A positive approach

to psoriasis and

psoriatic arthritis

Treatments forPsoriatic Arthritis:

An overview

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What are the aims of this leafletThis leaflet has been written to help you understand thetreatments currently available to treat psoriatic arthritis.The material is not designed as a replacement for yourdoctor’s advice and we are not recommending any singletreatment in preference to any other; the best treatmentschedule is the one which you and your doctor haveagreed is most suitable for your particular situation. Youmay wish to keep this leaflet for future reference andreread if your treatments change over time.

About psoriasis and psoriaticarthritisPsoriasis (sor-i’ah-sis) is a long-term (chronic) scalingdisease of the skin, which affects around 2% of the UKpopulation. It usually appears as red, raised, scalypatches known as plaques. Any part of the skin surfacemay be involved but plaques mostcommonly appear on theelbows, knees and scalp.A r o u n d 3 0% o f

people with psoriasismay deve lop anassociated psoriatica r t h r i t i s , w h i c hc a u s e s p a i n ,inflammation ands w e l l i n g i n t h e joints and tendons,a c c om p a n i e d b ystiffness, particularly inthe mornings.

What happens in psoriaticarthritis?In psoriatic arthritis and some inflammatory diseases, theimmune system doesn't work properly and this may causeinflammation to trigger damage by working against thebody's own tissues. In psoriatic arthritis, inflammation ischaracterised by redness, warmth, swelling and pain.Inflammation is a process by which the body's inner

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defence mechanisms, the white blood cells and othersubstances, protect the body against infection and foreigninvaders such as bacteria and viruses.The most commonly affected sites in psoriatic arthritis

are the hands, feet, lower back, neck and knees, withmovement in these areas becoming severely limited.Some people complain of other symptoms, which inthemselves are less easy to diagnose as psoriatic arthritis,such as fatigue, tiredness and exhaustion. People withpsoriatic arthritis will also often have nail psoriasis, withlittle or no involvement of the skin elsewhere.For more detailed information on psoriasis and psoriatic

arthritis, see our leaflets What is Psoriasis? and What is

Psoriatic Arthritis?

Although there are no cures for psoriatic arthritis, it canbe controlled and go into remission. Not everyone will beaffected in the same way and doctors will class thecondition as mild, moderate or severe. The types oftreatments offered can vary from mild drug therapies tophysical therapies and surgery.

Please note: The treatments are listed alphabetically and

not in any order of use or preference. The list is for

reference only and you should always follow your

healthcare provider's advice.

BiologicsBiologic agents are relatively new in the field of psoriaticarthritis management. They are made from biological(human or animal-based) proteins rather than artificialchemicals, much in the way that insulin was made fromanimal sources in the past.Biologic agents are different from other psoriatic arthritis

medications as they are designed specifically to blockparticular parts of the immune system that causeinflammation. This is different to some older disease-modifying drugs, like methotrexate, which generallysuppress the immune system, or anti-inflammatories,which treat the symptoms of the disease.It is thought that overactive cells in the immune system

set off a series of events in the body, eventually causingpsoriatic arthritis to develop in the joints and connectivetissue.Biologic agents work by blocking the action of specific

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immune messengers or targeting particular cells of theimmune system. These messengers cause inflammationin certain cells by triggering the immune system. The mostcommonly used biologic drugs in psoriatic arthritis aredrugs that block a messenger called TNF (tumournecrosis factor). Alternatively, biologic drugs can blockthe activation of certain immune cells (often T cells inpsoriatic arthritis) or the release of other messengers(called interleukin 12/23 or interleukin 17) from them. Thebiologic drugs act by copying the effects of substancesnaturally made by the immune system. The choice ofwhich biologic drug to use will depend on the severity ofyour joint and skin disease and any other medicalproblems which you have.In the UK they are not considered first-line therapy.

There are recommendations from the National Institute forHealth and Care Excellence (NICE), the ScottishMedicines Consortium (SMC) and the All Wales MedicinesStrategy Group (AWMSG) which define who can accessthese treatments. Usually they are only available topatients who do not respond to systemic therapies suchas methotrexate.Biologic agents are given by injection or infusion and

usually work quickly to relieve the symptoms and swellingassociated with psoriatic arthritis. Although studies showthat most people will improve within four to six weeks oftreatment, a majority will notice some improvement afterthe first or second injection or infusion. Some people,however, can take the full 12 weeks to notice a response.The most common side effects seen with injected

medicines include skin reactions at the injection site.These occur in fewer than 30% of people and may lastfor up to two weeks. The most significant side effect ofthese medications is an increase inthe risk of all types of infections,including tuberculosis (TB).Before starting an anti-TNF(tumour necrosis factor)medication, your risk of TBis assessed and a TB skinor blood test is often carriedout. The British ThoracicSociety (BTS) guidelines statethat Caucasian patients who areUK-born should not be tested, as

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the risk involved with TB prophylaxis (measures designedto preserve health) is higher than the risk of TB. Treatmentwith these agents should be stopped while you have anactive infection and are taking an antibiotic, or if you havea high fever. People with significant congestive heartfailure should not take anti-TNF agents.

CorticosteroidsCorticosteroids are synthetic drugs that closely resemblecortisol, a hormone which the body produces naturally.They work by reducing inflammation and the activity ofthe immune system. They are used to treat a variety ofinflammatory diseases and conditions.Steroids reduce the production of inflammatory

chemicals to help minimise tissue damage. They alsoreduce the activity of the immune system by affecting thefunction of white blood cells.Examples of corticosteroid medications include

cortisone, prednisolone and methylprednisolone.However, they should not be confused with anabolicsteroids, which are a different group of drugs used bysome athletes and weight lifters to build bigger muscles.Steroids can be given orally or by injection. Depending onthe site of the inflammation, they can be injected into avein or muscle, directly into a joint or bursa (the lubricatingsac between certain tendons and the bones beneaththem) or around tendons and other soft tissue areas. In low doses, steroid tablets may provide significant

relief from pain and stiffness for people with psoriaticarthritis. Temporary use of higher doses of steroids mayhelp a person recover from a severe flare-up of thecondition.Steroid injections can be added to other interventions,

including anti-inflammatory painkiller medications andphysiotherapy. Whether one or more of these treatmentmethods are used depends on the nature of the problem.Steroid injections can be one of the most effective waysto decrease pain and improve function, but they generallydo not cure the illness.Some people might develop side effects, although these

will vary from person to person. If steroid injections areinfrequent (less than every three to four months) it isunlikely that side effects will occur.

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Disease-modifying anti-rheumaticdrugs (DMARDs)If a person has persistent inflammation in several jointsfor longer than six weeks, the doctor might prescribe amedication called a DMARD (pronounced dee-mard).They are usually prescribed in addition to non-steroid anti-inflammatory drugs (NSAIDs), as NSAIDs are designed toreduce the day-to-day inflammation and the DMARDslows down the biological processes which cause thepersistent inflammation.The choice of a specific DMARD will depend upon

the type of inflammatory arthritis.S ome t i m e s f i n d i n g t h eappropriate maintenancedosage can be a matter oft r ia l and error, so theresponse may not be rapid.DMARDs are a diverseclass of medications thata p p r o a c h t h e t a s kof control l ing persistentinflammation through differentpathways, but each has beenproven effective in its own way. The most commonly prescribed are: methotrexate,sulfasalasine, leflunomide, azathioprine, gold therapyhydroxychloroquine, and chloroquine.In psoriatic arthritis there is a risk of significant damage

in the first two to three years before the disease iscontrolled. Doctors are prescribing DMARDs much earlierthan in the past because the benefits of controllingdamaging inflammation far outweigh the risks of reversibleside effects.These medications are routinely monitored by a doctor

in order to minimise those risks. It can take up to severalmonths before a person begins to feel sustained benefits.Speed of relief isn’t the main driver of these medications;it is the medication’s ability to control symptoms and anindividual’s ability to tolerate the medication over a longperiod of time that are important. The goal is to use theleast amount of drug necessary to keep the inflammatoryarthritis under control and, in so doing, reduce anypotential side effects.

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DMARDs come as tablets, capsules and, in somecases, injections; doses can range from once or twicedaily to once a week. A doctor will likely have to adjustthe medication from time to time, depending on theresults seen through regular monitoring.

The greater benefits offered by DMARDs carry anincreased risk of side effects. The vast majority of sideeffects are rare and virtually all are reversible by adjustingthe daily dose or switching DMARDs. Still, some sideeffects are common, such as flu-like symptoms, mouthsores, diarrhoea and nausea.

Mechanical pain relief TENS (Transcutaneous Electrical Nerve Stimulation) is asimple, non-invasive technique by which electricalcurrents, generated by a portable stimulating unitpowered by small, low-voltage batteries, are passedthrough the skin surface via two or four electrodes toactivate underlying nerves. Conductive gel or pre-gelledelectrodes are used to decrease resistance across theskin-electrode connection and the electrodes can beconcealed under clothing if necessary.

TENS produces a tingling sensation (electricalparaesthesia) within the painful area and the intensity andquality of electrical paraesthesia (ie pulse intensity, pulsefrequency and pulse pattern) can be varied and controlledby the patient according to his or her requirements. TENShas been shown to produce useful analgesic effects in alltypes of patients suffering from acute or chronic pain andhas gained worldwide attention and use.

TENS has many advantages over conventionaltreatment for pain. It does not require surgical interventionand, unlike analgesic drugs, has no serious adverseeffects. It can be used long-term and if necessary inconjunction with analgesics. Not every person respondsto TENS treatment, however; the efficacy is approximately60%. The reason for non-response to TENS by the other40% is unknown at this point in time. TENS machines areoften available through the pain management service orfrom physiotherapists and are widely available from largerchemists or pharmacies.

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Non-steroidal anti-inflammatorydrugs (NSAIDs) NSAIDs are commonly prescribed for the treatment ofpsoriatic arthritis and are symptom-modifying drugs. Theyact by reducing inflammation and suppressingprostaglandins. Prostaglandins play a valuable role withinthe body, but also drive the inflammatory process inarthritis. Many well-known products, such as aspirin andibuprofen, are types of NSAIDs and are used for milderdisease. Stronger drugs, only available on prescriptionfrom a doctor, might be offered if the milder treatmentsprovide little or no benefit. It takes time to find the mosteffective treatment and doctors may try various doses andproducts before establishing the optimum regimen.Because prostaglandins also provide other useful

functions, suppressing their action can cause unwantedside effects, particularly on the stomach. Long-term useof NSAIDs has led to some individuals developingstomach ulcers. Some drugs have a special entericcoating that prevents the drug from dissolving in thestomach but allows absorption in the small intestine,which makes it less irritating. For the same reason, astomach-protecting medication might be offered tocounteract this negative outcome or a selective NSAIDthat only targets certain elements of the inflammatoryprocess may be considered.

Occupational therapy andrehabilitationOccupational therapy helps people to manage, to thebest of their ability, all types of dailyactivities and tasks which mayhave been impai red byphysical or mental illness. An occupational therapistw o r k s a s p a r t o f amultidisciplinary team. Theyeither work for the healthservice or for social services.The two services work slightlydifferently but occupationaltherapists are all concerned with

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promoting a person’s independence in everyday tasks togive the best possible quality of life.

To see an occupational therapist you will normally needa referral from a GP or consultant.

When someone has psoriatic arthritis, pain and stiffnessmay make everyday tasks more difficult. Occupationaltherapists aim to reduce the amount of stress placed onthe joints. They will look at how an individual carries outdaily tasks, assessing their physical restrictions as well aslistening to how they are coping emotionally with them.They will then explore new ways to carry out tasks orsuggest equipment which can help lessen stress to thejoints or generally make life easier. For more information,see our Occupational Therapy & Psoriatic Arthritis

leaflet.

Pain managementPain management is offered for both acute and chronicpain. For pain related to psoriatic arthritis, pain relief canbe given by rheumatologists and general practitioners.The main aim is to control the inflammation in the joints,after which the pain should improve. However, it can takesome weeks before some treatments work effectively. Formany patients, this can be managed with psychologicaltechniques, eg meditation, analgesia (painkillers includingparacetamol and non-steroidal anti-inflammatory drugs),TENS (discussed above) and simple solutions like hot orcold packs, splints to support joints and input fromphysiotherapy.

For more complex pain problems, there are about 300pain management clinics in the UK, each run by a team of clinicians, including occupational therapists,psychologists, doctors, nurses and physiotherapists.Treatment is often combined to create a painmanagement programme, which can include groupsessions aimed at teaching individuals how to live withpain by using a variety of techniques in conjunction withtheir drug regimen. Techniques used may includepsychological techniques such as meditation, cognitivebehavioural therapy (CBT) and others. A referral from aGP or hospital specialist is required to see a painmanagement specialist or to join a pain managementprogramme.

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PodiatryPodiatrists and chiropodists specialise in the treatment ofproblems associated with the foot and lower leg, mostcommonly the treatment of minor problems such asverrucas, athlete’s foot and ingrowing toenails. For somepeople with psoriatic arthritis, podiatry can be a veryuseful service, not only for the obvious problemsassociated with nail psoriasis, but in assessing otherproblems associated with arthritis and providing simple solutions. These include orthotic devices or foot appliances such as inserts for shoes, which canhelp foot function, ease pain, improve gait and, mostimportantly, enable walking with reduced discomfort.Podiatrists work in a number of settings and individualscan be referred by a doctor or make appointmentsindependently.

PhysiotherapyPsoriatic arthritis can lead to pain, swelling and stiffnessin joints. You can prevent stiffness in a joint by putting itthrough a full range of movement on a daily basis. Regularexercise can also help maintain strength in the muscles,which makes daily tasks easier and can help you tomaintain good posture. It has also been shown to reducestress and improve mood, maintain bone density andreduce fatigue. So it is important to have an exerciseprogramme you perform on a daily basis to ensure youremain as fit and healthy as possible.

Physiotherapists work both in the NHS and privately.They are experts in the examination and treatment ofmuscles and joints. Some physiotherapists have a specialinterest in conditions like psoriatic arthritis and will workclosely with the local consultant rheumatologist. Your GPor consultant can refer you to see a physiotherapist in theNHS or you can self-refer to a private clinic.

Hydrotherapy is exercise in a warm pool. It is supervisedby a physiotherapist who uses the properties of water tohelp ease stiff joints and strengthen weak muscles. Thisservice is not widely available in all areas of the UK. Formore information, see our Physiotherapy & Exercise:

Psoriatic Arthritis leaflet.

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SurgeryIt has to be remembered that in most cases psoriaticarthritis can be managed with early diagnosis and certaindrug therapies, but unfortunately some individuals mayend up with a joint which has been so badly affected bythe condition that it requiressurgery.Surgery can include very

minor procedures, such asreleasing a trapped nerve orremoving painful linings tojoints. The most commonand radical surgery is toreplace a full joint such as aknee or hip, but other joints,including the joints of the fingers,wrists, elbows, ankles and shoulders,can also be replaced if they are badly damaged.Success rates in joint replacement is variable; function

and pain are the important drivers and hand operations inparticular are difficult to weigh up as function can bemuch worse after surgery and very occasionally thereplacement joint has to be removed. This can lead toconsiderable disability, so risk and benefit must becarefully assessed before these types of procedure areconsidered.

Topical analgesicsTopical analgesics include creams, ointments, gels, rubsand sprays for the treatment of acute musculoskeletalinjuries and mild to moderate pain caused by arthritis.These products may have local analgesic, anaestheticand anti-itch capabilities. Their use, and therefore benefit,is limited by an inability to be absorbed beyond the upperlayers of the skin.

LifestyleMaintaining a healthier lifestyle is beneficial for anyonewith psoriatic arthritis, but it is easy to lose confidencewhen you are in pain or have restricted mobility. It is alsooften difficult to keep fit under such circumstances, but

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avoiding exercise can increase the risk of associatedconditions such as diabetes andcardiac disease. If you areworried about the effect thatexercise may have becauseo f a n y p r e - e x i s t i n gconditions, speak to yourdoctor for advice. If youhave not exercised for awhile, start slowly andcarefully and then build up. Ifyou have swollen joints, it’s bestto take exercise which is low-impact, such as cycling, swimming and using across-trainer machine, rather than running.

Other forms of treatment Complementary therapies are increasingly popular. Sometherapies commonly classed as complementary oralternative therapies include: acupuncture, the Alexandertechnique, aromatherapy, chiropractic, herbalism,homeopathy, osteopathy, reflexology and yoga.

REMEMBER: Check the therapist’s qualifications. Theumbrella organisation for each therapy can tell you whattraining their members have undertaken, their code ofethics and refer you to qualified practitioners in your area.If you are on conventional medicine or treatments, tellyour doctor you are also using complementaryapproaches. Check with your doctor if you are unsureabout the safety of any complementary or alternativetreatment.

Further readingResearch and development of new treatments is ongoing.To learn how a new therapy is developed and trialled seeour Clinical Trials leaflet.

SummaryFor any treatment to work it is essential to follow theguidance given by your healthcare provider. Always readthe product labels and the patient information leaflet (PIL)supplied with your medication.

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Occasionally, treatments suddenly stop working(tachyphylaxis) or feel less therapeutic. With no knowncure at present, psoriatic arthritis is likely to be a lifelongdisease, so it may be necessary for your doctor to changeyour medication or treatment regimen from time to time.Whatever treatment you and your healthcare providerdecide is an appropriate course, make sure you report thebenefits, improvement and any adverse reactions as thiswill ensure you get the very best level of care.If you have any views or comments about this

information or any of the material PAPAA produces, youcan contact us via the details on the back page or onlineat www.papaa.org/user-feedback.

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

� NHS Choices (England): www.nhs.uk

� NHS 24 (Scotland): www.nhs24.com

� Health in Wales: www.wales.nhs.uk

� 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

� Gelfand JM, Weinstein R, Porter SB, Neimann AL,Berlin JA, Margolis DJ. Prevalence and treatment ofpsoriasis in the United Kingdom: A population-basedstudy. Arch Dermatol 2005; 141:1537-41.

� Cassell SE, Bieber JD, Rich P et al. The modified nailpsoriasis severity index: Validation of an instrument toassess psoriatic nail involvement in patients withpsoriatic arthritis. J Rheumatol 2007; 34:123.

� Thor a x 2005; 60:800-805. Doi : 10.1136/thx.2005.046797

� Chakravarty K, McDonald H, Pullar T et al. BSR/BHPRguideline for disease-modifying antirheumatic drug(DMARD) therapy in consultation with the BritishAssociation of Dermatologists. Doi:10.1093/rheumatology/ke1216b

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� Coates LC, Tillett W, Chandler DA et al. The 2012 BSRand BHPR guideline for the treatment of psoriaticarthritis with biologics

� Spondyloarthritis in over 16s: diagnosis andmanagement. National Institute for Health and ClinicalExcellence. NICE clinical guideline NG65. February2017

� Coates LC, Kavanaugh A et al. Group for Researchand Assessment of Psoriasis and Psoriatic Arthritis2015 Treatment Recommendations for PsoriaticArthritis.

� British National Formulary www.bnf.org/products/bnf-online/ accessed July 2017

� Mo n t h l y I n d e x o f M e d i c a l S p e c i a l i t i e swww.mims.co.uk accessed July 2017

� E l e c t r o n i c M e d i c i n e s C o m p e n d i u mwww.medicines.org.uk/emc accessed July 2017

There is a large body of evidence for the benefits ofexercise in inflammatory arthritis. It has usually beenstudied using rheumatoid arthritis (RA). NICE guidelines2009 state that exercise is beneficial for most individualswith RA. Evidence for exact prescription, modes ofexercise delivery and improving compliance with anexercise programme are limited. The current knowledge issummarised in:

� Cooney JK et al. Benefits of exercise in RA. Journal ofaging research 2011; 1-14 (article ID 681640).

� Hakkinen A et al. A randomised two-year study of theeffects of dynamic strength training on musclestrength, disease activity, functional capacity, andbone mineral density in early rheumatoid arthritis.Arthritis Rheum 2001; 44:515.

The above list is not exhaustive. For further referencesused in the production of this and other PAPAAinformation, contact us or go to: www.papaa./resources/references

About this informationThis 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:

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www.papaa.org The site contains information ontreatments and includes patient experiences and casehistories.

Original text written by PAPAA. Dr Laura Coates,consultant rheumatologist and NIHR clinician scientist,University of Oxford and Nuffield Orthopaedic Hospital,fully reviewed and revised this edition in July 2017.

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

Published October 2017

Review date July 2019

© PAPAA

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The charity for peoplewith psoriasis and psoriatic arthritis

PAPAA, the single identity of the Psoriatic Arthropathy Alliance and the

Psoriasis Support Trust.

The organisation is independently funded and is aprincipal source of information and educationalmaterial for people with psoriasis and psoriatic

arthritis in the UK.

PAPAA supports both patients and professionals byproviding material that can be trusted (evidence-

based), which has been approved and contains nobias or agendas.

PAPAA provides positive advice that enables peopleto be involved, as they move through

their healthcare journey, in an informed way which is appropriate for their needs and any

changing circumstances.

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