Psoriatic Arthritis Treatment
Treatment for psoriasis remains suppressive, rather than curative. Treatment of articular manifestations generally begins with non-steroidal anti-inflammatory agents (NSAIDs). However, in patients with aggressive and potentially destructive disease, disease-modifying anti-rheumatic drugs (DMARDs) should be added early on in the course. The following DMARDs should be considered:
- Methotrexate(ref 1,2) is effective for both the cutaneous and peripheral articular manifestations of psoriasis. It is generally the first choice of DMARD, given its efficacy and tolerability.
- Anti-malarials, retinoic acid derivatives, and psoralen with UV-A light (PUVA) may also benefit both the cutaneous and peripheral articular disease to varying degrees.
- Sulfasalazine may benefit the peripheral joints, but has no significant impact upon the activity of cutaneous disease.
- Cyclosporin A(ref 3-5) may be effective for both cutaneous and articular disease, but caution must be exercised given that as many as 21% of patients may develop hypertension and 17% nephrotoxicity.
- Etanercept®, Remicade®, and Humira®(ref 6-11), all tumor necrosis factor (TNF) inhibitors, have been found to be effective and well tolerated in the treatment of both psoriasis and psoriatic arthritis.
Intra-articular and low-dose systemic corticosteroids may be used as bridging therapy while treatment with a DMARD is instituted, but tapering of high-dose corticosteroids has been associated with the development of generalized pustular psoriasis.
Physical and occupational therapy are often critical to the development of interventions to both protect the involved joints and maintain function.
Factors that may portend a worse prognosis include extensive skin involvement; a strong family history of psoriasis; female gender; disease onset at <20 years of age; expression of HLA-B27, -DR3 or -DR4 alleles; and polyarticular or erosive disease.
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*Images within this article are from the American College of Rheumatology Slide Collection.
