Relieving the Pain of Psoriatic Arthritis
Drugs, diet and exercise can all help
Tracy Ottina, 46, a lawyer from North Reading, Mass., went to her nephew's wedding wearing a pair of casual flat shoes with her cocktail dress—not the look she would have preferred, but the shoes accommodated her orthotic inserts.
"No one batted an eye," she recalls, because her family understands that Ottina has psoriatic arthritis, which can make standing and walking painful. While not her first choice for fashion, the shoes and inserts provided some comfort and allowed her to dance a little at the wedding.
Ottina, who has had psoriasis all her life, was diagnosed with psoriatic arthritis at age 14, although she suspects she'd already had it for at least 10 years by then. "I remember as a little kid complaining about back problems, which is not something you hear too many kids complaining about."
Still, Ottina considers herself one of the lucky ones. "All I've ever known is some pain, especially in my back and feet. Some days, it's so incredibly painful that it hurts just to move. But from what I've read on online forums, where people with psoriatic arthritis describe their symptoms, I'm pretty fortunate."
Up to 30 percent of people with psoriasis may develop psoriatic arthritis, which, like any form of inflammatory arthritis, can cause pain, stiffness and swelling around the joints. "Psoriatic arthritis can affect any joint in the body, but the hands, feet, knees, ankles and sacroiliac (lower back) joints are attacked most often," says Houston rheumatologist Dr. Alan W. Friedman.
Like psoriasis, psoriatic arthritis is a chronic condition. It cannot be cured, but it can be controlled and it should be treated before it progresses and results in permanent joint damage.
Most people with psoriatic arthritis—about 85 percent—develop psoriasis first. "It can be up to 10 years before you get the arthritis," Friedman says. Sometimes, it's the other way around. "I'm often the one who may see them first with swollen joints and they didn't realize they had mild psoriasis," Friedman explains.
No one knows why some people with psoriasis develop psoriatic arthritis and others don't. "But there's no question that it's all one disease," according to Friedman. "The same white blood cells that are attacking the skin are also attacking the joints."
Treating the pain
Dermatologists are quite vigilant when they hear any of their psoriasis patients complain about joint pain or foot pain or vision problems, as they should be, and refer them to rheumatologists for treatment, if necessary, Friedman says. "It's not always obvious that they have the arthritis, but it's important to see a rheumatologist for a diagnosis because if it's allowed to progress, psoriatic arthritis can be crippling. And if you have joint destruction, you can't go back and fix it."
Treatment for psoriatic arthritis, like treatment for psoriasis, depends on the symptoms and severity of your disease and what medications you may already be taking.
Treatment might begin in a similar way as for rheumatoid arthritis, Friedman says. "If it's mild enough, you might get away with nonsteroidal anti-inflammatory drugs (NSAIDs)—such as ibuprofen or naproxen—that are available over-the-counter and in prescription strength."
Others with psoriatic arthritis may do well using a class of medications called disease-modifying anti-rheumatic drugs (DMARDs), which relieve pain by modifying the immune system to slow the progression of the disease. One of the best of these is methotrexate, Friedman says, noting that up to 40 percent of all psoriatic arthritis patients find that it relieves both their psoriasis and their joint pain.
Patients with severe psoriasis and severe psoriatic arthritis may be treated with biologic agents such as Enbrel, Humira or Remicade, which also are DMARDs. These drugs decrease inflammation and reduce pain by blocking molecules (called TNF antagonists) that cause the inflammation associated with psoriatic disease.
"You have to walk a fine balance with these drugs to get the effect that you want," Friedman cautions. "You want to weaken the immune system enough to control the skin disease and the arthritis, but still be able to fight off infections."
Exercise, diet for pain relief
A pain management specialist might suggest narcotics such as morphine or its relatives for people whose arthritis is crippling and whose pain is debilitating, but, says Friedman, "the best way to control the pain is to control the inflammation."
Dr. Heather Tick, clinical associate professor of family medicine as well as anesthesiology and pain medicine at the University of Washington in Seattle, recommends low-impact exercise and an anti-inflammatory diet to help manage the pain of psoriatic arthritis.
Exercise releases endorphins, "and those are natural painkillers," Tick says. Exercise also helps lubricate your joints and strengthen your muscles, she adds, "and when your muscles are strong, your joints are protected."
Some people with psoriatic arthritis—and other conditions as well—find relief with an anti-inflammatory diet, a diet low in sugar, refined flours and carbohydrates, and high in fruits, vegetables and fish. Fatty fish such as salmon and mackerel are high in omega-3 fatty acids, which have been shown to reduce inflammation.
Some people also find relief by eliminating foods such as dairy and/or gluten (a protein found in wheat, barley and rye) that can adversely affect their immune system, she says.
Tracy Ottina finds that staying away from a lot of processed foods and keeping her weight down seem to help. But her best advice, she says, "is to be active when you can and listen to your body and rest when necessary." The key, she adds, is not ignoring the condition. "There's a fine line between coping with it and not succumbing to it."
Megan Hutchinson, 34, of Mansfield, Texas, has had psoriasis since she was 8 and psoriatic arthritis since she was 16. She's not sure which is worse: the itchy skin when her psoriasis flares or the pain in her knees and ankles when her psoriatic arthritis flares.
Hutchinson has tried all the standard treatments—drugs, diet, exercise—with limited success. "As long as I keep moving, that does help some," she says. "But it's hard to stay active with my psoriasis, which goes from the very tip of my head to the soles of my feet."
When Hutchinson was out of options, she enrolled in drug trials, which seemed to help both conditions. But she had to stop taking the latest drug she tried when the Food and Drug Administration pulled it from the market. She's hoping to start on a new drug soon and praying that it will work as well as some of the others have.