Let’s Talk About Psoriatic Arthritis Treatment
If there’s a positive spin on being diagnosed with this painful disease, it’s that your options for getting better are growing by the day.
Even though there’s no cure for psoriatic arthritis (PsA), relief for your symptoms is likely just around the metaphorical corner—the research into treating this inflammatory condition is moving that fast. Drug therapies for PsA are more targeted than ever, and lifestyle changes can make big improvements in your condition. Once you’ve been diagnosed with PsA, your primary care doctor will likely refer you to a rheumatologist to discuss your treatment options. Let’s take a closer look at what those might entail.
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.
Nilanjana Bose, M.D.
Rheumatology Center of Houston
Iris Navarro-Millan, M.D.
Rheumatologist and an NIH-funded RA clinical researcher
Hospital for Special Surgery
New York, NY
Janelle Laughlin, M.D.
University of Colorado Health Longmont Clinic
That’s a doctor who is specially trained in diagnosing and treating PsA and other “rheumatic diseases” (musculoskeletal diseases and systemic autoimmune disorders). To see one, you may need a referral, either from your primary care doc or another physician.
Nope, sorry. PsA is not yet curable. If you are taking medication and your symptoms improve, do not stop taking your medications without talking to your doctor. Discontinuing your medications could cause your symptoms to return and even get worse.
PsA treatment varies as does the time it takes to see results. For example, you may get immediate relief from a cortisone injection, but it may take months for a biologic medication to work effectively.
Actually, yes. Kids can get this disease, and when they do, it’s referred to as pediatric psoriatic arthritis. If your child shows symptoms, seek treatment as soon as possible. The approach will be similar for that of adults with PsA.
Recap! What Is Psoriatic Arthritis, Again?
Driven by an out-of-whack inflammatory response, psoriatic arthritis (PsA) is a chronic condition where your joints, ligaments, and tendons come under attack by your immune system, leading to pain, swelling, and stiffness that can do serious joint damage if left unchecked.
The disease is related to (but different from) the inflammatory skin condition known as psoriasis—although about 30% of people with psoriasis will develop PsA at some point during their life, most commonly in their 30s and 40s.
While the jury is still out on the exact causes of PsA, experts believe it is a combination of genetics (about 40% of people with PsA have a family history of the disease), an overactive immune system, and things in the environment that you have been exposed to. It affects men and women in equal numbers and is most frequently diagnosed in people between the ages of 30 and 50.
How Is Psoriatic Arthritis Treated?
When it comes to PsA treatment, one size doesn’t fit all. Before deciding which approach is right for you, your doctor will do a physical exam and ask you questions to figure out how much (or little) PsA is getting in the way of your everyday activities.
Severe cases can cause long-term joint damage, while milder cases are more of an inconvenience, so it’s important to establish the degree to which PsA is affecting your personal situation first, before talking about treatment.
The goal of the treatment is simple: Reduce inflammation and the discomfort that you may be feeling so you can return to enjoying your life. The sooner treatment begins, the more successful it tends to be at easing symptoms and slowing down the disease. These are a few of the approaches you and your doc may discuss.
What Are the Medications for PsA?
Uncontrolled inflammation is the underlying cause of most of the discomfort associated with psoriatic arthritis. How severe your inflammation is will often determine which treatment your doctor will choose—or at least, which therapy you start with. Fortunately, there are many effective medications available. You may find that you need to try several in combination to get the best results.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are usually the first step if your symptoms are very mild. They can help control the inflammation and joint pain. Some people feel relief almost immediately, while in others it may take several days. These drugs are not recommended for long-term use since they carry side effects like stomach irritation, heart problems, and kidney damage.
The most common NSAIDs include:
Advil, Motrin (ibuprofen)
Bayer, Bufferin among others (aspirin)
In addition, COX-2 inhibitors, a subclass of NSAIDs, may be prescribed. These have a lower risk of internal bleeding or stomach ulcers—a common side effect of other NSAIDs that are used in large doses for a long time. Brand names include Bextra and Celebrex (celecoxib).
Shorthand for “disease-modifying anti-rheumatic drugs,” these treatments used to be the go-to regimen for treating PsA. They work by suppressing the body’s overactive immune system. Due to their immune-suppressing nature, they can come with side effects, like mouth sores, hair loss, stomach upset, infection, fatigue, or liver damage. If you are taking them, you should be closely monitored with regular (weekly to every few months) lab tests. Most DMARDs can all be taken orally, and methotrexate is also available as an injection.
The most common DMARDs include:
A sub-type of DMARDS, known as JAK inhibitors (short for Janus kinase) target a family of enzymes that trigger the immune system response. Drugs include:
Xeljanz and Xeljanz XR (tofacitinib)
Also known as biologic response modifiers, these medications hold much promise for the future of PsA treatments: Up to 60% of PsA patients achieved minimal disease activity after one year of treatment with biologics, according to a study in Arthritis Research & Therapy. These therapies have fewer side effects than DMARDs (although your risk of infection is greater).
Here’s how they work: Biologics are protein-based drugs derived from living cells cultured in a laboratory. Their job is to control certain parts of the immune system by targeting the proteins that fuel inflammation and shutting them down. They are categorized based on the cells they target.
These are a few options your doctor may prescribe:
Tumor Necrosis Factor (TNF) Inhibitors
This class of drugs is now the first line of prescription treatment for people with PsA, according to guidelines issued in 2018 by the National Psoriasis Society and the American College of Rheumatology. These meds lower inflammation and slow the progression of PsA by targeting an inflammation-causing substance in the body called tumor necrosis factor (TNF).
Delivered by self-injection or IV, examples of TNF inhibitors include:
Interleukin-17 (IL-17) or Interleukin 12 and 23 (IL-12/23) Inhibitors
Another type of biologic treatment that has been found to be effective in treating PsA, these drugs act on a different pathway to control inflammation in your joints. Like TNF inhibitors, these meds are only available via injection.
A type of white blood cell related to your immune system, T-cells signal to your body that it’s under attack and time to launch an assault. Unfortunately, that assault, by way of inflammation, is mistakenly directed at your joints and tendons.
This class of medication inhibits T-cells from becoming activated, thereby reducing inflammation and subsequent joint damage. It’s taken as an injection. Examples include Orencia (abatacept).
These drugs work by blocking an enzyme called phosphodiesterase 4 (PDE4), that is responsible for controlling inflammatory actions within the body’s cells. Currently there is only one PDE4 inhibitor approved for PsA. This drug—Otezla (apremilast)—can be taken orally.
Consider corticosteroids a short-term fix for symptoms while you’re waiting for other longer-term medications to take effect. (They can also be prescribed for immediate relief during a flare.) Corticosteroids can be taken orally, intramuscularly, or injected right into the joint.
Long-term use should be avoided since it can lead to side effects like high blood sugar, high blood pressure, bone loss, and glaucoma. Patients coming off the drug should taper slowly over a few weeks. The most common corticosteroid is Deltasone (prednisone).
Surgery for Psoriatic Arthritis
Surgery is not a standard treatment for those with PsA. However, if you’ve lived with psoriatic disease without a diagnosis or treatment, it is possible that it has caused permanent joint damage, in which case, your doctor may talk with you about arthoplasty—a procedure that replaces, reshapes, or reconstructs damaged joints.
It’s a serious surgery, but also a common one: More than a million joint replacement procedures are performed each year, mostly of the hip or knee (your shoulders, elbows, and joints in the hands and feet can be replaced as well). There are pros and cons to going this route—and it’s usually reserved for the most severe cases of joint damage. Talk with your doctor if it’s something you think might help.
Other Therapies for PsA
Along with medical procedures and drug intervention, there are a bunch of lifestyle changes you can make that will go a long way towards easing the painful symptoms of psoriatic arthritis. This list here can help you get started.
Drink less alcohol. Heavy drinking can lower your response to PsA treatment. Unchecked alcohol consumption will also fill you up with a glut of empty calories, leading to unwanted pounds that place extra stress on your joints.
Exercise more. Exercising regularly can help psoriatic arthritis in several ways: It reduces joint pain by keeping muscles strong and supporting the joints; it helps you lose or maintain a healthy weight so there is less load on your joints and ligaments; and it can improve your mood and reduce stress. If you are having a flare, you will need to listen to your body. Don’t be afraid to back off or take more frequent breaks as you work out. After all, any amount of exercise is better than none.
Explore hot/cold therapy. A warm shower or bath can work wonders on stiff, painful joints. Heat reduces muscle tension and stimulates blood circulation, which may help joints feel better. (Heat can also irritate your skin and cause a flare, so it’s a tricky balance.) A cold compress, on the other hand, may help reduce inflammation, swelling, and soreness during a flare or after more than your usual amount of activity.
Manage stress. The bottom line: Stress can trigger a flare. Try exercise, meditation, yoga, or deep breathing if tension is making your symptoms worse. And if anxiety or depression is interfering with your life or ability to function, don’t hesitate to seek help.
Quit smoking. Smoking can increase your risk of psoriasis and may make symptoms significantly worse. It can also prevent your treatment for working effectively. While the exact causes are unknown, one theory is that cigarettes contain thousands of different ingredients that may promote inflammation.
Sleep better. Sleep is incredibly important for everyone, but if you have psoriatic arthritis, it's especially key because a major part of joint and tissue repair happens when you are asleep. Unfortunately, pain related to PsA can interrupt sleep and so can certain medications like steroids. If you’re struggling to get a steady seven to nine hours a night, talk with your doctor about possible solutions.
Use topical creams. Applying creams or lotions containing capsaicin (an extract from chili peppers) may temporarily soothe minor joint pain. Ditto for those with camphor, menthol, or turpentine oil.
Watch your diet. While a direct correlation between diet and psoriatic arthritis has yet to be proven, avoiding foods known to trigger inflammation in the body is sort of a no-brainer. Desserts, soda, white bread, and other foods that are high on the glycemic index tend to cause a temporary spike in blood sugar, which promotes inflammation.
Wear supportive shoes. Sorry to say it, but your days of flip flops and cheap shoes may be behind you. Shoes that provide stability and cushioning can help your feet feel better and provide a solid foundation for your knees, hips, back, and neck. Do what you need to stay comfortable and supported. You may find that changing shoes several times a day is preferable.
Can Supplements Help With Psoriatic Arthritis?
There isn’t a ton of research to say conclusively one way or the other, but there’s little downside to adding these two natural supplements into your diet.
A few studies suggest that supplementation of about 3.3 grams daily of fish oil, which contains high amounts of omega-3 fatty acids, may help reduce pain and stiffness. Salmon, walnuts, and flax seed are also sources of omega-3s. Don’t overdo though: High doses of omega-3 supplements can cause nausea, cramps, and increase bleeding risks in people who take blood thinners. As always, talk with your doc first.
Turmeric has been used as a spice for centuries. Several small studies show that turmeric and its major ingredient (curcumin) may help treat arthritis symptoms just as effectively as pain medicines like ibuprofen. You can find it as a supplement and can also use it to cook with or add to your tea or smoothies.
Living With Psoriatic Arthritis
All of these options may sound overwhelming to you. It’s hard to know where to start—which is why the best thing you can do is make a list of questions and schedule an appointment with your doctor. As you talk, keep your mind focused on the fact that with the right treatment, the majority of those living with PsA get their symptoms under control and achieve remission. In fact, with certain treatment programs, more than half of patients see symptoms virtually disappear in a year’s time. Pretty good!
Of course, the trick is finding the right combination of meds, and that can be a bit of trial and error. Don’t give up. It can take months, but once you settle of a combo that works for you, you’ll be well on your way to getting your life back the way you want it. Most likely, you’ll need to stay on the meds indefinitely, since even though the disease may quiet down, it’s there, waiting to strike if given half a chance. Still, that’s a small price to pay for pain-free living.
PsA and Early Intervention: National Psoriasis Foundation. (n.d.). “Why Early Intervention is Critical for Psoriatic Arthritis” psoriasis.org/advance/early-diagnosis-critical-for-psoriatic-arthritis
PDE4 Inhibitors: National Psoriasis Foundation. (n.d.). “Coming Down the Pipeline.” psoriasis.org/advance/coming-down-pipeline
Alcohol Reduction: British Journal of Dermatology. (2019). “Modifiable Risk Factors and the Development of Psoriatic Arthritis in People with Psoriasis.” onlinelibrary.wiley.com/doi/abs/10.1111/bjd.18227
Fish Oil: Nutrients. (2017). “Marine Oil Supplements for Arthritis Pain: A Systematic Review and Meta-Analysis of Randomized Trials.” mdpi.com/2072-6643/9/1/42
Turmeric: Journal of Medicinal Food. (2016). “Efficacy of Turmeric Extracts and Curcumin for Alleviating the Symptoms of Joint Arthritis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.” ncbi.nlm.nih.gov/pmc/articles/PMC5003001/