From healthcentral.com
Without treatment, symptoms for PsA can get worse. Learn how to manage this disease so you can keep living an active life
Psoriatic arthritis (PsA) is a chronic inflammatory disease that can impact practically every part of your body. The chronic condition can lead to peripheral arthritis, skin disease, spine disease, enthesitis, dactylitis, nail disease, as well as other comorbidities such as eye disease and anxiety.
The complications and symptoms of psoriatic arthritis can worsen over time and negatively impact your quality of life. In years past, the prognosis for someone with a psoriatic arthritis diagnosis wasn’t great. But recent treatment advances have improved outcomes for those with this disease and lifestyle modifications are helping people with PsA stay active longer. We asked the experts what you can expect if you’ve been diagnosed with this disease and how you can slow its progression.
Typical Progression of Psoriatic Arthritis
Psoriatic arthritis often begins as the skin disorder psoriasis. Psoriasis causes rashes with itchy, scaly patches, and can be found anywhere on the body. About a third of people who have psoriasis will also develop psoriatic arthritis, according to the National Psoriasis Foundation.
Early in the disease course, it may be hard to determine if you have psoriatic arthritis. This stage of the condition is referred to as subclinical or preclinical, according to a 2022 article in the Journal of Dermatological Treatment. At the subclinical psoriatic arthritis stage, you may have joint inflammation and/ or changes to the joint that are detectable via diagnostic imaging techniques like ultrasonography or magnetic resonance imaging.
Largely, though, the joints are pain-free at this point, making it hard to know you have the condition, unless you go looking for it. In fact, subclinical symptoms indicating early PsA are widespread among patients with psoriasis who do not yet have a diagnosis of psoriatic arthritis, according to the article authors. In one study, 41% of patients with psoriasis in whom psoriatic arthritis was identified by rheumatologists were undiagnosed by their dermatologists.
The early stage of the disease can also be a difficult time for patients, says Hannah Pugh, an occupational therapist and head of clinical experience at Reactiv, a virtual physical therapy company in Brooklyn, NY. “During the early stages of PsA, treating and managing the condition can be challenging as patients have not yet received a diagnosis, which often means they have not started appropriate medication,” says Pugh, who works with patients who have a chronic condition to help them manage their condition and equip them with tools to regain control over their disease.
Beyond the early stages of psoriatic arthritis, how the condition progresses varies greatly from one person to the next. “It is a full-body disease,” acknowledges Laura Coates, Ph.D., an associate professor and researcher of psoriatic arthritis at the University of Oxford in England. “It can affect many different types of tissues—like your joints, tendons, skin, spine—and can affect any joint in the body,” she explains. Even for a single person the disease can look different from month to month or season to season.
Still, there are some issues that most psoriatic arthritis patients share in common that were identified by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). These complications and symptoms can worsen over time. According to a 2023 study in the journal Joint Bone Spine, people with PsA were also like to have:
Axial disease: Anywhere from 20% to 70% of people with psoriatic arthritis face the sacroiliitis and inflammatory back pain caused by this disease. Back pain typically increases as time goes on.
Dactylitis: 15% to 48% of patients with psoriatic arthritis also have this symptom, often referred to as “sausage digits.”
Enthesitis: 7% of psoriatic arthritis patients with a disease duration of five years have this complication.
Nail psoriasis: Anywhere from 40% to 67% of psoriatic arthritis patients have nail issues.
Peripheral arthritis: 64% of people living with psoriatic arthritis have this form of arthritis.
Skin psoriasis: 77% have active psoriasis.
Without treatment, uncontrolled inflammation can cause multiple psoriatic arthritis symptoms to occur at once. For example, in one study, 50% of people with psoriatic arthritis experienced peripheral joint involvement and skin psoriasis at the same time.
And for those with psoriatic arthritis who have skin involvement, progression is often unpredictable, according to Christopher Sayed, M.D., an associate professor of dermatology at the University of North Carolina at Chapel Hill. “Many patients with mild psoriasis may continue to have occasional mild flares that are controlled with topical medications, but it can decide to get worse at seemingly random times,” he says. Severe disease may predict even worse outcomes, says Dr. Sayed. “Patients that have had severe flares with extensive involvement of the skin are more likely to have more frequent and more severe swings in disease activity,” he explains.
Does Psoriatic Arthritis Affect Life Expectancy?
According to a 2022 study in the journal Rheumatology, among psoriatic arthritis patients, mortality rates may be slightly higher than in the general population. Researchers relate those stats to a greater amount of cardiovascular disease in the PsA community.
In another study, researchers set out to discover whether new treatment advances have translated into normalizing life expectancy for those with psoriatic arthritis. Compared to the general population, they found a small but significant increase in all-cause and cardiovascular mortality among women with psoriatic arthritis but not men. What’s more, mortality increased among patients who had used glucocorticoids but not biologic disease modifying anti-rheumatic drugs (bDMARDs).
The three leading causes of death for psoriatic arthritis patients (as well as the general population) were:
cardiovascular disease
malignancies
respiratory diseases
Death from cardiovascular disease was higher among women. The authors of the study hypothesized that risk factors such as obesity, hypertension, smoking, and diabetes may have been more prevalent among women with psoriatic arthritis.
Factors That May Affect PsA Life Expectancy
People with psoriatic arthritis have a higher burden of risk factors like obesity, hypertension, diabetes, smoking and cardiovascular disease compared to the general population. Each of these can play a role in life expectancy.
Obesity
The World Health Organization defines being overweight or obese as abnormal or excessive fat accumulation that may impair health. The prevalence of obesity among U.S. adults is about 42% where the rates of obesity for those with psoriatic arthritis is about 45%. The problem is that fat increases inflammatory proteins which promote more inflammation. Ongoing inflammation contributes to a number of different diseases that can lead to not only worse PsA but also a shorter life expectancy, according to the Arthritis Foundation. The good news? Losing weight can make a big difference. In one study, weight loss of more than 10% of body mass resulted in an increase in the percentage of patients achieving psoriatic arthritis remission from 6% to 63%.
Hypertension
High blood pressure, another name for hypertension, can damage your body over time if it goes untreated. It is measured in millimetres of mercury (mm Hg) and the optimal range is less than 120/80 mm Hg according to the American College of Cardiology. Body-wide inflammation is known to damage blood vessels, according to the Arthritis Foundation, which can put you at additional risk if your psoriatic arthritis is not controlled. Monitoring your blood pressure numbers and keeping your disease under control can be key to staying healthy.
Diabetes
The prevalence of type 2 diabetes in people with psoriatic arthritis ranges from about 6 to 20%, compared to 2 to 15% in the general population, according to a 2020 review. A higher risk of diabetes is reported in women with more severe forms of psoriatic arthritis. According to the authors of the review, the link between diabetes and psoriatic arthritis is not completely understood, but certain cytokines such as tumour necrosis factor alpha are suspected to play a role. The good news is that treating your psoriatic arthritis may help reduce your risk of diabetes.
Cardiovascular Disease
Also known as heart disease, cardiovascular disease refers to a few conditions including heart attack and stroke. According to the Arthritis Foundation, people with psoriatic arthritis actually have a doubled cardiovascular risk—they have traditional risk factors for heart disease such as obesity and diabetes and they experience whole body inflammation, which is known to damage blood vessels. Achieving and maintaining a healthy weight becomes especially important if you have PsA because obesity is associated with many cardiovascular risk factors.
Does Age of Diagnosis Matter?
According to a 2023 study, age of onset of psoriatic arthritis can make a difference in disease outcome. In the study, participants with PsA were put into two groups, those who were diagnosed after 60 years of age (late onset) and those diagnosed before 60 years of age (early onset).
Interestingly, people with late onset psoriatic arthritis displayed an increased risk of a major cardiovascular event, even with similar smoking habits and body weight as the group with earlier onset. The authors admit that there is a lot of research needed to understand why this relationship exists.
While some may be hesitant to try a biologic as they get older for treatment, there is research available suggesting that older people with psoriatic disease respond just as well as younger people to biologic treatment. In one study looking at psoriasis treatment with a biologic, the efficacy in elderly subjects (65 or older) was comparable to that in younger subjects throughout 52 weeks of treatment. Notably, 75% clear skin was reached by 82% of the elderly subjects and 79% of younger subjects at week 52. The total rate of adverse events was similar between the elderly and younger participants.
How Severely Can Psoriatic Arthritis Affect the Body?
Thanks to better treatment options and greater awareness of the condition, psoriatic arthritis is increasingly treated early on in the disease stages. That’s a good thing, because without treatment, heightened stiffness and pain can lead to a more sedentary lifestyle, which in turn can give rise to various health issues such as cardiovascular problems, high blood pressure, and mental health disorders, says Pugh. “In more severe cases where PsA remains untreated, cumulative damage to the joints can become permanent,” she explains. Such damage can make it difficult to complete daily tasks resulting in a loss of independence and reduced sense of overall well-being, she adds.
Frailty can be another outcome of untreated psoriatic arthritis, per an American College of Rheumatology study. Frailty is defined clinically as the state of increased vulnerability due to physical and functional decline. “The prevalence of frailty in older adults with psoriatic arthritis was higher than the prevalence found in older adults in the general population in prior studies,” says Sarah Lieber, M.D., a rheumatologist at Hospital for Special Surgery in New York City and co-author of the study.
The frailty in people with PsA was compounded by issues such as comorbid conditions and falls, says Dr. Lieber, who also found that other PsA-related symptoms seemed to multiply when frailty was not addressed. For instance, “we found that anxiety was more common among adults with psoriatic arthritis who were frail than those who were not frail,” she says.
How Does Psoriatic Arthritis Impact Quality of Life?
The presence of enthesitis, dactylitis, inflammatory back pain, and peripheral joint involvement when you have PsA is significantly associated with a worse general quality of life, according to a 2023 study in the journal Joint Bone Spine.
In addition, if left untreated, the functional limitations and chronic pain of psoriatic arthritis can have a profound impact on a person’s mental health, says Pugh. In turn, “a decreased mental state can impact a person’s ability to hold a job, maintain healthy relationships, and affect their physical abilities,” she adds.
Research supports the risk that untreated psoriatic arthritis can have on mental health. In a 2022 study, researchers discovered that depression prevalence was higher in patients with than without PsA. Anxiety prevalence was also higher among psoriatic arthritis patients. According to the same study, depression remains underrecognized and undertreated in over half of moderately-to-severe patients.
Fortunately, a revolution in psoriasis disease treatment over the last 25 years has led to the development of many effective treatments. “Even the worst cases often respond very well to treatments, and because we have more than a dozen drugs that range from very good to great, we can troubleshoot when one doesn’t work well,” says Dr. Sayed.
Many of these drugs lead to substantial improvement within one to two months, and by three to four months, most medications reach their maximum effectiveness, he says. The key: Early diagnosis—timely detection and treatment of psoriatic arthritis is known to result in improved outcomes over time.
Beyond Medication
Researchers now know that psoriatic arthritis outcomes are based on more than medication alone. For instance, both physical and occupational therapy have been shown to improve PsA symptoms over time. “Physical therapy is a very important part of treating psoriatic arthritis,” says Laura Coates, Ph.D., an associate professor and researcher of psoriatic arthritis at the University of Oxford in England. PT along with medication is an effective way to treat inflammation, control pain and maximize function with psoriatic arthritis, she adds.
Other lifestyle factors that may help with your psoriatic arthritis prognosis include:
Diet
Exercise
Maintaining a healthy weight
Smoking cessation
Stress reduction
Having psoriatic arthritis doesn’t mean that you are destined to live with comorbidities or enjoy less of your life compared to others without the condition. However, it does mean that there is an increase in risk factors and complications, especially with untreated disease. The good news is that you can control your destiny by taking charge of your lifestyle and medical care.
According to the Arthritis Foundation, the first order of business in increasing your life expectancy with psoriatic arthritis is to quit smoking since tobacco increases inflammation and decreases treatment effectiveness. Eating a heart healthy diet and moving with intention can also make a difference—cutting the risk of heart disease nearly in half. The importance of staying on top of your treatment is also critical, since under treatment of PsA leads to uncontrolled inflammation which is the driver of many serious conditions.
Takeaways
Psoriatic arthritis impacts different people in different ways. Skin, joints, tendons, and bones including the spine are commonly impacted. If psoriatic arthritis isn’t diagnosed and treated early, over time the symptoms can worsen, multiply, and lead to permanent joint damage. A reduced quality of life, including a negative impact on mental health, often accompanies more severe disease. Fortunately, new and more targeted treatments today make it possible to slow disease progression and prevent future damage in a matter of months. Physical and occupational therapy along with lifestyle changes such as smoking cessation and weight loss can also help you to live your best life.
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