Arthritis mutilans is a rare and severe form of arthritis that affects the hands and feet. It is most common in people with psoriatic arthritis but can also develop in those with rheumatoid arthritis.
Psoriatic arthritis mutilans is very rare. Approximately 5 percent of people with psoriatic arthritis (PsA) develop this condition. Arthritis mutilans can cause bone loss, also called osteolysis, which leads to changes in the shape of the fingers or toes and can impair a person's movement. It can also cause neck or lower back pain.
PsA mutilans can result in permanent damage to the fingers, toes, hands, and feet. However, research has provided evidence that early diagnosis and treatment of PsA can prevent the progression of joint damage to arthritis mutilans.
In this article, we look at the symptoms, causes, and treatment of PsA mutilans.
PsA mutilans occurs when PsA becomes severe, and the resulting inflammation attacks bone tissue and causes it to break down. The body then reabsorbs the bone.
When a person develops PsA mutilans, they may experience the following symptoms:
- fingers or toes that shorten and bunch together, which is called telescoping
- loose skin that bunches up over shortened fingers or toes
- joints in the hands and feet that are difficult or impossible to move
- bones that fuse, which doctors refer to as ankylosis
- other abnormalities of the anatomy of the fingers and toes
The distinctive appearance of telescoping fingers and bunched skin is sometimes called opera glass hand. This term describes how telescoping fingers may lengthen like opera glasses when a physician pulls them open during a physical examination.
People with PsA mutilans will also have other symptoms of PsA and possibly psoriasis too, which can include:
- joint pain or throbbing
- stiffness and swelling in joints
- nails that separate from the nail bed or look pitted
- red patches of skin with silvery scales
- tenderness, pain, and swelling of the tendons, which connect muscle to bone
- uveitis, which can cause painful red eyes and blurry vision
PsA mutilans happens when PsA becomes severe and interferes with normal bone growth and regeneration. The acute inflammation attacks bones and joints, and the body absorbs bone tissue, resulting in loss of bone and deformities in the hands or feet.
PsA and psoriasis are autoimmune diseases in which the immune system attacks healthy cells in the body.
- With PsA, the immune system attacks healthy joints, causing inflammation, pain, swelling, and other symptoms.
- In psoriasis, the immune system causes skin cells to renew too quickly, leading to red rashes with a covering of silvery scales that flake off.
The exact cause of the excessive immune response is not clear, but it may have a genetic component. Researchers have identified several genes that can increase the risk of getting psoriasis and PsA. About 40 percent of people with PsA have a family member with psoriasis or arthritis.
However, genetics is not the only cause. Experts believe that some environmental factors, such as injuries or infections, may also affect a person's risk of developing psoriatic disorders.
Having PsA or psoriasis is a risk factor for PsA mutilans. However, most people with these conditions will not get PsA mutilans.
The authors of a case report state that with today's effective treatments for PsA, PsA mutilans has become extremely rare. Many of the reported cases in medical literature show that PsA mutilans often develops when a person with PsA has not received treatment for many years.
It is possible to conclude from this that even if a person gets PsA, their risk of PsA mutilans is low if they take effective medications to control inflammation.
Experts do not know why some people get PsA and others do not. One study found that having both obesity and severe psoriasis skin symptoms increases a person's risk of getting PsA. However, research has not linked these factors to a person's risk of getting PsA mutilans.
A doctor may be able to identify arthritis mutilans from a physical examination because it causes distinctive changes in a person's fingers and toes.
However, they may need to run tests to determine whether PsA or rheumatoid arthritis (RA) is causing arthritis mutilans. Some of the tests may include:
An X-ray can show whether there is damage to or reabsorption of the bones and joints. Doctors may see a pencil-in-cup formation of joints. One side of the joint or end of the bone may resemble the pointed end of a pencil with the adjacent bone having a flatter, cup-like appearance.
While doctors cannot use a blood test to diagnose PsA, it can help them diagnose or rule out RA. People who have RA usually have a specific antibody in their blood, which people without the condition do not have. In addition, people with PsA may have higher levels of inflammation in their blood.
An MRI scan can provide a doctor with a more detailed look at the joints.
The presence of signs of psoriasis can be a clue as to whether a person has PsA. A doctor may check for the distinctive red rash with silvery scales.
There is no specific treatment for PsA mutilans, but treatments for PsA can help slow or stop joint damage and bone loss.
Biologics, disease-modifying antirheumatic drugs (DMARDs), and new oral treatments aim to control the condition by targeting the immune system.
Pain relief medication can help manage symptoms when flares occur.
Biologics are an emerging drug class that targets specific parts of the immune system. Guidelines from 2018 recommend these drugs as a first-line treatment for most people with a new diagnosis of PsA.
Doctors give these as an injection (shot) or intravenous infusion. They are a long-term therapy that can help prevent flares, reduce the severity of symptoms, and protect the body from long-term damage.
However, biologic therapy may not be suitable for everyone, and the drugs can cause some adverse effects. A doctor will discuss the options with the patient.
If a person cannot use a biologic drug, a doctor may recommend a DMARD.
These can reduce inflammation and help a person manage PsA by decreasing the body's overactive immune response. Managing inflammation can reduce the risk of permanent damage.
New oral treatments
Oral small-molecule drugs may be a suitable option for people who cannot undergo biologic therapy. These drugs target small molecules in the immune cells to stop inflammation from PsA that can lead to PsA mutilans.
Nonsteroidal anti-inflammatory drugs
Nonsteroidal anti-inflammatory drugs, such as ibuprofen, naproxen, and aspirin, can help relieve pain.
Aggressive physical therapy can help some people with PsA mutilans keep their joints mobile. It may also help prevent PsA mutilans from getting worse. Moving the joints can help relieve some of the inflammation resulting from PsA mutilans.
Turmeric has powerful anti-inflammatory abilities and could help prevent or minimize PsA flares.
There is not enough evidence to suggest that turmeric alone can treat PsA or PsA mutilans. However, the authors of a systematic review and meta-analysis concluded that it could provide a complement to medications and other clinical management.
It is important to talk with a doctor before taking supplements and other remedies as they can interfere with some medications and potentially have adverse side effects.
Physical activity provides several benefits for people with PsA. It can help keep joints flexible, boost mood, and improve overall mental well-being.
As PsA mutilans can cause a loss of function in the affected joints, it may interfere with a person's quality of life. People who have digit abnormalities from PsA mutilans can find it difficult to carry out daily tasks.
Some of the following measures can help a person with PsA mutilans cope with their symptoms:
- Seeing a clinician regularly to ensure that treatment is working. Doing this can help prevent the disease from getting worse.
- Talking with a doctor about all aspects of health. Physical pain is one symptom of PsA, but some research suggests that the disease may also cause depression, anxiety, and other mental health issues. Tell a doctor if PsA mutilans is affecting any aspect of well-being.
- Joining a support group. Talking about PsA and arthritis mutilans with others who understand can help with emotional well-being. Online, local, and national support groups exist for people with PsA.
- Getting help. If possible, a person should ask friends, neighbors, or family members for help with difficult tasks. People with PsA mutilans may benefit from having a private duty nurse or health care aide if they are unable to take care of their personal tasks and home responsibilities.
Experts have not identified a definitive way to prevent PsA mutilans, but taking medications for PsA and keeping the inflammation under control may help prevent it or slow its progression.
Many people can achieve remission from PsA with today's medications. Remission means that the condition is not active in the body and is not getting worse, which may help reduce the risk of the individual getting PsA mutilans or joint damage from PsA.
Even after achieving remission, however, a person will need to continue taking their PsA medications to keep the disease from coming back.
Early and aggressive treatment of PsA can help preserve a person's quality of life and the function of affected joints.
Although there is no cure for PsA, and it is not possible to restore lost bone, today's advanced treatments are an effective way to slow the progression of the disease and help prevent the onset of PsA mutilans.