A positive approach

to psoriasis and

psoriatic arthritis

Psoriatic Arthritis:

When to Treat

What are the aims of this leaflet?This leaflet has been written to help you understandmore about who is involved in the ongoing monitoringand treatment of your psoriatic arthritis, includingoptions, decisions, planning and assessments.

About psoriasis and psoriaticarthritisPsoriasis (sor-i’ah-sis) is a long-term (chronic) scalingdisease of the skin, which affects about 3% of the UKpopulation. It usually appears as red, raised, scalypatches known as plaques. Any part of the skin surfacemay be involved but the plaquesmost commonly appear onthe elbows, knees ands ca l p . L i v i n g w i t hpsoriasis and psoriatica r t h r i t i s c a n b echallenging, stressfuland even distressing.T h i s c a n h a v e anegative psychologicalimpact on an individual’s life.See our Psychological Aspects ofPsoriasis leaflet for more information.

Up to 30% of people with psoriasis may develop anassociated psoriatic arthritis, which causes pain andswelling in the joints and tendons, accompanied bystiffness, particularly in the mornings.

The most commonly affected sites are the hands, feet,lower back, neck and knees, with movement in theseareas becoming severely limited. For more detailedinformation on psoriasis and psoriatic arthritis see ourleaflets What is Psoriasis? and What is PsoriaticArthritis?

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Who is involved in treatingpsoriatic arthritis?

After receiving a diagnosis of psoriatic arthritis the nextstep is to decide what sort of treatment would be bestfor you. This process will involve discussion with a teamof healthcare professionals involved in your care. Thisteam is usually, but not always, led by your doctor (GP)or a rheumatologist and may include:

l a dermatologist

l a physiotherapist

l a specialist nurse

l an occupational therapist

l a podiatrist

l a psychologist.

Planning your treatment should be a two-way processbetween you and your team to ensure you receive thetreatment that is right for you.

Planning to treatPsoriatic arthritis can be highly variable and differentpeople may be affected in different ways, such as thenumber of joints or tendons affected. The best treatmentfor you may therefore be very different to the besttreatment for someone else. Not only does the patternof arthritis vary but it also waxesand wanes with episodes off lare (act ive arthr i t is )which will then settle of their own accord(remission).Some people with

mild disease may needminimal or even notreatment at all and peoplewith severe disease may need

stronger and even combinations of treatments. Drugtreatments prevent damage to joints but cannot repairthose already damaged, so the earlier treatment isreceived the better for people with severe arthritis.Your specialist will assess your prognosis (how your

arthritis may progress and how severely you will beaffected) to identify if you may have a more severe formof psoriatic arthritis and so benefit from early treatment.This is not always obvious in the first year or two of thedisease and since many individuals with psoriaticarthritis will only be mildly affected, simple and localtreatment and the use of the safest drugs possible maybe all that is recommended. If your arthritis doesprogress there are now a number of different drugtreatments available.

Assessment

The first steps in deciding when to treat and whichtreatment is best for you will be taken when yourspecialists have assessed your condition. The membersof your team will examine your joints to see how they areaffected; you may also have x-rays and blood tests aspart of this assessment. With this information your teamwill be able to make a prognosis. Damage to your jointsvisible on x-rays or high inflammation markers on yourblood tests can indicate a greater likelihood of damagein the future and so you may benefit from moretreatment. Psoriatic arthritis is very variable; a smallnumber of people (5%) have a very severe form but themajority have milder patterns. There has been a lot ofwork carried out recently on the genetic predispositionof psoriatic arthritis, but doctors are not yet in a positionto use genetic tests to make treatment decisions.

Treatment options

There are a wide range of treatment options available.These are generally ranked by potential side effects

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(a non-intentional effect that can occur from atreatment). Treatment is considered in a stepwisefashion. This allows people to climb this escalation oftreatment in a way that means starting with the leastintrusive therapy that might control their disease (andsymptoms) with the minimum risk of unwanted sideeffects and may include:

Non-drug therapy:

l physiotherapy (restore movement and function)

l occupational therapy (rehabilitation andadaptation)

l podiatry (foot, ankle and lower limb)

l orthotics (devices)

l complementary therapies (pilates, yoga,hydrotherapy etc).

Medical therapy:

l analgesics (painkillers such as paracetamol)

l non-steroidal anti-inflammatory drugs (NSAIDS)

l steroids

l disease modifying anti-rheumatic drugs(DMARDS)

l biologic drugs

l non biologic drugs.

Surgical therapy:

l operations such as joint replacement(arthroplasty).

Treatment considerations

Treatment has two main goals: first to prevent flare upsand to improve your symptoms, such as reducing pain,stiffness and fatigue; and second to prevent damage toyour joints. Treatments such as physiotherapy, exerciseand education about psoriatic arthritis are likely tobenefit almost everybody with the condition, though

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research in th is area is very limited. Importantly,because these are notdrug treatments they donot have the samepo t e n t i a l f o r s i d eeffects.

Drugs used to treat anydisease carry the possibilityof side effects, some of themmild but some may be serious. The treatments used forrheumatic diseases are no exception. Even a milder drugthat is available without prescription, such as aspirin oribuprofen, can cause indigestion and/or gastrointestinalbleeding (such as stomach ulcers). The more powerfulanti-inflammatory drugs, which are only available onprescription, also have a risk of side effects, particularlystomach ulcers.

Other drugs may have to be given alongside, to try toprevent these side effects. Your team will therefore tryto find a balance in your therapy to give you the mildesttreatment, with the fewest potential side effects, that willcompletely control your symptoms and disease.

The newer drugs, such as biologics, have andhopefully will continue to revolutionise the treatment ofrheumatic diseases, including psoriatic arthritis, enablingmany patients to lead a normal and relatively pain-freelife. These more powerful drugs are not curative but maysuppress the disease to a significant degree, forexample preventing flares from occurring and preventingor delaying long-term damage to the joints. Their sideeffects have the potential of being more severe and caninclude damage to the bone marrow, kidneys, liver andskin. Biologic drugs therefore should only be prescribedafter discussion between patient and doctor so that therisks, benefits and possible impacts are fullyunderstood. For further information on treatments seeour Treatments for Psoriasis: An overview leaflet and

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our Treatments for Psoriatic Arthritis: An overviewleaflet. For information about physiotherapy andexercise see our Physiotherapy & Exercise: PsoriaticArthritis leaflet.

A partnership

Deciding which treatment is right for someone withpsoriatic arthritis is not just a specialist’s decision basedon which treatment is best. Treatment needs to betailored to each individual person and will be a balanceof what therapy is most likely to improve the symptomsand disease and what each person’s thresholds are fortaking medication and the risks of potential side effects.This will be different for each person with psoriaticarthritis, but the right decision will be possible throughactive discussion with the team looking after theindividual.People with psoriat ic

a r t h r i t i s s hou l d b ep r e p a r e d t o a s kquestions of their teamduring consultationsand should equally be prepared to takedecisions as to whetherthey will or will not accepttreatment for their condition.

Reviewing treatments

Whatever treatment is decided on, it should be reviewedon a regular basis. How often you need to be revieweddepends on the treatment you have been given andshould be discussed with your doctor. At your reviewsyour team will discuss your symptoms with you,examine your joints and may ask for blood tests or x-rays to reassess your condition. In this way the team can

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check the treatment is working and does not need to bechanged.

Can I get financial support?

Many people worry about what happens if they cannotwork or need financial help because of the effects ofpsoriatic arthritis. Fortunately for many, with goodtherapy and management the condition can becontrolled and allow for a full and active working life. Butif you do find that even for a short period of time you arelikely to need help, visit the national governmentwebsites online. If it is easier, contact your localgovernment or council office, where you should bedirected to the appropriate resource and information.

Useful contacts

For information about health matters in general and howto access services in the UK, the following websitesprovide national and local information.

l NHS Choices (England): www.nhs.uk

l NHS 24 (Scotland): www.nhs24.com

l Health in Wales: www.wales.nhs.uk

l HSCNI Services (Northern Ireland):http://online.hscni.net

These sites are the official sites for the National HealthService and provide links and signposting services torecognised organisations and charities.

References:n Gelfand JM, Weinstein R, Porter SB, Neimann AL,Berlin JA and Margolis DJ. Prevalence and treatmentof psoriasis in the United Kingdom: a population-based study. Arch Dermatol. 2005; 141: 1537-41

n Ritchlin CT, Kavanaugh A, Gladman DD, et al.Treatment recommendations for psoriatic arthritis. AnnRheum Dis. 2009; 68: 1387-94.

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n Coates LC, Kavanaugh A, Mease PJ, Soriano ER,Laura Acosta-Felquer M, Armstrong AW, Bautista-Molano W, Boehncke WH, Campbell W, Cauli A,Espinoza LR, FitzGerald O, Gladman DD, Gottlieb A,Helliwell PS, Husni ME, Love TJ, Lubrano E, McHughN, Nash P, Ogdie A, Orbai AM, Parkinson A, O'SullivanD, Rosen CF, Schwartzman S, Siegel EL, Toloza S,Tuong W, Ritchlin CT.Group for Research andAssessment of Psoriasis and Psoriatic Arthritis 2015Treatment Recommendat ions for Psor iat icArthritis.Arthritis Rheumatol. 2016 May;68(5):1060-71.

n Gladman DD, Antoni C, Mease P, Clegg DO and NashP. Psoriatic arthritis: epidemiology, clinical features,course, and outcome. Ann Rheum Dis. 2005; 64 Suppl 2: ii14-7.

n Ash Z, Gaujoux-Viala C, Gossec L, et al. A systematicliterature review of drug therapies for the treatment ofpsoriatic arthritis: current evidence and meta-analysisinforming the EULAR recommendations for themanagement of psoriatic arthritis. Ann Rheum Dis.2011.

n Ramiro S, Smolen JS, Landewé R, van der Heijde D,Dougados M, Emery P, de Wit M, Cutolo M, Oliver S,Gossec L.Pharmacological treatment of psoriaticarthritis: a systematic literature review for the 2015update of the EULAR recommendations for themanagement of psoriatic arthritis.Ann Rheum Dis.2016 Mar;75(3):490-8.

n Gossec L, Smolen JS, Gaujoux-Viala C, et al.E u r o p e a n L e a g u e A g a i n s t R h e um a t i s mrecommendations for the management of psoriaticarthritis with pharmacological therapies. Ann RheumDis. 2011; 71: 4-12.

n Gossec L, Smolen JS, Ramiro S, de Wit M, Cutolo M,Dougados M, Emery P, Landewé R, Oliver S, AletahaD, Betteridge N, Braun J, Burmester G, Cañete JD, Damjanov N, FitzGerald O, Haglund E, Helliwell P,Kvien TK, Lor ies R, Luger T, Maccarone M,

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Marzo-Ortega H, McGonagle D, McInnes IB, Olivieri I,Pavelka K, Schett G, Sieper J, van den Bosch F, VealeDJ, Wollenhaupt J, Zink A, van der Heijde D.EuropeanLeague Aga i n s t Rheuma t i sm ( EULAR )recommendations for the management of psoriaticarthritis with pharmacological therapies: 2015update.Ann Rheum Dis. 2016 Mar;75(3):499-510.

n Kyle S, Chandler D, Griffiths CE, et al. Guideline foranti- TNF-alpha therapy in psoriatic arthritis.Rheumatology (Oxford). 2005; 44: 390-7.

n Coates LC, Tillett W, Chandler D, Helliwell PS,Korendowych E, Kyle S, McInnes IB, Oliver S,Ormerod A, Smith C, Symmons D, Waldron N,McHugh NJ; BSR Clinical Affairs Committee &Standards, Audit and Guidelines Working Group andthe BHPR.The 2012 BSR and BHPR guideline for t h e t r e a tmen t o f p s o r i a t i c a r t h r i t i s w i t hbiologics. Rheumatology (Oxford). 2013 Oct;52(10):1754-7.

n Zangger P, Gladman DD, Urowitz MB and Bogoch ER.Outcome of total hip replacement for avascularnecros is in systemic lupus erythematosus. J Rheumatol. 2000; 27: 919-3.

n Ng SC and Chan FK. NSAID-induced gastrointestinaland cardiovascular in jury. Current opinion ingastroenterology. 2010; 26: 611-7.

Further references used in the production of PAPAAinformation can be found at www.papaa.org/resources/references.

About this information

This material was produced by PAPAA. Please be awarethat research and development of treatments is ongoing.For the latest information or any amendments to thismaterial, please contact us or visit our website. The sitecontains information on treatments and includes patientexperiences and case histories.

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Dr William Tillett, consultant rheumatologist, RoyalNational Hospital for Rheumatic Diseases, Bath, fullyreviewed and revised this leaflet in 2012.

A peer review has been carried out by Dr PhilipHelliwell, Leeds Institute of Rheumatic andMusculoskeletal Medicine, University of Leeds, in April2014, June 2016 and March 2018.

A lay review panel has provided key feedback on thisleaflet. The panel includes people with or affected bypsoriasis and/or psoriatic arthritis.

Published: April 2018

Review Date: Sept 2020

© PAPAA

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The charity for people

with psoriasis and

psoriatic arthritis

PAPAA is independently funded and is a principal source of information and educationalmaterial for people with psoriasis and psoriatic

arthritis in the UK.

PAPAA supports both patients and professionals by providing material that can be trusted

(evidence-based), which has been approved and contains no bias or agendas.

PAPAA provides positive advice that enablespeople to be involved, as they move through their healthcare journey, in an informed way which is appropriate for their needs and any

changing circumstances.

Contact: PAPAA

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