Psoriatic Arthritis
Psoriatic Arthritis
Psoriatic Arthritis
Nail Psoriasis
Nail Psoriasis
Extensive Skin Psoriasis
Extensive Skin Psoriasis
Psoriasis behind Ear
Psoriasis behind Ear

Psoriasis is a chronic autoimmune skin condition due to rapid reproduction of cells. This results in red or pink dry, raised patches of skin thickening associated with scaling. Skin psoriasis affects almost 1% population. Psoriasis commonly affects skin over elbows, knees, shin and scalp. There are various types of skin psoriasis – psoriasis vulgaris being the most common form.
Silvery white flakes or scales composed of dead skin cells develop on top of skin lesions. These become loose and shed from skin lesions. Dry skin with cracking, itching and pain are other features of skin psoriasis. Psoriasis can affect palms and soles only and can also present as scalp dandruff. Various other patterns are also observed. Nail psoriasis is a peculiar form in which nails show pitting and discoloration and may separate from nail bed.

The exact cause of this disease is unknown although it is related to a combination of factors such as genetic predisposition (40% patients have family history), environmental factors, job stress, emotional distress, social embarrassment and local trauma. Some drugs, such as lithium and beta blockers, are known to cause psoriasis flares.

There appears to be a peculiar association between psoriasis and HIV infection. Psoriasis usually has remissions and relapses – worsening in colder season and improvement in warmer climate.
Severity of psoriasis can be assessed by measuring the area involved and the amount of redness, thickening as well as scaling in the involved area. There is no cure for psoriasis although dermatologists can control the disease with local applications (retinoids, vitamin D analogues, moisturizers and immunomodulators), phototherapy (ultraviolet light with or without psoralen sensitization) and systemic drugs such as methotrexate and new biologic agents.
5-25% of psoriasis patients develop arthritis - this is known as psoriatic arthritis. Severe skin disease and longer duration of skin psoriasis are often associated with arthritis. PsA can also occur in patients with quiescent psoriasis. Some patients may not have skin psoriasis but have 1st or 2nd degree relative with psoriasis. Children, too, can develop psoriasis and PsA.

Features
Many patients with psoriatic arthritis have diffuse joint pains without any swelling. Swelling usually affects less than 5 joints at a time.The joint involvement is asymmetric. Fingers, toes and large joints of limbs are usually affected and may be mistaken for gout. The pain is usually very severe to start with. Joint swelling is not like rheumatoid arthritis – it is more firm. The involvement of terminal joints of fingers and toes is typical of PsA. Other typical features of PsA include swelling of entire finger or toe (sausage digit) and enthesitis. Enthesitis is swelling in the area where muscle tendons attach to bones. Typical sites of enthesitis in PsA are outer side of elbow, inner side of knee and back of your heel. PsA can also involve spine in about 5% cases. This manifests as pain and stiffness in the back. In about 15% cases of PsA, joints of hands and feet get severely mutilated and deformed.

Investigations
PsA is a clinical diagnosis and no blood tests are required. A negative rheumatoid factor helps in diagnosis. Uric acid is usually raised due to increased cell turnover (mistaken diagnosis of gout). Raised inflammatory markers such as ESR and CRP indicate an active and more severe disease. X-Rays of involved joints show new bone formation around the joint and bone - a typical finding of PsA. Ultrasound and MRI examinations can help in diagnosis of enthesitis. Other blood tests are ordered for monitoring therapy.
Assessments
The group of research and assessment of psoriasis and psoriatic arthritis has issued guidelines for assessment of disease for planning of appropriate therapy. The assessment is based on number of joints involved, extent of skin involvement, number of enthesitis sites, and response of dactylitis as well as spinal disease to therapy. The disease can then be classified as mild, moderate or severe. All patients must also be assessed for function, fatigue and quality of life.
Co morbidities
Many disease conditions are usually associated with psoriasis. These include raised uric acid levels, raised lipids, obesity, high blood pressure, diabetes, colitis, bone changes, eye inflammation, heart disease, atherosclerosis and shortening(by about 10 years) of life-span. Anxiety and depression usually accompany leading to social isolation and related problems. Onset of psoriasis at young age appears to be an adverse prognostic factor. Under treatment of psoriasis may contribute to increased incidence of co morbidities in psoriasis patients.
Treatment
All patients of psoriasis and PsA must be aggressively treated jointly by a dermatologist and a rheumatologist. Treatment of PsA includes drugs such as methotrexate (which works on skin as well as joints), salazopyrine and leflunomide. Newer biologic drugs approved for PsA include etanercept, infliximab and adalumimab. Biologic agents are particularly advised in spinal involvement, nonresponsive enthesitis, finger swellings and severe disease. Vitamin D and calcium supplements are beneficial in these patients. Nutritious diet, avoidance of alcohol and smoking are also advisable. Painkillers, physiotherapy exercises, local steroid injections (for joints and enthuses) and surgery are required in selected cases. Patient education and supports are extremely essential in management of this chronic relapsing disease.

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