Psoriasis arthropathica L40.50

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 05.03.2021

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Synonym(s)

psoriatic arthritis; Psoriatic arthritis; Psoriatic Arthritis; psoriatic arthritis (e)

Definition
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Psoriatic form of chronic rheumatoid factor negative polyarthritic syndrome with DIP and PIP on hands and feet. Psoriatic arthritis is a destructive arthritis in 25% of cases and causes permanent disability. The arthritis can precede the skin symptoms by years and vice versa (see also psoriatic arthritis)

Occurrence/Epidemiology
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  • Psoriasis in the population: 1-3
  • Arthritis psoriatica in patients with psoriasis: 5-15%.
  • Arthritis psoriatica in the whole population: 0,1-0,2%
  • Men and women fall ill equally frequently.

Etiopathogenesis
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Associations with the HLA genes CW6, B13, B17, B27, DR7 are known. The probability of contracting the disease is 50 times higher for first-degree relatives. It is also possible that bacteria (streptococci) are responsible for the development.

Manifestation
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Localization
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Frequently infestation of the knee joint, then finger, ankle and toe joints; so-called "transverse infestation": Inclusion of the finger end joints as well as the toe joints or "infestation in the beam": Basic, middle and end joints affected (so-called dactylitis) with swelling of a finger or toe.

Clinical features
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5 courses of the disease are known:
  • Preferential involvement of the finger end joints and nail changes
  • Severe deformity with ossifications/articular stiffness and joint changes leading to mutilation.
  • Symmetrical infestation of several joints (comparable to rheumatoid arthritis without rheumatoid factors)
  • Infestation of one or less joints in the course of psoriasis (see below psoriasis vulgaris).
  • Psoriatic arthritis with spinal manifestation.

Laboratory
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Uric acid (strong increase of uric acid is said to correlate with a severe course of the disease). Negative rheumatoid factors. 10-15% of patients with psoriatic arthritis show antibodies against cyclic citrullinated peptides ( CCP-AK). In spinal inflammation mostly pos. HLA-B27.

General therapy
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  • Cooperation with the rheumatologist. Protection of the joints during the attacks, endurance training between the attacks. In addition to movement exercises, movement baths (34 °C) and connective tissue massages, complementary ergotherapy (joint protection, self-help training, functional training).

    Notice! No tablet without physiotherapy!

  • As a decongestant measure during an acute episode, ice packs soothe the swelling, in other cases heat packs with fango or mud. In addition, short wave treatment, interference current treatment or ultrasound. Helpful are vitamin E in a dosage of 400-800 mg/day, additionally selenium and zinc substitution. The intake of eicosanoids, e.g. omega-3 fatty acids (Epamax), has proved extremely effective.

    Remember! The drugs do not heal, but enable the patient to live with his or her disease as free of symptoms as possible!

External therapy
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  • Non-steroidal anti-inflammatory drugs in ointment or gel base (e.g. Target Gel, Voltaren Emulgel).
  • Glucocorticoids: Intra-articular glucocorticoid injections such as triamcinolone crystal suspension (e.g. Lederlon) under the usual aseptic conditions. For finger and toe joints, 1.5-3 mg intra-articularly, hand and ankle joints 10-20 mg intra-articularly are sufficient. Infiltration of the peritendinous tissue and painful tendon attachments.

Internal therapy
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Step-by-step therapy see below. Tab. 2 "Stepwise therapy for psoriasis arthropathica".

  • Non-steroidal anti-inflammatory drugs: Indometacin (e.g. Amuno) 100-150 mg/day, diclofenac (e.g. Voltaren Drg.) 100-200 mg/day or ibuprofen (e.g. ibuprofen Klinge Drg.) 800-1200 mg/day p.o. Therapy to be used as needed or regularly.
  • Glucocorticoid shock therapy: For intermittent relapse activity, glucocorticoid shock with prednisone equivalent (e.g. Decortin) 40 mg/day p.o., reduce by 5 mg every 3 days. Caveat. Gastric protection with e.g. Riopan gel.

Reminder. Every moderately severe or severe, clinically active psoriatic arthritis requires a basic therapy!

  • Methotrexate: In severe cases methotrexate (e.g. Lantarel tbl.) 10-20 mg/week p.o. or i.m. (total dose max. 1.5 mg/week). (total dose max. 1.5 g!).
  • Fumaric acid esters: Alternative trial with fumarates 1000-1200 mg/day p.o. (e.g. Fumaderm), gradual dosage. Improvement of symptoms after about 2-3 months.
  • Combination therapy: The combination of MTX and fumarates has proven to be effective, especially in acute relapses. After about 3-4 months, after the acute attack has subsided, MTX can be discontinued and the Fumaderm therapy is continued. Close laboratory monitoring is a matter of course.

In case of a refractory relapse, "pulse therapy" with high-dose glucocorticoids i.v. such as prednisolone (e.g. Solu Decortin H) 500-1000 mg/day on 3 consecutive days.

Notice. Glucocorticoids are not successful in all cases!

  • Basic therapy: Peroral gold therapy (e.g. Auranofin) 6 mg/day p.o. If there is no improvement after 4-6 months, the dose may be increased to 9 mg/day p.o.
    Alternative: Sulfasalazine (e.g. Azulfidine): Initial 500 mg/day p.o., weekly increase by 500 mg up to max. 2-3 times 1000 mg/day.
  • Ciclosporin A (Sandimmun): Very effective and indicated in severe forms (dosage: 2.5 mg/kg bw/day p.o.).
  • Etanercept (e.g. Enbrel): In refractory cases.
  • Leflunomide (e.g. Arava): initially 100 mg/day for 3 days, then 20 mg/day. Comparable results exist with sulfasalazine with regard to efficacy and safety (TOPAS study). Therapeutic effect is expected after 4-6 weeks.
  • Golimumab (Simponi): 1 time/month 50 mg s.c. (on the same day of each month), if necessary in combination with the individually required dose of MTX.
  • Upadacitinib is a selective and reversible JAK inhibitor. In human cell-based assays, upadacitinib preferentially inhibits JAK1 or JAK1/3 signaling pathways compared to other cytokine signaling pathways mediated via JAK2. Dosage 15 mg alternatively 30 mg/day.

Notice. Basic therapy must be avoided in pregnancy and infertility. Anticonception is indicated with all basic therapeutics, with cytotoxic substances also in men.

Operative therapie
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Recurrent joint effusions may require synovectomy, tendon or arthroplasty.

Naturopathy
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Order therapy:

Lactovegetable diet: Naturopathically, the adherence to a lactovegetable diet with avoidance of animal meat and eggs (max. 2 portions / week) is recommended. Additionally polyunsaturated fatty acids, here e.g. in capsule form (e.g. Epamax®).

Excessive joint stress should be avoided in the stage of acute inflammation.

Phytotherapy:

Harpagophyti radix: Psoriatic arthritis can be treated supportively with African devil's claw root(Harpagophyti radix), commercially available as e.g. Rivoltan®, Doloteffin®. Harpagophyti radix has anti-inflammatory and weak analgesic effects. A positive evaluation of the Commission E/ESCOP with assured effect in degenerative diseases of the musculoskeletal system, supportive in pain in the lumbar spine, digestive complaints and loss of appetite, is available. Side effect: Stimulates appetite and digestion.

Aternative: Salicis cortex, the willow bark, can also be used in a supportive way. Willow bark was already included in the German Pharmacopoeia (DAB 10) in 1991, confirmed in 1997 by the monograph of Commission E and ESCOP. The daily dose was increased to 240 mg (ESCOP monograph, 1997).

Supplementary: Frankincense resin, Boswella serrata H15 (see frankincense below), has anti-inflammatory effects by inhibiting the enzyme 5-lipoxygenase, which induces leukotriene synthesis. It is effective in diseases with elevated leukotriene levels such as bronchial asthma, rhinitis allergica, rheumatoid arthritis, lupus erythematosus, psoriasis, ulcerative colitis, Crohn's disease, multiple sclerosis.

A dosage of 2 x 450 mg is recommended.

Therapy with frankincense can be combined with the therapy of biologics with insufficient effect on arthritis.

Tables
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Forms of psoriatic arthritis (according to Moll and Wright)

Clinical forms

Frequency of manifestation (%)

DIP and PIP-infection like Heberden- and Bouchard-Polyarthrosis

6

Deforming mutant polyarthritis

5

Symmetrical polyarthritis

25

Asymmetric Oligoarthritis

Arthritis with axial skeletal involvement such as sacroiliitis, spondylitis, HLA-B27

20


Step-by-step therapy for psoriasis arthropathica

Level

Therapeutic measures

I

Physiotherapeutic measures

Nonsteroidal anti-inflammatory drugs

Glucocorticoid injections intra-articular

II

Like level I, plus basic therapeutic agents such as sulfasalazine or gold

Alternative: Fumaric acid

Intermittent systemic glucocorticoid shock

III

As stage I, but also methotrexate

IV

Ciclosporin as Ultima ratio

Diet/life habits
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Omission of animal protein in the sense of a lactovegetable diet. Meat, fish or eggs should be eaten a maximum of 2 times a week. Unsaturated fatty acids appear to relieve joint pain, itching, redness and scaling in milder forms.

Note(s)
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Tumor necrosis factor-α inhibitors ( Infliximab, Etanercept) are used for the treatment of psoriatic arthritis. The occurrence of psoriasiform or eczema-like skin changes of unclear etiology under therapy with these inhibitors has been described. This was investigated in a study with 8 volunteers. The authors postulate that the psoriasiform skin changes are rather to be interpreted as drug reactions and are not causally induced by psoriasis.

Literature
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  1. Manger B (2002) Kommission Pharmkotherapie, Deutsche Gesellschaft für Rheumatologie. Revised recommendations of the Deutsche Gesellschaft fur Rheumatologie on therapy with tumor necrosis factor-inhibiting active substances on inflammatory diseases. Z Rheumatol 61: 694-697
  2. Davison SC et al (2002) Etanercept for severe psoriasis and psoriatic arthritis: observations on combination therapy. Br J Dermatol 147: 831-832
  3. Davidson A, Diamond B (2001) Autoimmune diseases. N Engl J Med 345: 340-350
  4. Galadari H et al (2003) Newly available treatments for psoriatic arthritis and their impact on skin psoriasis. Int J Dermatol 42: 231-237
  5. Mease P (2002) Psoriatic arthritis: the role of TNF inhibition and the effect of its inhibition with etanercept. Clin Exp Rheumatol 20: S116-121
  6. Mease P (2006) Current treatment for psoriatic arthritis and other spondyloarthritides. Rheum Dis Clin North Am 32: 11-20
  7. Sarzi-Puttini P et al (2002) Long-term safety and efficacy of low-dose cyclosporin A in severe psoriatic arthritis. Rheumatol Int 21: 234-238
  8. Schopf RE et al (2002) Treatment of psoriasis with the chimeric monoclonal antibody against tumor necrosis factor alpha, infliximab. J Am Acad Dermatol 46: 886-891
  9. Seneschal J et al. (2007) Psoriasiform drug eruptions under anti-TNF treatment of arthritis are not true psoriasis. Acta Derm Venereol 87: 77-80

  10. Smolen JS et al (2019) Upadacitinib as monotherapy in patients with active rheumatoid arthritis and inadequate response to methotrexate (SELECT-MONOTHERAPY): a randomised, placebo-controlled, double-blind phase 3 study. Lancet 393:2303-2311.

  11. Zachariae H (2003) Prevalence of joint disease in patients with psoriasis: implications for therapy. Am J Clin Dermatol 4: 441-447.

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Last updated on: 05.03.2021