Let's Talk About the Signs and Symptoms of Psoriatic Arthritis
Psoriatic arthritis isn't always easy to spot. In fact, some don't even have psoriasis! Here's what to look for instead. by Tracy Davenport, Ph.D. Health Writer
Given its name, it’s natural to assume that everyone who develops psoriatic arthritis (PsA) also has the uncomfortable skin plaques caused by psoriasis. While that’s usually the case, it is possible for joint pain and swelling to be the first sign. What’s more, by the time you make a doctor’s appointment for one achy joint, the pain may have moved on to different one altogether. Because the symptoms of PsA can be sneaky and similar to other inflammatory conditions, it’s important to have yours evaluated by a rheumatologist who can pinpoint the source and get you on a treatment plan. And the sooner the better: With early detection and the right medication, the majority of people with psoriatic arthritis will reach remission and become symptom-free.
Our Pro Panel
We went to some of the nation's top experts in PsA to bring you the most up-to-date information possible.
Lawrence Brent, M.D
Professor of Medicine in the Section of Rheumatology
Temple University Hospital
Vivian P. Bykerk, M.D.
Director of the Inflammatory Arthritis Center
Hospital for Special Surgery
New York City
Rebecca Haberman, M.D.
Rheumatologist and Clinical Instructor
New York University Langone Health
New York City
Yes. It is common to have both PsA and osteoarthritis, especially if you are over 60. The majority of people over the age of 60 have osteoarthritis, which develops from the accumulation of everyday wear and tear on joints. The symptoms of PsA can also be similar to RA, but if the blood tests for RA come back positive, then your arthritis would be called rheumatoid arthritis.
Yes. According to the Arthritis Foundation, approximately 300,000 children are affected by some type of pediatric arthritis, including psoriatic arthritis. Children are more likely than adults to experience the onset of psoriasis and psoriatic arthritis at the same time.
Absolutely. Lyme disease, inflammatory bowel disease, and lupus can all cause joint symptoms and will need to be ruled out before a PsA diagnosis can be made.
Yes, in fact, if you have been diagnosed with PsA, it is important to remain active and develop a regular exercise routine. If you are feeling too sore to exercise, it may be helpful to work with a physical therapist to help you find a routine that will work for you.
What Is Psoriatic Arthritis Again?
Let’s make one thing clear: Psoriatic arthritis (PsA) and psoriasis are two related—but separate—systemic autoimmune conditions, both of which are driven by an out-of-whack inflammatory response. In psoriasis, your skin is the primary target, which leads to those uncomfortable, itchy rashes. In PsA, the immune system mistakenly zeroes in on the joints, ligaments, and tendons, causing joint pain, swelling, and stiffness. If left untreated, PsA can permanently damage the joints, seriously interfering with your ability to move or function normally.
About 30% of people with psoriasis will go on to develop PsA, and while we don’t know the exact cause, scientists believe genetic susceptibility, an overactive immune system, and environmental factors (the things you’re exposed to) all play a role.
What Are the Early Symptoms of Psoriatic Arthritis?
Each PsA case is unique. Some people may feel only mild symptoms that come on slowly; others may experience severe symptoms that take hold very quickly. Delaying treatment by as little as six months can result in permanent joint damage, so if you notice any of the follow symptoms, have them checked out ASAP.
Psoriasis. Most people with psoriatic arthritis first have psoriasis and its associated skin symptoms. While psoriatic arthritis usually starts about 10 years after psoriasis begins, it is possible to develop psoriatic arthritis without having the tell-tale skin symptoms.
Joint pain and swelling. According to Arthritis Research and Therapy, 88% of those living with psoriatic arthritis have ongoing joint pain or soreness, and 60% report the pain affects more than four joints. Common locations for joint pain include:
knee (41% of people with PsA experience joint pain here)
Notice how we stuck to the singular in our list above. That’s because PsA typically strikes asymmetrically, meaning only one knee (or ankle or index finger) is affected at a time. Another tricky part of PsA is that the pain, stiffness, and swelling can come and go—affecting different parts with each flare.
Reduced range of motion. When your joints are inflamed, they just can’t move as well. Stiffness may be especially noticeable after sitting or sleeping. You may even feel like the joint is stuck. Walking up and down stairs or getting in and out of a car may become suddenly or increasingly difficult.
While some people with PsA may feel only mild discomfort, others can develop severe stiffness that prevents them from performing simple tasks. Sometimes the joint pain improves once you get going and moving, but other times it can stay sore throughout the day, depending on the level of inflammation.
Tenderness in tendons. Along with your joints, the tendons that attach to your bones can also become inflamed, causing tendonitis. This symptom can easily be attributed to an injury or overuse, so it’s important to pay attention to other signs that may be cropping up. One specific type of tendonitis tightly associated with psoriatic arthritis is a sudden swelling in the fingers and toes known as dactylitis. Your affected digits will look like little sausages.
Fatigue. The feeling wiped out not matter how much you’ve rested is one of the most troubling symptoms of PsA, impacting about half of those living with the disease. While there may be multiple causes for fatigue, the inflammation associated with PsA can be at least partially to blame. The proteins that are released during an inflammatory response play a role. (It’s hard work for your body to keep fighting inflammation.)
Living with the stress of chronic pain can also cause poor sleep and depression, both of which contribute to fatigue. There may also be co-existing conditions such as fibromyalgia, which makes almost everyone feel tired. Fatigue by itself can be a difficult symptom to pin on psoriatic arthritis, but if you are feeling more tired than usual, and experiencing some other symptoms, telling your doctor about your exhaustion may help connect the PsA dots.
Nail problems. PsA affects fingernails and toenails in at least half of those living with psoriatic arthritis. You may notice small pits on the surface of your nail, it might separate from your nail bed, or it might turn a color that’s different from usual.
Eye problems. The inflammation that PsA creates throughout your body can impact your eyes and cause a range of symptoms that include:
How Is PsA Different From RA?
Both psoriatic arthritis and rheumatoid arthritis (RA) are types of inflammatory arthritis so there are similarities. However, there are also differences.
Most people with PsA will also have psoriasis.
RA doesn’t affect your skin.
RA often shows up as swelling in both joints, like two knees, where PsA will present in a more asymmetrical pattern, like a right hip and left knee being sore.
Dactylitis, the swelling of a finger or toe, is also more common in PsA than in RA.
Bloodwork can indicate RA, but there is not yet a blood test for PsA.
We don’t know as much about what causes PsA flare-ups as we do with RA. PsA flares can be sudden and make things worse, or they can also be persistently low-grade.
For example, whenever you go for a walk, you need to ice a joint afterwards. With a big flare, it might be suddenly difficult to go for a walk, period. Or you may have no serious flares over the course of a year, but regularly have annoying joint symptoms. Staying in close contact with your doctor can help you adjust your treatment until you find the best fit for your PsA.
What Happens If PsA Goes Untreated?
Psoriatic arthritis was once thought to be a mild, non-progressive form of arthritis. We now know that PsA is a chronic and progressive disease. If it goes untreated, it will worsen and may cause permanent damage to your body, particularly your joints.
Half of those with PsA will develop joint erosions within two years without treatment, according the Journal of Arthritis and Therapy. Psoriatic arthritis can also cause your joint space to narrow, leading to more pain and stiffness, and it can lead to bone deformities (think crooked fingers).
More than half of those living with psoriatic disease have at least one comorbidity (a second disorder), and at least 40% have three or more comorbid conditions according to the Arthritis Foundation. The most common comorbidities related to psoriatic arthritis include:
Researchers have found several causes for the coexistence of these disorders with PsA, and no surprise, high levels of inflammation is top of the list.
How Is Psoriatic Arthritis Diagnosed?
Unfortunately, there’s no way to immediately diagnose PsA. Your doctor will perform a physical exam that will include taking your medical history to determine if psoriasis or PsA runs in your family. He or she will also check your skin for signs of psoriasis, which may appear as red or dry scaly patches, examine your joints for symptoms like swelling or tenderness, and check your fingernails for telltale pitting and flaking.
Your doctor will press or probe the soles of your feet and around your heels, checking for tenderness. He or she may also run lab tests to rule out other causes of joint pain like rheumatoid arthritis or gout. These include:
Blood tests. While there is no a simple blood test to detect PsA, running a blood test while you are experiencing symptoms will help with a diagnosis. If it reveals that you are carrying a rheumatoid factor (RF), your symptoms are most likely related to rheumatoid arthritis instead of psoriatic arthritis. People with PsA are almost always RF negative. Your doctor will also pay close attention to your C-reactive protein (CRP) levels, which rise when a condition is causing inflammation in the body.
Joint fluid tests. Drawing fluid from a swollen joint can help your doctor rule out gout, a condition that may look similar to PsA. Our joints are surrounded by synovial fluid, a thick liquid that helps your joints move smoothly. A disorder like gout or an infection can change the way the synovial fluid looks and feels. If the joint fluid analysis comes back and the results show you have a high uric acid level, this could indicate gout instead of PsA.
X-rays. While x-rays may not be useful in the early part of PsA before any changes to the bones have occurred, they may be helpful once the disease has progressed. X-ray results can show the type of joint damage that has occurred or if the bones are changing shape. Aging and other types of arthritis can also cause changes to the bones, so this information is just one piece to consider. Since X-rays are less expensive than other types of imaging, they are often ordered first.
Magnetic resonance imaging (MRI). An MRI scan can provide a detailed image of both hard and soft tissue. Because one of the hallmark symptoms of psoriatic arthritis is inflammation of the joint tissue, an MRI can provide the doctor with specific information about if and where you have inflammation.
Unlike many other diseases, no one sign or symptom will determine if you have PsA. Some detective work is required to fit all the pieces together in a possible psoriatic arthritis diagnosis.
- Symptoms of Psoriatic Arthritis: National Psoriasis Foundation. (n.d.). “About Psoriatic Arthritis.” psoriasis.org/about-psoriatic-arthritis
- Joint Pain and Stiffness: Arthritis Research and Therapy. (2018). “Secukinumab Provides Rapid and Sustained Pain Relief in Psoriatic Arthritis Over 2 years: Results from the FUTURE 2 Study.” arthritis-research.biomedcentral.com/articles/10.1186/s13075-018-1610-3
- Permanent Joint Damage: Arthritis Research and Therapy. (2015). “Early Biomarkers of Joint Damage in Rheumatoid and Psoriatic Arthritis.” link.springer.com/article/10.1186/s13075-015-0652-z
- Other Health Conditions: Arthritis Foundation. (n.d.). “Metabolic Comorbidities of Psoriatic Arthritis.” arthritis.org/about-arthritis/types/psoriatic-arthritis/articles/psa-metabolic-comorbidities.php