The “Other” Symptoms of Psoriatic Arthritis

From creakyjoints.org

When you have psoriatic arthritis (PsA), being on the lookout for these non-skin, non-joint symptoms can help you head off serious complications. And if you have psoriasis, they might be early signs of PsA. 

If you have psoriatic arthritis (PsA), you’re probably aware that about 85 of people with PsA also have psoriasis (an inflammatory condition of the skin). As if dealing with joint pain, fatigue, and scaling, burning, and itching skin isn’t enough – you may also experience symptoms that go beyond your skin and joints. That’s because the chronic inflammation underlying your PsA can go to work body-wide, affecting organs, tissues, and body systems beyond the skin and joints. 

Reporting these symptoms to your doctor as soon as possible can help fend off more serious problems and lead to more effective relief for your PsA. It’s also essential to note: If you have psoriasis, these symptoms may be the earliest clues that you may have PsA. 

Symptoms of Psoriatic Arthritis We Don’t Always Talk About

Here’s a closer look at some of the PsA symptoms that can fly under the radar and what you should know about them. 

Nail Problems

If you have psoriasis and have not yet been diagnosed with psoriatic arthritis (PsA), or if you have unexplained joint pain without skin issues, it’s worth checking your nails. Nail pitting is one of the earliest and most common signs of PsA, affecting about 80 percent of all people with psoriasis. “It looks almost like you poked your nail with a safety pin,” says Dr. Carroll. Onycholysis, which is the splitting, easy breaking, or cracking of the nail bed, is another nail sign. 

In fact, nail issues are such a telltale sign of PsA that, according to Dr. Carroll, “when someone is coming in with new joint pain and we’re trying to figure out why they have it, and they don’t have obvious skin manifestations, I will look at the nails…sometimes that is the only skin sign.”  

This is what happened to Eddie Applegate, a TV-commercial traffic manager in Atlanta. “I was having joint pain and rashes on my face and hairline,” says Eddie, who has been living with PsA for 20 years. “I went to an urgent care doctor who looked at my nails and saw the pitting, and that helped him confirm the diagnosis of PsA. He also looked at the rash on my face and said, ‘That’s psoriasis’ — a dermatologist had earlier misdiagnosed it as acne.” 

Eye Issues

When it comes to PsA, “red eyes, changing vision, and especially painful eyes are concerning,” says Emily Carroll, MD, an internist focusing on rheumatological diseases at New York’s Mount Sinai Hospital. Those are symptoms of a condition called uveitis, or inflammation of the uvea, which is the middle layer of the eye. Left untreated, it can lead to vision loss, so it’s important to see an ophthalmologist.  

Adds Dr. Carroll, “If uveitis occurs even though a person with PsA is already taking methotrexate, this might be a reason to go to a stronger treatment, such as a biologic.”  

PsA can also be associated with less serious eye problem, including: 

• Pink eye (redness, crusting, swelling) 
• Dry eye syndrome (gritty, burning sensation) 
• Swelling of the sclera (the white part of the eye) 

Ashley Krivohlavek, 39, has had psoriasis since she was 12 years old and was diagnosed with psoriatic arthritis (PsA) when she was 30. She says that dry eyes are “especially tragic” for her, mainly because of the blow to her vanity.  

“When I was a kid, I got made fun of in school for glasses. Eventually, I started wearing contacts and was happy, but about two years after my PsA diagnosis, my ophthalmologist said, ‘You have extremely dry eye, and I don’t know if you’ll be able to wear contacts,” recalls Ashley. “The arthritis had already taken so much — I couldn’t play bass or piano anymore. I like to travel, and that wasn’t in the cards either — and now this.” 

Ashley had been able to wear contacts for special occasions until about six months ago, when she wore them to a wedding but found removing them so painful that she feared she had scratched her cornea. “My doctor told me I had zero chance to wear contacts ever again,” says Ashley, who now keeps her eyes lubricated with over-the-counter eye drops and may explore stronger options with her doctor. 

Shortness of Breath

Unfortunately, people with PsA are at higher risk of atherosclerosis, heart attack, and stroke, says Dr. Carroll. “One reason is that PsA is seen more commonly in people who have metabolic syndrome, a cluster of conditions including high cholesterol, high blood pressure, and obesity,” she explains. “But even beyond that, the inflammatory nature of PsA alone raises risk.”  

The same inflammation that attacks joints also attacks blood vessels, leading to narrower arteries and plaque build-up. So, if you experience shortness of breath when doing everyday activities, tell your doctor and have it checked out. It could be a sign of heart disease.  

Luckily, Ashley, who does arthritis advocacy work through the Global Healthy Living Foundation and helps her dad run their asphalt manufacturing business in Tulsa, OK, has no heart issues, but she says, “I’ve been very diligent about checking my heart health because of the inflammation from PsA. I got tested recently, and my endocrinologist says everything looked great.”  

Eddie’s PCP does an EKG at least once a year: “He wants to make sure we get ahead, especially because I have a family history of heart disease.” 

Swollen Digits

Even before any joint problems have been detected, PsA may reveal itself with fingers or toes so swollen they look like sausages. Known as dactylitis, it affects about half of people with PsA at some point during the course of the disease and is often a signal of joint damage. “When I was first diagnosed and not on a good treatment plan, my fingers would swell so badly, I couldn’t put bracelets or rings on,” says Ashley. “The swelling in my toes was so bad that wearing anything other than big, bulky athletic shoes was really difficult.” 

If you notice symptoms — your entire finger or toe (not just the knuckle) might be so swollen you won’t really be able to use it, and it may feel warm and painful — see your doctor right away. Prompt treatment, such as with biologics or JAK inhibitors, can help ensure dactylitis doesn’t become a chronic problem. “Finding the right treatment plan really did help a lot,” says Ashley, who started managing her PsA with a biologic two years ago. “It has given me my life back.” 

Back Pain

Although PsA is known for causing peripheral arthritis — inflammation and stiffness in the hands, wrists, feet, knees, and ankles — it can also attack elsewhere.  

“One of the things people don’t really talk about is the spine in PsA,” says Ashley, who underwent physical therapy for her spine last summer. “Even my rheum, when I brought it up, said PsA doesn’t really do that.”  

However, a study in Annals of the Rheumatic Diseases found that about 43 percent of people with PsA also have back symptoms — also known as axial PsA or spondylitis. “It’s the worst because walking hurts, lying down hurts. It just feels very tight and almost burning, like there’s stuff rubbing together,” says Ashley.  

If you’re experiencing back pain, tell your rheumatologist — certain imaging tests can help them make an accurate diagnosis and adjust your treatment accordingly. 

https://creakyjoints.org/about-arthritis/psoriatic-arthritis/other-symptoms-psoriatic-arthritis/ 

Clubbing of the Fingers or Toes

From verywellhealth.com

Finger or nail clubbing can point to an underlying health condition

Clubbing of the fingers, also described as hypertrophic osteoarthropathy (HOA), is an enlargement of the ends of the fingers accompanied by a downward sloping of the nails.

Clubbed fingers by themselves are not harmful, but since it can be a sign of lung cancer, among other diseases, it is important that your medical team identifies the cause and that you are treated for your underlying condition.

This article covers causes and symptoms of clubbed fingers and clubbed nails, along with how clubbed fingers are diagnosed and treated.

Desherinka / WIkimedia Commons / CC BY-SA 4.0 

Also Known As

Clubbing is also referred to as clubbed fingers, digital clubbing, watch-glass nails, drumstick fingers, Hippocratic fingers, Hippocratic nails.

Verywell / Jessica Olah

Primary vs Secondary Clubbing

Clubbed fingers, nails, or toes are typically a sign of severe disease, but not always.

Primary (idiopathic) clubbing is clubbing that occurs alone, without the presence of any underlying disease. Primary clubbed fingers, toes, and nails are a rare inherited trait—accounting for just 3% of all clubbing cases.

Secondary clubbing occurs as an effect of another health problem, such as lung cancer, heart disease, or cirrhosis of the liver. In fact, secondary clubbing is caused by lung cancer or lymphoma in approximately 80% of cases.

Is Finger Clubbing Rare?

The most common cause of secondary finger clubbing is lung cancer, however, only 5% to 15% of people with lung cancer develop clubbed fingers. Primary finger clubbing is far more rare.

Symptoms

Clubbing can involve your fingers and/or toes. It is typically bilateral (affecting both hands and/or feet) and it should be equal in terms of its extent on both sides.

If you or your child has primary HOA, then your fingers or toes may naturally appear large, bulging, and rounded. This will be noticeable during childhood or during the teenage years, and it will not change much over time. With primary HOA, other family members are also likely to have finger clubbing and/or toe clubbing.

Secondary clubbing happens gradually, and it causes a change in the appearance of your fingers and/or toes. With secondary clubbing, which is caused by disease, you would also have other features that are not seen in primary clubbing.

Features of secondary clubbing include:

• Softening of the nails
• Nail beds that soften and feel spongy
• Nails that seem to "float" instead of being firmly attached to your fingers
• Disappearing of the angle between your nails and cuticle
• Enlargement or bulging of the distal portion of your finger (where your finger meets your nail)
• Warm, red nail beds
• Nails that curve downward and look like the bottom of the round part of a spoon

Eventually, the nail and skin around the nail may become shiny, and the nail develops ridging.

Is Finger or Nail Clubbing Painful?

Clubbed fingers or clubbed nails by themselves are usually painless, and many people with clubbed digits are unaware of the issue. Painful clubbing may occur in some people with certain conditions that cause scarring in the lungs.

Causes

Primary clubbing is hereditary, and it is passed down via genes. Hereditary clubbing is simply a physical feature, like the colour of your eyes or your height. Several genes have been associated with primary clubbing, including the HPGD gene and the SLCO2A1 gene.

Secondary clubbing occurs as one of the effects of chronic lung and heart disease. Lung cancer is the most common cause of clubbing. This sign is also associated with a number of other chronic illnesses, including conditions that involve the thyroid gland or the digestive system.

There are a number of health risk factors associated with secondary clubbing, including:

• Lung cancer
• Interstitial pulmonary fibrosis
• Lung abscess
• Pulmonary tuberculosis
• Pulmonary lymphoma
• Congestive heart failure
• Infective endocarditis
• Cyanotic congenital heart disease
• Bronchiectasis
• Cystic fibrosis
• Other types of cancer, including liver, gastrointestinal or Hodgkin lymphoma
• Inflammatory bowel disease
• Liver cirrhosis
• Gastrointestinal neoplasms
• Celiac disease
• Dysentery
• Graves' disease
• An overactive thyroid gland

Can HIV Cause Clubbed Fingers?

People with HIV have a much higher risk of developing chronic lung disease and lung infections, which can inevitably lead to clubbed fingers.

How Clubbed Nails Affects Nail Beds

The medical conditions that can cause clubbing are generally associated with decreased oxygen levels. Experts suggest that clubbing occurs as your body undergoes changes in response to low oxygen.

Several processes affect the nail beds in secondary clubbing. The nail enlargement occurs due to the growth of excess soft tissue beneath the nail beds. The enlargement is associated with inflammation and a proliferation of small blood vessels in the nail beds.



A protein called vascular endothelial growth factor stimulates the growth of blood vessels, and this protein is considered a major factor in the physical changes that occur in clubbing.

Diagnosis

Clubbing can be subtle, so it may be difficult for you and your medical team to verify this change in your digits.

There are a few objective criteria that are used to assess clubbing, and they can help in determining whether you have developed this physical change:

• Lovibond's profile sign: Normally, there is a sharp angle between the nail bed and the cuticle. When you have clubbing, the natural angle is lost as the nail angles down instead of up.
• Distal/interphalangeal depth ratio: The phalanges of your finger are the sections between each bending joint. Your distal phalange, the one that includes your nail, is normally shorter depth-wise than the neighbouring phalange. Clubbing is indicated when the opposite is true.
• Schamroth's sign: The sharp angle between your nail bed and cuticle forms a tiny diamond-shaped hole when you place your hands together with the top of your nails facing each other. When this gap disappears, it is described as Schamroth's sign.

Assessing Underlying Conditions

Often, clubbed fingers or toes develop due to a chronic medical condition that was diagnosed years before the clubbing developed. When you start to have clubbing of your digits, your medical team will evaluate you to identify any underlying disease that could be causing it.

Even if you have an established lung or heart condition, your medical team will assess your condition to identify any progression that could require an adjustment of your treatment.

Tests that you may need in the evaluation of clubbing include:

• A physical examination to assess for signs such as weight loss, difficulty breathing, skin changes, alterations in your pulse, or altered blood pressure
• A pulse oximeter to measure your blood oxygen level
• Pulmonary function tests (PFTs)
• Arterial blood gas test
• Chest imaging tests, such as chest X-ray or chest computerized tomography (CT)
• Blood tests, including complete blood count (CBC), electrolyte levels, liver function tests (LFTs), and/or thyroid tests
• An electrocardiogram (Echocardiogram to assess your heart function
• Abdominal imaging tests such as CT or ultrasound
• A biopsy if there is a concerning lesion noted on an imaging test

Treatment

Usually, the abnormal shape and size of the digits do not cause health problems, but any underlying disease that causes clubbing needs to be medically and/or surgically managed, as appropriate. Treatments may prevent your clubbing from worsening and, in rare cases, can reverse some or all of the physical features of clubbing.

There are a variety of approaches used to treat the underlying cause of clubbing. Your treatment will depend on your situation. You may need management of respiratory disease, treatment of heart disease, or interventional therapy for cancer.

A Word From Verywell

If you notice clubbed fingers or toes, be sure to discuss this with your healthcare provider. Clubbing can be diagnosed in your healthcare provider's office. Although clubbing itself is harmless and doesn't require treatment, it is often associated with health conditions that can worsen without treatment.

FREQUENTLY ASKED QUESTIONS

• Can clubbed fingers go away?

  If the underlying cause of clubbed fingers is treated, yes, they can go away. Heart and lung diseases are the most common problems. These may need to be treated with medication or surgery.
• What are the stages of finger clubbing?

  There are five stages or grades of clubbing:

  • Grade 1: The nail bed becomes soft
  • Grade 2: There are changes in the angle of the nail fold (the skin beneath the cuticle that holds the nail in place)
  • Grade 3: The nail takes on a more obvious curve
  • Grade 4: The end of the finger becomes thicker (club-like)
  • Grade 5: The nail takes on a shiny appearance
    
• How do I prevent clubbing from coming back?

  If you’re at risk for clubbing, you should take steps to avoid conditions that might worsen lung or heart problems. Stopping smoking is essential. You can also lower your chances of catching viruses that cause lung infections by following a healthy diet, getting exercise, and receiving necessary vaccines.
  

• How do you tell if your nails are clubbing?

  You can tell if you have clubbed nails by checking for what's known as the Schamroth's sign. Check for it by pressing the nails of both point fingers together; there should be a small, diamond-shaped space between the nail beds. If there is not, you may have clubbed nails.

https://www.verywellhealth.com/clubbing-of-fingers-914776