trying to increase the angle of abduction;
walk forward on a straight, unbending foot so that only the pelvic muscles work;
sit on a chair so that the sacrum is located as close to the back as possible. After this, bend forward so that you can reach your toes with your fingertips;
Lie on your back and, bending your knees, place your feet on the floor. Perform alternate hip abductions so that the outer side touches the floor.

Treating psoriatic arthritis at home

In mild to moderate cases of the disease, which is not accompanied by complications to the internal organs, psoriatic arthritis is treated on an outpatient basis - that is, at home with periodic visits to the doctor (usually as needed).

At home, the patient can treat psoriatic arthritis with tablets and gels, do self-massage of sore joints and do paraffin baths and therapeutic exercises.

Treatment of psoriatic arthritis

Drug treatment of psoriatic arthritis

Treatment of psoriatic arthritis with tablets is similar to therapy for rheumatoid arthritis.

Nonsteroidal anti-inflammatory drugs
. If the course of the disease is favorable, NSAIDs can be used to control the symptoms of arthritis as an independent remedy. However, most often it is necessary to include basic drugs.
Glucocorticoids
. Steroid drugs are used in case of ineffectiveness of NSAIDs in short courses. They help quickly relieve swelling, pain and symptoms of the inflammatory process, but have side effects. For inflammation of the ligamentous apparatus, GCs are used topically.
Chondroprotectors (Artracam)
are the only group of drugs that promotes the regeneration of joint tissue. They help achieve stable remission for long months, eliminate symptoms of inflammation and significantly reduce pain. Treatment of psoriatic arthritis with tablets containing chondroitin and glucosamine sulfate helps to establish metabolism in joint tissues and improve the quality of joint lubrication - this reduces joint wear and prevents further destruction of cartilage.
Basic anti-inflammatory drugs
. DMARDs are indicated for highly active psoriatic arthritis. They help reduce the intensity of symptoms. Only a doctor should select the drug (some DMARDs are ineffective for spinal lesions).
Genetically engineered biological drugs
are the most modern, but still quite expensive, method of treating arthritis of an autoimmune nature.

Causes of spondyloarthritis

Until now, scientists cannot name the exact causes of ankylosing spondylitis.

One possible reason is hereditary predisposition. The majority of patients (about 96%) with ankylosing spondylitis are carriers of the HLA-B27 gene, which is believed to have structural similarities to certain infectious agents. As a result of the formation of cross-reacting antibodies, the body’s immune system ceases to distinguish “self” from “foreign” cells and begins to destroy the cells of its own body. This is how the autoimmune inflammatory process in the joints begins.

It has been suggested that Bechterew's disease is a psychosomatic disease, which can be triggered by the patient's mental characteristics or severe prolonged stress. Studies have shown that many patients lack psychological flexibility in solving problems, but are dissatisfied with themselves, their lives, work, family, etc.

1 Preventative massage

2 Preventive massage

3 Diagnosis of ankylosing spondylitis

Factors that provoke secondary spondyloarthritis are:

inflammatory diseases of the genitourinary system;
intestinal infection (dysentery, salmonellosis, yersiniosis, etc.);
disruption of the endocrine system;
hypothermia of the body, etc.

Prevention of psoriatic arthritis

To prevent psoriatic arthritis, as well as to curb the activity of the disease, patients are recommended to undergo regular physical activity (PT) and maintain orthopedic correct postures while doing housework and performing work duties. Patients with psoriasis should be equipped with an ergonomic working and sleeping place to prevent injury to soft tissues or disruption of their trophism (this can cause inflammation). Also recommended:

reduce body weight if you are overweight;
to refuse from bad habits;
do a 5-minute warm-up at least 3 times a day;
protect yourself from hypothermia;
follow a diet;
take chondroprotectors (for example, Artracam) at least 4 months a year to preserve joints, prevent arthritis or achieve long-term remission.

Take care of your health - and don’t get sick!

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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