From miningjournal.net
By Dr. Conway McLean
Skin problems come in all shapes and sizes, afflicting most Americans at some point in their lives. Often, these are predictable, the blistering rash produced by a poison ivy patch. Skin lesions can be deadly, the obvious example being a malignant melanoma. On occasion, they are a reflection of a systemic disease, the most common representative being psoriasis. Many Americans have heard of it but for most, their understanding is usually, dare I say it, skin deep.
Psoriasis is one of many autoimmune disorders, others include rheumatoid arthritis and lupus. The association between these various diseases is an immune system which becomes overactive and attacks some tissue or structure, in this case the skin. The typical manifestation of this disease is the characteristic patches of reddened skin with silvery scales, the psoriatic rash. Nails can also be affected, often misleading the sufferer to assume they have a fungal infection. Those things which stimulate an attack of psoriasis are many, from infections to stress, cold temps, and numerous others, varying from person to person.
As to why some people are prone to psoriatic attacks, we do not know. Genetic, environmental, and immunologic factors have all been implicated. Psoriasis is quite common with roughly 1% of the adult population afflicted. As is usually the case, many variations of psoriasis are known, from differing locations and types of the rash to the organs involved. Psoriasis has been found to be associated with diabetes and heart disease, but the most frequent is the joint disease referred to as psoriatic arthritis (PsA).
Early on, PsA was considered to be a less aggressive condition as compared to rheumatoid arthritis. But this opinion has changed: psoriatic arthritis can cause as much if not more disease and disability. The pattern of joint involvement will vary from person to person. Some may have just a few joints affected, while others have many. Generally, the joint changes develop on only one side of the body, unlike RA where both limbs are. Foot involvement is a significant concern in PsA as it can lead to pain and disability. Ultimately, this means reduced mobility and quality of life.
There is a characteristic pattern for the inflammation accompanying PsA, as there is with each of the autoimmune joint-involving diseases. In terms of symptoms, psoriatic arthritis may produce stiffness in the joints, especially after a period of inactivity such as after waking up in the morning. One diagnostic feature is the development of “sausage toes,” referring to the swollen, painful toes associated with psoriatic arthritis. A single digit can be affected or many.
Other anatomical structures that may be affected include the Achilles tendon, the plantar fascia (the structure usually responsible for heel pain), as well as the joints in the ball of the foot. A joint attack can be aggravated by dietary factors. Saturated fats, sugar, alcohol, processed meats, and carbs are notorious candidates since, along with adding pounds, they increase levels of inflammation in the bloodstream. These are known to be triggers for a psoriatic arthritis flare.
Some of the deeper compartments of the foot can be affected by PsA. In this scenario, the individual experiences pain, swelling, stiffness, tenderness with weight bearing on the limb. In the later stages, deformities evolve leading to real disability. Structural damage can occur to numerous tissues, including cartilage, joint capsule, ligaments, and bones. Psoriatic arthritis not only can lead to functional impairment but also increases the risk of death.
A natural question when it comes to the topic of treatment is in regards to a cure. Put plainly, there is none. None of our most frequently prescribed pharmaceuticals are curative. Numerous routes of administration are utilized in the treatment of psoriatic arthritis, from a multitude of topical preparations for the various rashes and skin manifestations, to parenteral medications (intravenously).
Although not truly a therapy, vitamin D apparently is helpful for those with psoriatic arthritis. Certainly, vitamin D is considered beneficial for overall health, but D also seems to reduce systemic inflammation because it helps your body retain calcium and phosphorus, both of which are important to build bone. More important to this discussion, it also may help reduce inflammation which is thought to play a role in the development of psoriatic arthritis.
One of the most frequently consumed drugs ever, ibuprofen is a mainstay of treatment of psoriatic arthritis, as are all the non-steroid anti-inflammatory drugs (NSAID is the usual acronym). These work well temporarily but are known to lose their effectiveness with time.
When it comes to immediate, powerful treatment for reducing the inflammation of PsA, corticosteroids are the most frequently prescribed medications for treating mild to moderate cases. These come in various topical formulations such as ointments, creams, gels, and sprays, but also are often prescribed orally or by injection. These drugs are powerful agents for reducing systemic inflammation.
Foot orthotics have also been shown to allow for better, more comfortable ambulation and weight bearing. When the correct materials are chosen, these can provide both cushioning and stability. Many try over-the-counter products, but these can’t provide the precision of a custom device.
Surgery for arthritis is done to ease severe pain when other treatments have not helped. Differing goals for surgery may be in mind, such as improving movement of a joint, potentially making for a more comfortable gait. Improving alignment of a joint is another helpful objective, such as straightening a bent toe, allowing a foot to be “shoeable.” This means the foot can wear a shoe without incurring pain or problems.
Foot and ankle problems are common in people with PsA. These changes may be the disease’s first and most important musculoskeletal manifestation. And though many methods of minimizing or controlling the symptoms are in use, the absence of any cure is frustrating to sufferers. Perhaps further research will uncover the roots of psoriatic arthritis and a solution will become available. Until then, we make do with the methods we have, with all their limitations and complications.
EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.
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