• Psoriasis: Most patients with PsA develop a scaly rash (psoriasis) first before developing arthritis. Psoriasis can develop on any part of the body, but is more common over the scalp, hair line, elbows, knees, belly button and natal cleft.
• Peripheral arthritis: Any joint can be affected by the disease including the arm and leg joints. Patients usually have joint pain, swelling and stiffness in the morning for more than 30 minutes.
• Axial disease: The joints in the spine and the buttock (sacroiliac joints) may be affected, leading to pain and stiffness in the back and buttock respectively.
• Nail psoriasis: Patients may develop nail changes such as pitting, thickening, detachment of the nail plates and staining.
• Dactylitis: Sausage-like swelling may affect an entire finger or toe.
• Enthesitis: Inflammation along tendon and ligament insertion points leading to pain and swelling, worsened with specific movements e.g. pain over the back of the heel where the achilles tendon inserts (tendoachilles tendinitis), sole of the feet (plantar fasciitis) and around the elbow (tennis elbow or golfer’s elbow).
• Other symptoms may include:
o Tiredness
o Diarrhoea, blood in the stools which may occur due to inflammation in the intestines
The symptoms of PsA can be alleviated, and joint damage can be prevented by prompt and appropriate treatment. It is important for patients with PsA to attend regular medical check-ups and take medications as prescribed, even when they feel well, to avoid disease flares.
• Disease-modifying anti-rheumatic drugs (DMARDs) are medications that suppress the overactive immune system from further damaging the joints. Some of these medications come in the form of tablets (examples include methotrexate, leflunomide, sulfasalazine, ciclosporin A) or may be given as subcutaneous injections (injections under the skin usually given in the abdomen or thighs) e.g. methotrexate.
• Biologics: These are targeted injectable drugs given subcutaneously or through the vein. They are usually used in patients who do not respond to DMARDs, or who have significant axial disease, dactylitis or otherwise severe disease (examples include infliximab, adalimumab, golimumab, etanercept, certolizumab pegol, secukinumab, ixekizumab, risankizumab, guselkumab and ustekinumab).
• Targeted DMARDs are oral tablets and are usually given to patients with more severe disease or when conventional DMARDs have failed to control disease activity adequately (e.g. tofacitinib and upadacitinib; apremilast).
• Some patients require combination therapy with more than one of the above medications. Patients on DMARDs will require regular blood tests to monitor for any potential side effects.
• Non-steroidal anti-inflammatory drugs (NSAIDs) are useful adjunctive agents for pain control and reduction of joint inflammation. Examples include diclofenac and naproxen.
• In patients with severe joint inflammation, a needle may be inserted to remove joint fluid and steroids may be injected directly into the affected joint(s) for rapid relief.
• For psoriasis:
o Regular moisturisers are recommended to reduce scaling and itch.
o Topical medications such as steroid creams, salicylic acid, coal tar shampoo and Vitamin D-based creams are often used.
o Phototherapy with ultraviolent light may be recommended by the Dermatologist.
Physiotherapy and occupational therapy may be recommended in patients who have functional impairment from joint deformities and to relieve pain.
PsA is often associated with other medical conditions such as osteoporosis, obesity, metabolic associated steatotic liver disease (MASLD) (fatty liver), high cholesterol, diabetes and high blood pressure. These conditions should be addressed as part of holistic care for PsA. Certain vaccinations are recommended to prevent common infections, such as influenza, pneumococcal, Respiratory Syncytial Virus (RSV) and shingles.
Seek a doctor’s advice as soon as possible. You may be referred to a specialist (rheumatologist) who will confirm the diagnosis and start you on appropriate treatment. Once diagnosed, it is important to start treatment as soon as possible.
This condition is managed by the Division of Rheumatology and Allergy. The division also runs a specialised multidisciplinary TARGET Arthritis clinic to provide fast-track care for patients with early PsA and difficult-to-treat disease using a structured treat-to-target approach.
