This article is about the most important broadlines for the management of psoriatic arthritis and skin psoriasis.  

For management purposes we divide psoriasis-related disorders into three big entities:

The musculoskeletal entity which we call psoriatic arthritis and that is managed by the rheumatologist

The dermatological entity which can be psoriasis of the skin or the scalp or the nails and these are managed by the dermatologist

And the associated comorbidities entity which mostly comprises high blood cholesterol and high blood pressure that associate with severe intense psoriatic arthritis or severe skin psoriasis and that are managed by the internist or the general practitioner.

 

Since eye inflammation is not common in this disease so we will not give it much space here. If it happens, management will be coordinated between the rheumatologist and ophthalmologist.

 

So, we are here to discuss the first three big entities.

 

Once we define which entities are affected in a given patient, you don’t have to have all 3 entities of course, we go to the next step which is breaking down each entity into its smaller components and assessing the extent of affection and inflammation in each of those components.

And I will explain what I mean:

 

For example, if you have psoriatic arthritis, that is, you have an affection in the structures of your musculoskeletal system, we need to define where exactly is your affection among the structures of your musculoskeletal system: is it inflammation of the peripheral joints, like the joints of the hands and feet and ankles and knees? Or is it inflammation of the tendons mostly? We call this tenosynovitis. Or is it inflammation of those parts of the tendons that attach to the bones. We call this enthesitis. Or is it affection of the joints of the spine and sacroiliac joints in the back of the pelvis. We call this spondylitis and sacroiliitis.

 

And why do we need to make that level of distinction?

Because when we prescribe a treatment plan, what is good for inflammation of one structure might not always be good for another. For example, inflammation of the joints of the hands and feet can respond nicely to a class of medications that we call non-biologic disease modifying anti-rheumatic drugs or non-biologic DMARDs, and only if one or more of the medications from that class fail due side effects or due to failure to control this inflammation do we proceed to substituting or adding to our prescription a medication from the more powerful class of medications that we call biologic DMARDs. Please refer to my two videos about those two classes of medications for more information about them. I will leave the links in the comments below.

 

On the other hand, if we document that your inflammation is mostly, not in the peripheral joints of the hands and feet but rather is in the spine, the non-biologic DMARDs have no place here from the start and it is only biologic DMARDs that are really effective. So, here if antiinflammation painkillers do not work for a mild spine affection, we skip the step of trying a non-biologic DMARD and we proceed straight away to the more powerful biologic DMARDs. This is an example of how the process goes.

 

So, what if a patient has inflammation both in the peripheral joints and in the spine at the same time? Most likely we skip the non-biologic DMARDs step as this is of no use for the spine and we will still proceed to the biologic DMARDs that should control the spine and of course also the peripheral joints. It is exceptional that you will have a patient who will require a biologic DMARD that works so nicely for the spine but not that much for the peripheral joints in which case we combine a non-biologic DMARD for the peripheral joints.

 

So, as you can see, the final management decisions will be related or dictated by where the main affection happens.

 

Now the second entity: skin.

How about if you have psoriasis of the skin or the scalp or the nails? Here, the dermatologist will decide mostly at the start on topical treatments, creams and emollients, maybe also PUVA, ultraviolet light therapy. If, inflammation however is so intense or if patients do not respond, the dermatologist will proceed to non-biologic DMARDs, and if medications from that family are not enough to control the skin disease, he will, lastly, proceed to biologic DMARDs.

 

Communication and collaboration between the rheumatologist and the dermatologist, as you can also see, is very important in the management of psoriatic disorders because we sometimes need to coordinate management of the skin entity and the musculoskeletal entity together.

 

It is very important to note here that when we prescribe non-biologic DMARDs for inflammation of the musculoskeletal system or for the skin, there are some medications that are so good for both entities, like methotrexate for example. There are some medications that are known to be good and effective for the joints but not really for the skin like salasopyrin or leflunomide. I am using the scientific names by the way as trade names are different in different countries. And there are some medications that are so popular for skin affection but that are not as effective for the joint affection like cyclosporine for example. All this makes a good communication between the rheumatologist and the dermatologist more and more important.

 

Regarding the high blood cholesterol and the high blood pressure that associate with psoriasis diseases, this is more likely to be under control or to even be prevented by good treatment of the first two entities, the skin and the musculoskeletal entities. If we control them, we can save patients a lot of trouble and prevent the development of atherosclerosis of the blood vessels over the long term.

 

In all cases, treatment of any entity should be started as early as possible. The earlier the better the outcome always.

 

When discussing management of psoriatic arthritis and skin psoriasis we should not of course ignore the important role of patient education, instructions for lifestyle modification and physical therapy if needed.

 

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This post was prepared and published by  Dr. Hatem Eleishi. Dr. Hatem Eleishi is a professor of rheumatology at Cairo university (Egypt) and is especially dedicated to supporting arthritis patients with online educational videos and articles about arthritis causes and treatment. He also runs a rheumatology clinic in Cairo and a center for www.tabibakom.com/en that, in addition to providing online rheumatology consultations, also provides online medical consultations in several different medical specialties by expert consultants from Egypt, Canada and the United States.

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