PSORIASIS and COMORBIDITIES – PSORIATIC ARTHRITIS

WHAT IS COMORBIDITY?

 Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

Psoriatic Arthritis

Spondyloarthropathies

CHART 1: Comorbidities Associated with Psoriasis 1,2,3

Psoriatic arthritis (PsA) is an inflammatory arthropathy, which is associated with psoriasis in approximately 25% of patients. It is characterized by stiffness, pain, swelling, and tenderness of the joints as well as the surrounding ligaments and tendons. It affects men and women equally and typically presents at the age of 30 to 50 years. Skin lesions usually precedes the onset of PsA by an average of 10 years in the majority of patients but 14– 21% of patients with PsA develop symptoms of arthritis prior to the development of skin lesions.4

human_hand_bones-en The Foot

                  The Hand                                                                                             The Foot

The presentation of PsA is variable and can range from a mild, non-destructive arthritis to a severe, debilitating, erosive arthropathy.

There are various classifications for PsA:-

• Monoarthritis of the large joints – inflammation and arthritis in one joint.

PsN 1 Finger

          Swelling evident in the joint between the Intermediate and Proximal Phalanges in the index finger

  • Distal interphalangeal arthritis – affecting the joint between the Distal and Proximal phalanges.
  • Spondyloarthritis – affecting the spine and, in some people, the joints of the arms and legs.

Symmetrical deforming polyarthropathy – similar to that of rheumatoid arthritis

PsN all Distal Joints

Deformity of the Distal interphalangeal joints with varying degrees of severity seen across all of the fingers from severe to mild.

If PsA is left untreated, a percentage of patients may develop chronic inflammation with progressive deforming joint damage which leads to severe physical limitations and disability. So it is very important for a patient with psoriasis who is experiencing joint swelling or pain to be reviewed by a Rheumatologist as soon as possible. However, as there is no specific test for PsA, the diagnosis of PsA is based on clinical judgement. The main aspect is the absence of rheumatoid factor (91-94%), this key finding together with the specific presentation of joint pain and inflammation plus the presence of psoriasis skin lesions all combine to lead the Practitioner and the Rheumatologist to diagnose PsA. X-rays may aid diagnosis and can show the extent and location of joint damage. Other types of scans such as MRI or CT scans can also be used to look at the joints in more detail.

In many patients articular patterns change or overlap in time. Enthesitis, inflammation at the sites where tendons or ligaments insert into the bone, may occur at any site, but more commonly at the insertion sites of the plantar fascia (the fibrous band of tissue (fascia) connecting the heel bone to the base of the toe bones), the Achilles tendons, and ligamentous attachments to the ribs, spine, and pelvis. PsA is unusual in that it can affect joints on only one finger or toe, several joint on one side or on affect joints on both sides of the body. PsA symptoms often resemble those of rheumatoid arthritis. Both diseases cause the joints to become inflammed, painful, swollen and warm to the touch.4

The most common symptoms are:-

  • Swollen fingers and/or toes.  PsA can cause a painful, sausage-like swelling of the fingers and/or toes. Swelling and deformities in the hands and feet before having significant joint symptoms may occur.

  • Foot pain. Psoriatic arthritis can also cause pain at the points where tendons and ligaments attach to the bones — especially at the back of the heel or in the sole of the foot.
  • Lower back pain.Some sufferers develop a condition called spondylitis as a result of PsA which causes inflammation of the joints between the vertebrae of the spine and in the joints between your spine and pelvis (sacroiliitis).

Skin lesions in patients with PsA and psoriasis may vary from a mild to a severe presentation and the skin activity is commonly not indicative of the severity of the arthritis symptoms. It is important to note that skin lesions and symptoms normally precede arthritic signs and symptoms in 80% of psoriatic arthritis patients. Whilst simultaneous onset of arthritic and psoriatic symptoms will occur in approximately 13% of patients, only 3% of patients will have joint involvement preceding the development of skin lesions.5

People with PsA often experience pain, stiff joints and muscle weakness and often this is due to lack of use so a regime of light exercise is very important to improve overall health and to keep the joints as flexible as possible. It may be of benefit for people with PsA to consult with an exercise physiologist / remedial therapist who can give advice as the most suitable exercises that are patient specific, including how to get started safely, so that the potential to aggravate the joints are kept to a minimum.

Some of the types of exercise that should be discussed with your physiologist / therapist are:-

  • Aerobic exercises – walking, swimming or gentle water aerobics
  • Muscle-strengthening exercises – light weights
  • Muscle-stretching exercises
  • Hydrotherapy – supervised structured exercises of specific extremities and joints in warm water.

Use of Assistive Devices

An assistive device is a tool or implement that makes a particular function or action easier or possible to perform, e.g.:-

Clothing Aids

  • Velcro on clothes and shoes or elastic shoelaces.
  • Button and zipper hooks.
  • Leg-Up Leg Lifter allows users with limited mobility to avoid having to bend down or hold onto clothing to lift their leg.
  • Long handled shoe horns.

Grooming Aides

  • Fit Combs, brushes and toothbrushes with easier-to-hold handles for ease of use.
  • Or use Long handled brushes and combs that have anti-slip handles.
  • Use a toothpaste dispenser that automatically dispenses a set amount of toothpaste onto a brush.

Bathing and Showering Aides

  • Use a long handled hair washer that can be used to apply shampoo and massage the user’s scalp while reducing strain on the hands, shoulders, or arms.
  • Long handled foot wash brush to assist people with limited access to their feet.
  • Long handled sponge or cloth body washers.
  • Long handled lotion or ointment applicators.

Cooking and Cleaning Aides

  • Finger loop utensils.
  • Oven knob turner.
  • Cut resistance gloves and Finger protector (slicing) guard.
  • Easy glide plastic bag opener.
  • Jar “pop” openers.
  • Tin pull top openers.

Walking Aides

  • Walkers, canes, knee and ankle braces.

Remember there are many websites available where you can purchase any number of assistive devices.

It is important not to lock oneself away and use immobility as an excuse not to socialize. Use group exercise classes to not only improve one’s fitness and mobility but also use the opportunity to talk to other class member’s, or join a support group ….. just the act of talking and sharing can be enough to ensure that you do not become depressed.

 

 

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Lloyd P. et al.; Psoriatic Arthritis: An Update; Hindawi Publishing Corporation Arthritis Volume 2012, Article ID 176298, 6 pages doi:10.1155/2012/176298
  • Gottlieb A.B. et al.; Clinical characteristics of psoriatic arthritis and psoriasis in dermatologists’ offices; Journal of Dermatological Treatment. 2006; 17: 279–287