What's to know about psoriatic arthritis flare-ups
One study has found that people who do not receive treatment within the first two years of onset will have more severe problems.
A flareup, flare, or relapse is a time when the symptoms get worse. It is difficult to know when a flare-up will occur, but avoiding some triggers may help prevent them.
Treatment can help manage inflammation and the symptoms it causes. Newer medications, known as biologics, reduce both the risk of a flare and the severity of symptoms if one does occur.
Experts do not know exactly what causes PsA to appear, but — like psoriasis — it is a type of psoriatic disease.
The link between psoriasis and PsA
Stiffness and fatigue can indicate the start of a PsA flare.
Psoriasis and PsA are not the same conditions, but scientists have found close links between them, and they can occur together.
Many people with psoriatic disease have only skin involvement or only joint problems. Among those who experience both, 70% of people have skin changes first, 15% develop skin symptoms after PsA appears, and for 15%, both symptoms appear at the same time.
Research shows that people with psoriatic disease often have similar genetic features to each other. Specific genetic changes appear to underlie different types of PsA and psoriasis. At least 10% of people may have genes that can lead to psoriasis
These features can run in families. If a person's close relative has psoriatic disease, there is a chance that they may develop it too. However, not everyone in this situation will develop the disease.
This is because environmental factors also play a role. If a person has the genetic features but has no exposure to certain triggers, they are unlikely to develop psoriasis or PsA.
Triggers for initial onset include having strep throat or another infectious disease, which may trigger an overreaction in the immune system in susceptible people.
Triggers for onset and a flare include:
- Stress, which can trigger symptoms and make them worse.
- Medications, such as lithium, antimalarials, beta blockers quinidine, and indomethacin.
- Physical stress on the joints, for example, through obesity, which can make inflammation worse.
- Smoking, which is prevalent in people with psoriasis.
- An injury, such as a blow to the knee.
A person who already has PsA may find that symptoms worsen when they change their medication. Other individual triggers might include a lack of sleep, overexertion, or a poor diet.
Avoiding these triggers may help prevent PsA or a flare from starting.
Swollen fingers are a hallmark of PsA.
Early signs of a flare include:
- pain, throbbing swelling, stiffness, and warmth in the joints
- a worsening of skin symptoms
- tenderness, pain, and swelling in tendons
- swollen fingers and toes
- difficulty moving
- stiffness and tiredness after sleep
- nail changes
Symptoms and severity can vary widely between individuals. They can be mild and develop slowly, or they can be quick and severe.
When to see a doctor
A person should see a doctor if they have:
- the beginning of joint pain, especially if there is a personal or family history of psoriasis
- new or worsening symptoms
- the signs of a new flare
- pain in a single joint, which could indicate an infection
Early treatment of initial symptoms or a flare can help:
- manage PsA overall
- reduce the impact of a flare and the severity of symptoms
- limit permanent joint damage
Treatment can help manage symptoms during a flare and improve the overall outlook of psoriasis and PsA. Following the treatment plan can help reduce the risk of a flare.
Biologics and alternatives
Long-term use of biologics can help:
- prevent flares
- reduce the severity of symptoms during flares
- prevent long-term damage
They work by targeting specific parts of the immune system.
Biologics are not suitable for everyone, however, and especially those who are prone to frequent infections.
In these cases, a doctor may prescribe methotrexate, cyclosporine, or apremilast (Otezla), which a person can take by mouth. These types of medication are known as oral small molecule drugs (OSM).
Another option is tofacitinib (Xeljanz).
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, reduce inflammation, pain, and swelling. A person can apply them to the skin or take them by mouth.
If this is not effective, a doctor can prescribe a stronger pain relief medication.
People with PsA should always ask their doctor before taking NSAIDs or other over-the-counter (OTC) drugs, as there may be adverse effects or interactions with other medications.
Steroid treatment can help reduce inflammation, swelling, and pain during a flare. They are available as a topical treatment to apply the skin, in tablet form, or a doctor may inject the drug directly into the joint.
Long-term use can lead to adverse effects, so a doctor will only prescribe steroids during a flare and when symptoms are severe.
Disease-modifying antirheumatic drugs (DMARDs) suppress substances in the body that cause inflammation. They can help to limit joint damage, reduce pain, and slow the progression of PsA.
Adverse effects include:
Long-term side effects include:
- an increased risk of infection
- liver damage
DMARDs are a long-term option that can help manage PsA overall.
Low-impact exercise can strengthen muscles and boost a person's mood.
During a flare, a person may benefit from:
- getting medical help as soon as symptoms appear
- following their current treatment plan
- getting enough rest and sleep
- reducing activity levels
- doing low-impact exercise, such as tai chi, yoga, and swimming, unless it will worsen symptoms
- following a healthful diet
- limiting alcohol intake
- limiting stress, where possible
Smoking can make symptoms worse and increase the risk of long-term problems. Guidelines published in 2018 strongly recommend that people with PsA who smoke should join a smoking cessation program.
Learning as much as possible about PsA, its effects, and the treatment options available can help a person feel in control of their situation and equip them to take an active role in staying as well as possible.
A 2018 systematic review concluded that the following natural remedies might help people with psoriasis.
Physical therapy may also help.
What natural remedies might help with PsA? Find out here.
PsA is a type of psoriatic disease that can lead to joint problems, fatigue, and other symptoms. Symptoms can worsen during times of flare.
Getting an early diagnosis, starting treatment as soon as possible, and knowing and avoiding triggers can help reduce the number of flares and the severity of symptoms.
If a flare begins, a doctor can help manage it by prescribing or adjusting medications. Following the doctor's instructions about medication and lifestyle measures can also help an individual manage a flare.
In the long term, new biologic drugs and other therapies are showing promise for reducing flares, managing symptoms, and possibly slowing the progress of PsA.
I have had severe psoriasis for several years and now I am starting to develop PsA. Will this also be severe? If I have flares, will both types happen at the same time or at different times?
Although, there is some concern that the PsA may also be a severe form, it may not be. The initial 3 to 6 months of arthritis symptoms may give you an idea of what your pattern of symptoms will be.
Working closely with your doctors in the early stage of arthritis is important to develop the best treatment plan. Skin flares and joint flares can occur at the same time, but they also occur separately. Usually a pattern for each individual will become apparent over time.Nancy Carteron, MD, FACR Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.