Psoriatic Arthritis Treatment

Treatment of PsA is variable, depending on the clinical manifestation.  There is no consensus on specific treatment of PsA, but the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has published recently guidelines for the treatment of the different manifestations of PsA based on literature review and expert consensus.

For mild peripheral arthritis, non-steroidal anti-inflammatory drugs (NSAIDs) and/or intra-articular corticosteroids may be used.  Injections of joints covered by psoriatic plaques should be performed with caution due to the abundance of bacteria usually discovered on the skin lesions.

For moderate-to-severe disease, disease-modifying antirheumatic drugs (DMARDs) and/or TNF inhibitors should be considered.

The following DMARDs may be used:

  • Methotrexate is effective for both the cutaneous and peripheral articular manifestations of psoriasis. It is generally the DMARD of first choice, given its efficacy, safety, and tolerability profile.
  • Leflunomide is effective for both the cutaneous and peripheral arthritis of psoriasis.  Like methotrexate, it has potential liver toxicity and patients need to have liver enzymes monitored periodically.
  • Sulfasalazine may benefit the peripheral arthritis, but has no significant impact upon the activity of cutaneous disease.
  • Cyclosporin Amay 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®, 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.

References

  1. Willkens RF, Williams HJ, Ward JR, et al: Randomized, double blind, placebo-controlled trial of low dose pulse methotrexate in psoriatic arthritis. Arthritis Rheum 27:376, 1984.
  2. Espinoza LR, Zakraoni L, Espinoza CG, et al: Psoriatic arthritis: Clinical response and side effects of methotrexate therapy. J Rheumatol 19:872, 1992.
  3. Gupta AK, Matteson EI, Ellis CN, et al: Cyclosporin in the treatment of psoriatic arthritis. Arch Dematol 125:507, 1989.
  4. Salvarani C, Macchioni P, Olivieri I, et al: A comparison of cyclosporine, sulfasalazine, and symptomatic therapy in the treatment of psoriatic arthritis. J Rheumatol 28:2274, 2001.
  5. Sarzi-Puttini P, Cazzola M, Panni B, et al: Long-term safety and efficacy of low-dose cyclosporin A in severe psoriatic arthritis. Rheumatol Int 21:234, 2002.
  6. Mease PJ: Etanercept in the treatment of psoriatic arthritis and psoriasis: a randomized trial. Lancet 356:385, 2000.
  7. Mease PJ: Cytokine blockers in psoriatic arthritis. Ann Rheum Dis 60:iii37, 2001.
  8. Iyer S, Yamauchi P, Lowe NJ: Etanercept for severe psoriasis and psoriatic arthritis: observations on combination therapy. Br J Dermatol 146:118, 2002.
  9. Cauza R, Spak M, Cauza K, Hanusch-Enserer U, Dunky A, Wagner E. Treatment of psoriatic arthritis and psoriasis vulgaris with the tumor necrosis factor inhibitor infliximab. Rheumatol Int 22(6):227, 2002.
  10. Antoni C, Dechant C, Hannis-Martin Lorenz PD, Wendler J, Ogilvie A, Lueftl M, Kalden-Nemeth D, Kalden JR, Manger B. Open-label study of infliximab treatment for psoriatic arthritis: clinical and magnetic resonance imaging measurements of reduction of inflammation. Arthritis Rheum 47(5):506, 2002.
  11. Mease PJ, Gladman DD, Ritchlin CT, Ruderman EM, Steinfeld SD, Choy EH, Sharp JT, Ory PA, Perdok RJ, Weinberg MA; Adalimumab Effectiveness in Psoriatic Arthritis Trial Study Group.Arthritis Rheum. Adalimumab for the treatment of patients with moderately to severely active psoriatic arthritis: results of a double-blind, randomized, placebo-controlled trial. Arthritis Rheum 52(10):3279-89, 2005.

*Images within this article are from the American College of Rheumatology Slide Collection.

Updated: October 3, 2012

Grant Louie, M.D., M.H.S.

About Grant Louie, M.D., M.H.S.

Assistant Professor of Medicine
Johns Hopkins University