Psoriatic arthritis

Psoriatic arthritis is a chronic inflammatory disease of the joint, spine and enthesis associated with psoriasis. The disease belongs to the group of seronegative spondyloarthropathies. Screening of patients for early diagnosis is performed by a rheumatologist and / or dermatologist among patients with various forms of psoriasis, actively revealing the characteristic clinical and radiological signs of joints and / or spine and / or enthesis. In the absence of psoriasis taking into account the presence of relatives of the first or second degree of kinship.

[1], [2], [3], [4], [5], [6]

Epidemiology

Psoriatic arthritis is considered the second most frequent inflammatory disease of joints after rheumatoid arthritis, diagnose it in 7-39% of patients with psoriasis.

Due to the clinical heterogeneity of psoriatic arthritis and the relatively low sensitivity of diagnostic criteria, it is difficult to accurately assess the prevalence of this disease. Evaluation is often hampered later development of typical signs of psoriasis in patients suffering from inflammatory joint disease.

According to different authors, the incidence of psoriatic arthritis is 3.6-6.0 per 100 000 population, and the prevalence is 0.05-1%.

Psoriatic arthritis develops at the age of 25-55 years. Men and women suffer equally often, except for psoriatic spondyloarthritis, which is 2 times more common in men. In 75% of patients, joint damage occurs on average after 10 years (but not more than 20 years) after the appearance of the first signs of psoriatic skin lesions. In 10-15% psoriatic arthritis precedes the development of psoriasis, and in 11-15% develops simultaneously with skin lesions. It should be noted that in most patients there is no correlation between the severity of psoriasis and the severity of the inflammatory process in the joints, except for the case of synchronous occurrence of two diseases.

[7], [8], [9], [10], [11], [12], [13], [14]

Causes of the psoriatic arthritis

The causes of psoriatic arthritis are not known.

As environmental factors, the role of trauma, infection, and neuro-physical overload is discussed. 24.6% of patients reported an injury in the onset of the disease.

[15], [16]

Pathogenesis

It is believed that the disease of psoriatic arthritis occurs as a result of complex interactions between internal factors (genetic, immunological) and environmental factors.

Genetic factors

Many studies indicate a hereditary predisposition to the development of both psoriasis and psoriatic arthritis: more than 40% of patients with this disease have relatives of the first degree of kinship suffering from psoriasis, and the number of cases of these diseases increases in families with identical or twins twins.

Seven PSORS genes responsible for the development of psoriasis have been identified to date, which are localized at the following chromosomal loci: 6p (PSORS1 gene), 17q25 (PSORS2 gene), 4q34 (PSORS3 gene), lq (PSORS4 gene), 3q21 (PSORS5 gene). 19p13 (PSORS6 gene), 1p (PSORS7 gene).

The results of immunogenetic phenotyping in patients with psoriatic arthritis are contradictory. Population studies have revealed an increased incidence of genes for the main histocompatibility complex of HLA: B1Z, B17, B27, B38, DR4 and DR7. In patients with psoriatic arthritis and with x-ray signs of sacroiliitis, HLAB27 is more often detected. With a polyarticular, erosive form of the disease - HLADR4.

It should be noted and not the HLA-associated genes entering the region of the main histocompatibility complex, in particular, the gene encoding TNF. When studying the polymorphism of the TNF-a gene, a reliable relationship between the alleles of TNF-308, TNF-b + 252 and erosive psoriatic arthritis was revealed. With early disease, this fact has prognostic value for the rapid development of destructive changes in the joints, and the carriage of TNF-a-238 in the representatives of the Caucasian population is considered as a risk factor for the development of the disease.

[17], [18], [19], [20], [21], [22], [23], [24]

Immunological factors

Psoriasis and psoriatic arthritis are considered diseases caused by violations of T-cell immunity. The main role is assigned to the TNF-a key pro-inflammatory cytokine, which regulates inflammation through a variety of mechanisms: gene expression, migration, differentiation, cell proliferation, apoptosis. It was found that in psoriasis keratocytes receive a signal for enhanced proliferation when T-lymphocytes are released by various cytokines, including FIO-a,

In the psoriatic plaques themselves, a high level of TNF-a is detected. It is believed that TNF-a promotes the production of other inflammatory cytokines, such as IL-1, IL-6, IL-8, and granulocyte-macrophage colony-stimulating factor.

High concentrations of TNF-a in the blood of patients with psoriatic arthritis are associated with such clinical manifestations as:

• fever;
• enthesopathy;
• osteolysis;
• the appearance of destructive changes in the joints:
• ischemic necrosis.

In the early psoriatic arthritis, cerebrospinal fluid in the CSF is detected in high concentrations with IL-10. TNF-a and matrix metalloproteinases. A direct correlation between TNF-α levels is shown. Matrix metalloproteinase type 1 and markers of cartilage degradation. In patients with synovial syncope biopsies, intensive infiltration of T- and B-lymphocytes, in particular CD8 + T cells, was detected. Also, they are identified in places where the tendons attach to the bone even in the early stage of inflammation. CD4 T cells produce other cytokines: IL-2, interferon y, and lymphotoxin, which are found in the cerebrospinal fluid and synovia of patients with this disease. Frequent sporadic cases of psoriasis in HIV infection are one of the evidence of the involvement of CD8 / CD4 cells in the pathogenesis of psoriatic arthritis.

Recently, the issue of the reasons for the enhancement of bone tissue remodeling in psoriatic arthritis in the form of resorption of terminal phalanges of the fingers, the formation of large eccentric joint erosions, and the characteristic pencil in cup type deformation are discussed. When biopsies of bone tissue in the areas of resorption revealed a large number of multinuclear osteoclasts. Two signaling molecules are needed to convert osteoclast precursor cells to osteoclasts: the first is a macrophage colony stimulating factor that stimulates the formation of macrophage colonies that are precursors of osteoclasts, the second is the RANKL (receptor activator of NF-KB ligand receptor activator NF-KB ligand) , which triggers the process of their differentiation into osteoclasts. The latter has a natural antagonist - osteoprotegerin, which blocks the physiological reactions of RANKL. It is suggested that the mechanism of osteoclastogenesis is controlled by the ratio between the activity of RANKL and osteoprotegerin. Normally, they should be in equilibrium, if the RANKL / osteoprotegerin ratio is violated in favor of RANKL, uncontrolled formation of osteoclasts occurs. In synovial biopsy specimens of patients with psoriatic arthritis, an increase in the level of RANKL and a decrease in the level of osteoprotegerin were detected, and in the serum, an increase in the level of circulating CD14 monocytes, the precursors of osteoclasts.

The mechanism of pationitis and ankylosis in psoriatic arthritis is not yet clear; involve the participation of a transforming growth factor b, vascular endothelial growth factor, bone morphogenic protein. Increased expression of transforming growth factor b was found in the synovia of patients on psoriatic arthritis. In an experiment on animals, bone morphogenic protein (in particular, type 4), acting in conjunction with the vascular endothelial growth factor, promoted the proliferation of bone tissue.

Symptoms of the psoriatic arthritis

The main clinical symptoms of psoriatic arthritis:

• psoriasis of the skin and / or nails;
• defeat of the spine;
• defeat sacroiliac articulations;
• entesite.

Psoriasis of skin and nails

Psoriatic skin damage can be limited or common, in some patients psoriatic erythroderma is observed.

The main localization of psoriatic plaques:

• the scalp;
• area of the elbow and knee joints;
• navel area;
• axillary areas; about mezhyagodichnaya fold.

One of the frequent manifestations of psoriasis, except for rashes on the skin of the trunk and the scalp, is psoriasis of the nails, which can sometimes be the only manifestation of the disease.

Clinical manifestations of psoriasis of the nails are diverse. The most common are:

• psychedelic psoriasis;
• onycholysis:
• podnoggevye hemorrhages, which are based on papillomatosis of papillae with dilated terminal vessels (a synonym for subungual psoriatic erythema, "oil spots");
• subungual hyperkeratosis.

Peripheral psoriatic arthritis

The onset of the disease can be either acute or gradual. In most patients, the disease is not accompanied by morning stiffness, for a long time may be limited and localized on one or more joints, such as:

• interphalangeal joints of hands and feet, especially distal ones;
• metacarpophalangeal;
• metatarsophalangeal;
• temporomandibular;
• wrist-wrist;
• ankle;
• ulnar;
• the knee.

Less common psoriatic arthritis can debut with hip joint lesions.

Often the involvement of new joints occurs asymmetrically, in the joints of the hands randomly (chaotically). Characteristics of peripheral inflammation of the joints:

• involvement of distal interphalangeal joints of hands and feet with the formation of "radish-shaped" deformation; about dactylyte;
• Axial psoriatic arthritis with periarticular phenomena (simultaneous lesion of three joints of one finger: metacarpal or metatarsophalangeal, proximal and distal interphalangeal joints with a peculiar cyanotic-crimson coloration of the skin over the affected joints).

5% of patients have a mutating (osteolytic) form - a "visiting card" of psoriatic arthritis. Outwardly this fails with shortening of fingers and feet due to resorption of terminal phalanges. At the same time there are multiple multidirectional subluxations of the fingers, there is a symptom of the "looseness" of the finger. The bones of the wrist, the interphalangeal joints of the hands and feet, the styloid processes of the ulnar bones, the heads of the temporomandibular joints are also subjected to osteolysis.

Dactylite is found in 48% of patients with psoriatic arthritis, many of them (65%) involve toes with the subsequent formation of radiographic signs of destruction of articular surfaces. It is believed that dactylitis develops due to inflammation of flexor tendons, and as a result of inflammation of interphalangeal, metatarsophalangeal or metacarpophalangeal joints of one finger. Clinical manifestations of acute dactylitis:

• severe pain;
• swelling, edema of the entire finger;
• painful limitation of mobility, mainly due to flexion.

In combination with periarticular phenomena, the axial inflammatory process in the joints forms a "sausage-shaped" deformation of the fingers. Dactylitis can also be not only acute, but also chronic. It is noted thickening of the finger without pain and redness. Persistent dactylitis without adequate treatment can lead to rapid formation of flexion contractures of the fingers and functional limitations of the hands and feet.

Spondylitis

Occurs in 40% of patients with psoriatic arthritis. Often, snundilitis is asymptomatic, with isolated spinal injury (without signs of peripheral inflammation of the joints) - a rarity: it is met only in 2-4% of patients. Changes are localized and sacroiliac joints, ligamentous apparatus of the spine with the formation of syndesmophytes, paravertebral ossitis.

Clinical manifestations are similar to Bekhterev's disease. Characterized by the pain of the inflammatory rhythm and stiffness, which can occur in any part of the spine (thoracic, lumbar, cervical, sacrum area). In most patients, changes and spine do not lead to significant functional impairment. However, 5% of patients develop a clinical and X-ray picture of typical ankylosing spondylitis, right up to the formation of a "bamboo stick".

Enthesitis (enthesopathy)

Epteziz - the place of attachment of ligaments, tendons and articular capsule to the bone, enthesitis - a frequent clinical manifestation of psoriatic arthritis, manifested by inflammation in the attachment of ligaments and tendons to the bones with subsequent resorption of the subchondral bone.

The most typical localizations of entesite are:

• posterolateral surface of heel bone directly at the site of Achilles tendon attachment;
• the place of attachment of the plantar aponeurosis to the lower edge of the calcaneal tuber;
• tuberosity of the tibia;
• place attachment of ligament muscles "rotator cuff" shoulder (to a lesser extent).

Enthesies and other localizations may be involved:

• First bone chondral joint on the right and left;
• 7th bone chondral joint on the right and left;
• Zadnevruzhnye and anteroposterior in the iliac bones;
• Crest of the ilium;
• A spinous process of the 5th lumbar vertebra.

X-rays are manifested in the form of periostitis, erosions, osteophytes.

[25], [26], [27], [28], [29], [30], [31], [32]

Forms

There are five main clinical variants of psoriatic arthritis.

1. Psoriatic arthritis of distal interphalangeal joints of hands and feet.
2. Asymmetric mono / aligoarthritis.
3. Mutilating psoriatic arthritis (osteolysis of articular surfaces with the development of shortening of fingers and / or fingers).
4. Symmetric polyarthritis ("rheumatoid-like" variant).
5. Psoriatic spondylitis.

Distribution to these clinical groups is carried out on the basis of the following features.

• The primary lesion of the distal interphalangeal joints: more than 50% of the total joint account is the distal interphalangeal joints of the hands and feet.
• Oligoarthritis / polyarthritis: the involvement of less than 5 joints is defined as oligoarthritis, 5 joints and more - as polyarthritis.
• Mutilating psoriatic arthritis: revealing signs of osteolysis (radiologic or clinical) at the time of examination.
• Psoriatic spondyloarthritis: inflammatory pain in the spine and localization in any of the three departments - lumbar, thoracic or cervical, reduced mobility of the spine, revealing radiographic signs of sakroileitis, including isolated sacroiliitis.
• Symmetric polyarthritis: more than 50% of affected joints (paired small joints of hands and feet).

[33], [34], [35], [36], [37]

Diagnostics of the psoriatic arthritis

The diagnosis is based on the detection of skin and / or nail psoriasis in the patient or his close relatives (according to the patient's words), the characteristic lesion of the peripheral joints, signs of spinal cord injury, sacroiliac joints, enthesopathies.

When interviewing a patient, it is necessary to establish what preceded the disease, especially if there were complaints of the gastrointestinal tract or genitourinary system, eye (conjunctivitis), which is necessary for differential diagnosis with other diseases of the group of seronegative spondyloarthropathies, in particular reactive post-enterocolitis or urogenital inflammation of joints, Reiter's disease (the sequence of involvement of joints, the presence of complaints from the spine, sacroiliac joints).

[38], [39], [40], [41], [42]

Clinical diagnosis of psoriatic arthritis

On examination, pay attention to:

• presence of skin psoriasis of characteristic localization:
• a hairy part of a head, behind auricles:
• area of the navel:
• crotch area:
• interygodic fold;
• axillary hollows;
• and / or the presence of psoriasis of the priest.

When examining the joints, the characteristic signs of psoriatic arthritis are revealed:

• dactylyte;
• inflammation of the distal interphalangeal joints.

Palpate the attachment sites of the tendon.

Identify the presence or absence of clinical signs of sacroiliitis by direct or lateral pressure on the wings of the iliac bones, determine the mobility of the spine.

The condition of internal organs is assessed in accordance with general therapeutic rules.

[43], [44], [45], [46], [47]

Laboratory Diagnosis of Psoriatic Arthritis

There are no specific laboratory tests for psoriatic arthritis.

There is often a dissociation between clinical activity and laboratory performance. RF is usually absent. At the same time, 12% of patients with psoriatic arthritis are diagnosed with RF, which creates certain difficulties in diagnosis, but is not a reason for revising the diagnosis.

Analysis of cerebrospinal fluid does not give specific results, in some cases high cytosis is detected.

Activity of peripheral inflammation of the joints with psoriatic arthritis is assessed by the number of painful and inflamed joints, the level of CRP, the severity of pain in the joints and the activity of the disease.

Instrumental diagnosis of psoriatic arthritis

A great help in diagnosis is provided by data from an x-ray examination of the hands, feet, pelvis, spine, where the characteristic signs of the disease are found, such as:

• osteolysis of articular surfaces with the formation of changes like "pencil in a glass";
• large eccentric erosion;
• resorption of terminal phalanges of fingers;
• bone proliferation:
• asymmetric bilateral sakroileitis:
• paravertebral ossitis, syndesmophytes.

Different authors proposed variants of classification criteria, which took into account the most vivid manifestations of psoriatic arthritis, such as:

• confirmed psoriasis of the skin or nails of the patient or his relatives;
• asymmetric peripheral psoriatic arthritis with a predominant lesion of the joints of the lower extremities:
  • hip,
  • the knee.
  • ankle,
  • metatarsophalangeal,
  • joints tarsely,
  • interphalangeal joints of toes.
• damage to the distal interphalangeal joints,
• presence of dactylite,
• inflammatory pain in the spine,
• defeat sacroiliac joints,
• enthesopathy;
• X-ray signs of osteolysis;
• the presence of bone proliferation;
• absence of RF.

As diagnostic criteria in 2006, the International Panel for the Study of Psoriatic Arthritis proposed the criteria CASPAR (Classification Criteria for Psoriatic Arthritis). The diagnosis can be established in the presence of an inflammatory disease of the joints (lesions of the spine or enthesis) and at least three signs from the following five.

• The presence of psoriasis, psoriasis in the past or a family history of psoriasis.
• The presence of psoriasis is defined as a psoriatic lesion of the skin or scalp, confirmed by a dermatologist or rheumatologist.
• Information about psoriasis in the past can be obtained from a patient, family doctor, dermatologist or rheumatologist, o Family history of psoriasis is defined as the presence of psoriasis in relatives of the first or second degree of kinship (according to the patient).
• Typical for psoriasis lesions of the nail plates: onycholysis, "thyme symptom" or hyperkeratosis - recorded in a physical examination.
• Negative result of the study for the presence of RF using any method, except latex test: preferably solid-state ELISA or nephelometry.
• Dactylitis at the time of examination (defined as a swelling of the entire finger) or an indication of dactylitis in a history recorded by a rheumatologist.
• X-ray confirmation of bone proliferation (ossification of the joint edges), excluding the formation of osteophytes, on the radiographs of the hands and feet.

Indications for consultation of other specialists

Psoriatic arthritis is often combined with such diseases as:

• hypertonic disease;
• cardiac ischemia;
• diabetes.

If there are signs of these diseases, patients need consultation of the relevant specialists: cardiologist, endocrinologist.

With the development of signs of progressive destruction and deformation of the joints of the hands, ischemic necrosis of the supporting (hip, knee) joint, consultations of the orthopedic surgeon for solving the issue of endoprosthetics,

Example of the formulation of the diagnosis

• Psoriatic arthritis, knee joint monoarthritis, moderate activity, stage II, functional insufficiency 2. Psoriasis, limited form.
• Psoriatic arthritis, chronic asymmetric polyarthritis with predominant lesion of the joints of the feet, high activity, stage III, functional insufficiency 2.
• Psoriatic spondylitis, asymmetric bilateral sakroileitis, stage 2 on the right, stage 3 on the left. Paravertebral ossification at the level of Th10-11. Psoriasis is common, psoriasis of the nails.

To determine the activity, radiological stage and functional deficiency, the same methods are currently used as for rheumatoid.

Differential diagnosis

Unlike rheumatoid arthritis, psoriatic arthritis is characterized by a lack of pronounced morning joint joint stiffness, symmetrical joint damage, frequent involvement of distal interphalangeal joints of hands and feet, lack of RF blood.

Erosive osteoarthritis of distal interphalangeal joints of brushes with reactive synovitis may also resemble psoriatic arthritis (distal form). However, as a rule, osteoarthritis is not accompanied by inflammatory changes in the blood, signs of spine injury (inflammatory pain in any part of the spine), psoriasis of the skin and nails. Unlike Bechterew's disease, psoriatic spondyloarthritis is not accompanied by significant functional impairment, often asymptomatic, asymetrical sakroilei, often slowly progressing, on the roentgenograms of the spine, gross paravertebral ossicata are found.

Certain difficulties for differentiation are psoriatic arthritis, if the latter occurs with keratodermia of the palms and soles, the defeat of the nails. Differentiate these diseases by the nature of the skin lesions, and also on the basis of the chronological relationship between the onset of joint inflammation and the acute urogenital and intestinal infection. With psoriatic arthritis, rashes are of a persistent nature. Patients often identify hyperuricemia, which requires the elimination of gout. Diagnosis may be assisted by examination of cerebrospinal fluid, tissue biopsies (if tofus are available) for the detection of uric acid crystals.

[48], [49], [50], [51], [52], [53], [54], [55]

Treatment of the psoriatic arthritis

The purpose of therapy is to adequately influence the main clinical manifestations of psoriatic arthritis:

• psoriasis of the skin and nails;
• spondylitis;
• dactylyte;
• entesite.

Indications for hospitalization

Indications for hospitalization are:

• complex differential-diagnostic cases;
• poly- or oligoartricular joint damage;
• relapsing psoriatic arthritis of the knee joints; the need to introduce lower limbs into the joints;
• selection of therapy for BPD;
• carrying out of therapy by biological agents;
• assessment of the tolerability of previously prescribed therapy.

Non-drug treatment of psoriatic arthritis

The use of a complex of therapeutic gymnastics both in a hospital and at home is especially important for patients with psoriatic spondyloarthritis in order to reduce pain, stiffness and increase in overall mobility.

Patients with low activity are recommended to sanatorium treatment with the use of hydrogen sulphide and radon baths.

Drug treatment of psoriatic arthritis

Standard therapy of psoriatic arthritis includes NSAIDs, BPVP, intraarticular injections of HA.

[56], [57], [58], [59], [60]

NSAIDs

Use mainly diclofenac, indomethacin in average therapeutic doses. Recently, in practical rheumatology, selective NSAIDs have been widely used to reduce unwanted effects from the gastrointestinal tract.

Systemic glucocorticosteroids

Evidence of their effectiveness, based on the results of controlled studies, with psoriatic arthritis is not, except for the opinion of experts and descriptions of individual clinical observations. Use of glucocorticosteroids is not recommended because of the risk of exacerbation of psoriasis.

Intra-articular administration of glucocorticosteroids is used in mono-oligoarticular form of psoriatic arthritis, and also in order to reduce the severity of the symptoms of sacroiliitis by the administration of glucocorticosteroids to the sacroiliac joints.

Basic anti-inflammatory drugs

Sulfasalazine: effective against the symptoms of joint inflammation, but does not inhibit the development of radiologic signs of joint destruction, it is usually well tolerated by patients, prescribed at a dose of 2 g / day.

Methotrexate: Two placebo-controlled studies were conducted. The efficacy of intravenous pulse therapy with methotrexate at a dose of 1-3 mg / kg of body weight, methotrexate at a dose of 7.5-15 mg / week inwards, and a higher efficacy of methotrexate 7.5-15 mg in the third / week compared with cyclosporin A in a dose of 3-5 mg / kg. Methotrexate had a positive effect on the main clinical manifestations of psoriatic arthritis and psoriasis, but did not inhibit the development of radiographic signs of joint destruction.

When methotrexate was used in high doses, one patient died from bone marrow aplasia.

Cyclosporine : No placebo-controlled studies were conducted. In controlled comparative studies of cyclosporine at a dose of 3 mg / kg / day and other DMARDs, its positive effect on the clinical manifestations of joint inflammation and psoriasis was shown, according to a general assessment of the activity of psoriatic arthritis by a doctor and patient (mean total effect). With a duration of observation of 2 years, it was noted that the progression of radiographic signs of joint damage slowed.

Leflunomide: the effectiveness of the drug is shown in an international double-blind, controlled trial. Leflunomide had a positive effect on the course of psoriatic arthritis, according to the score of painful and swollen joints, a global assessment of the activity of the disease by a doctor and patient. In 59% of patients, as a result of treatment, an improvement was achieved in the criteria of the effectiveness of PsARC (Psoriatic Arthritis Response Criteria) therapy, the basic quality of life indicators were improved, and the severity of psoriasis decreased (a weak overall effect). At the same time, leflunomide slowed the development of destructive changes in the joints.

The drug is administered orally at a dose of 100 mg / day for the first three days, then 20 mg / day.

Gold salts, aminoquinoline preparations (hydroxychloroquine, chloroquine) in psoriatic arthritis are ineffective.

[61], [62], [63], [64]

Inhibitors of TNF-a

Indications for the use of TNF-a inhibitors: the lack of the effect of therapy with DPO, in combination or separately, in adequate therapeutic doses:

• constant high "disease activity (the number of painful joints more than three, the number of swollen joints more than three, dactylitis is considered as one joint);
• acute dactylyte;
• generalized enterosopathy;
• psoriatic spondylitis.

The efficacy of infliximab in psoriatic arthritis was also confirmed by multicenter placebo-controlled randomized trials, IMPACT and IMPACT-2 (Infliximab Multinational Psoriatic Arthritis Controlled Trial), which included more than 300 patients.

Infliximab is given in a dose of 3-5 mg / kg in combination with methotrexate or in the form of monotherapy (with intolerance or contraindications to the use of methotrexate) according to the standard scheme.

The algorithm of therapy of psoriatic arthritis depends on clinical manifestations. Sequence of administration of the main groups of drugs.

• Peripheral psoriatic arthritis:
  • NSAIDs;
  • DMAP;
  • intra-articular injection of glucocorticosteroids;
  • inhibitors of TNF and (infliximab).
• Psoriasis of skin and nails:
  • steroid ointments;
  • PUVA-therapy;
  • systemic use of methotrexate;
  • systemic use of cyclosporine;
  • inhibitors of TNF-a (infliximab).
• Psoriatic spondylitis:
  • NSAIDs;
  • introduction of glucocorticosteroids into the sacroiliac joint;
  • pulse therapy with glucocorticosteroids;
  • inhibitors of TNF-a (infliximab).
• Dactylite:
  • NSAIDs;
  • intraarticular or periarticular administration of glucocorticosteroids;
  • inhibitors of TNF-a (infliximab).
• Entezit:
  • NSAIDs;
  • periarticular administration of glucocorticosteroids;
  • inhibitors of TNF-a (infliximab).

Surgical treatment of psoriatic arthritis

Surgical methods of treatment are necessary in case of destructive lesion of large supporting joints (knee and hip joints, hand and foot joints) with pronounced functional impairments. In these cases, endoprosthetics of hip and knee joints, reconstructive operations on the hands and feet are performed. Stubborn inflammatory processes of knee joints are an indication for surgical or arthroscopic synovectomy.

Approximate terms of incapacity for work

The duration of incapacity for psoriatic arthritis is 16-20 days.

[65], [66], [67], [68]

Further management

After discharge from the hospital, the patient should be under the supervision of a rheumatologist and dermatologist at the place of residence to monitor the tolerability and effectiveness of therapy, promptly treat exacerbations of inflammatory processes in the joints, assess the need for the use of biological therapy.

What should the patient know about psoriatic arthritis?

When the first signs of inflammation in the joints of a patient with psoriasis appear, he should turn to a rheumatologist. If you have diagnosed psoriatic arthritis, but provided you receive adequate and timely treatment, you can stay active and working for many years. The choice of the therapy program depends on the clinical form of the disease, the activity of the inflammatory process in the joints and the spine, the presence of concomitant diseases. During treatment, strive to fully comply with all the recommendations of a rheumatologist and dermatologist, see your doctor regularly to monitor the effectiveness and tolerability of all medications prescribed to you.

Prevention

Specific prevention of psoriatic arthritis does not exist.

[69], [70], [71], [72], [73]

Forecast

If psoriatic arthritis rapidly progresses, accompanied by the appearance of erosive changes with a significant disruption of the function of the joints, especially in the case of the mutating form of the disease or the development of ischemic necrosis of large (supporting) joints, the prognosis of the disease will be serious.

The combined standard mortality rate among patients is higher than in the population, by an average of 60% and is 1.62 (1.59 for women and 1.65 for men).

[74]