Psoriasis is a chronic disease that generally presents as a skin condition, which generally presents as a red to purple, scaly rash. There are several different subclassifications of psoriasis. About 30% of patients with psoriasis will develop symptoms of psoriatic arthritis (PsA) and experience painful, swollen joints. Occasionally, PsA is the first manifestation of disease a patient displays, but more often, PsA occurs as the disease progresses. Psoriatic arthritis can occur in several different places in the body, especially the feet.
“Everybody should know that psoriasis is just not limited to the skin,” Dr. Saakshi Khattri, a dermatologist/rheumatologist at Mount Sinai Health System, said in a previous interview with SurvivorNet. “So, as a rheumatologist and a dermatologist, that’s like the biggest thing that I am always on the lookout for when I see a patient with psoriasis… If you have what looks like psoriasis on the skin and then you start to have joint pains or swelling of a joint.”
What Causes Flare-Ups in Psoriatic Arthritis?
Read MoreTriggers of PsA
Flare-ups of PsA can be unpredictable in nature and often occur without a known cause. However, some common triggers have been identified:- Dry skin
- Cold climates
- Illness or infection
- Certain medications
- Skin trauma or injury
- Stress
- Sun damage
- Tobacco and/or alcohol consumption
How Long Do PsA Flares Last?
Psoriatic arthritis is usually intermittent. Patients will experience flare-ups followed up by period(s) of remission. How long either the flares or exacerbation-free period lasts is generally unpredictable. However, flares can last from several days up to several months. Some patients may always experience symptoms, while others may not.How is Psoriatic Arthritis in Feet Diagnosed?
The symptoms of PsA are very similar to other conditions, including rheumatoid arthritis and gout, that cause stiffness and pain within the joints. For this reason, your healthcare team should rule out other inflammatory conditions first. This is done through diagnostic imaging, blood tests, and a thorough evaluation of the patient's medical history.
Approximately 1/3 of patients with psoriasis will have a family member who also has this hereditary condition. If a patient is experiencing stiffness, swelling, and pain in the joints, and also has a family member with PsA or another type of psoriasis, it is likely that the patient has PsA as well. Rheumatologists are typically involved in the diagnosis of PsA and will also guide you will choosing the best treatment options available.
What Does Psoriatic Arthritis in Feet Feel Like?
Psoriatic arthritis can be found in several different parts of the body, including the hands, fingers, lower back, and knees. However, it is most commonly found in the feet. Less often, it has been found to affect the eyes, nails, and gastrointestinal (GI) tract. PsA may affect just one side of the body, or both sides simultaneously. It can be quite painful, similar to other arthritic conditions. Specifically, the back of the heel and the bottom of the foot are the most common locations patients report significant pain. There can also be pain or tenderness surrounding the tendons in the feet. The majority of patients report that associated symptoms negatively impacts their quality of life.
In addition to pain, swollen feet and toes are associated with psoriatic arthritis. The complete swelling of a toe or finger is called dactylitis and is seen in approximately 40% of patients. This swelling is often worse immediately in the morning or after long periods of sitting or lying down. Movement tends to help relieve symptoms, which is why PsA is worsened after the feet have been still for long periods. Swelling is often accompanied by stiffness and the area may even be warm to the touch.
About 50% of patients have enthesitis, which is inflammation where tendons and ligaments attach to bone. This is not generally seen in other arthritic conditions and is commonly found in the tendons/ligaments of the feet. It can cause significant pain and impact a patient's mobility.
Symptoms of Advanced Disease
Psoriatic pain and swelling can cause a patient to limit the use of their feet and legs. This can result in developing muscle weakness from a lack of use. Patients may also begin to lose range of motion. Early diagnosis and treatment of is important because in some cases, PsA can actually begin to cause damage to the joint. In advanced disease, patients may experience bone spurs or bone erosion. This structural damage can be permanent. This significantly impacts a patient's mobility because it causes the bone to either wear away or sometimes fuse, decreasing the function and range of motion of the foot.
The severity of symptoms varies amongst patients. There is not a connection between the severity of symptoms with psoriasis and PsA. Having severe skin lesions due to psoriasis, does not necessarily translate to experiencing more intense complications with psoriatic arthritis.
How to Manage Psoriatic Arthritis in Feet
There are treatment guidelines specific to PsA, that were developed by the National Psoriasis Foundation. Much like psoriasis of the skin, psoriatic arthritis can be treated with certain medications, non-pharmacologic therapies, and lifestyle changes. The choice of therapy for psoriac arthritis is based upon the severity of disease and the patient’s response to treatment. It may also be influenced by comorbidities, patient goals and preferences regarding routes of drug administration and cost of treatment to the patient.
“Half of the patients with psoriatic arthritis are not being treated with a systemic medicine,” Dr. George Han, a dermatologist at Northwell Health/Lenox Hill Hospital, said in an interview with SurvivorNet. “That is just not okay in this day and age when we have so many treatments that can really stop the joint damage in its drugs.
“So I think we are in a place where we’ve got great treatments, but we need to make sure we connect that to the right people.”
Medications
Disease-modifying antirheumatic drugs (DMARDs) are often prescribed and have been shown to improve the progression of disease. This class includes older drugs such as methotrexate, sulfasalazine, and leflunomide. PsA remains incurable, but DMARDs slow disease progression. These drugs work by decreasing the immune system response, which leads to a reduction in certain inflammatory markers.
TNF-alpha inhibitor biologics decrease a particular inflammatory marker in circulation known as TNF-alpha. This helps to slow the action of the immune system to help control the disease. According to treatment guidelines, this class of medications is a first-line recommendation. There are also other biologics available that target different components of the immune system. Some targets include interleukins, T-cells, and JAK kinase. Biologic medications are typically only used in those with moderate to severe disease.
Nonsteroidal anti-inflammatory drugs (NSAIDs) can help to reduce swelling and inflammation as well as provide some pain relief. This type of medication is a common initial treatment option for mild cases. Many options are available over-the-counter (OTC). Some doctors may also recommend steroid injections in more severe cases. Patients should always talk with their healthcare team before starting any medication.
Lifestyle Changes
Maintaining healthy weight is highly recommended. This improves the condition in two ways. First, not having excess weight reduces the physical pressure on your feet. Second, fatty tissue is more susceptible to the inflammatory response and can further aggravate the condition.
Healthy weight can be maintained by regular exercise. Non-impact movement especially, such as swimming or biking, benefits swollen joints and helps preserve joint mobility. Physical or occupational therapy is often utilized to find appropriate exercises and stretches that will challenge a particular patient without exacerbating symptoms. Supportive shoes and resting when needed are also important factors of safe exercise. Sometimes, if swelling is significant, soaking the feet or using an ice pack to reduce inflammation can be helpful
Although psoriatic arthritis flares in the feet can cause significant pain and swelling for most patients, it is important to remember that this is a relatively common disease. Most patients will have the best success with a combination of lifestyle changes and medications.
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