Angina

Psoriatic arthritis prognosis. Criteria for diagnosing psoriatic arthritis

Psoriasis is a chronic, relapsing disease that manifests itself mainly in the form of rashes of profusely scaly plaques on the skin, but which can also be accompanied by damage to other organs, primarily damage to the joints, as well as bones, muscles, pancreas, lymph nodes, and kidneys. , various neurological and psychiatric symptoms. Therefore, modern scientists sometimes prefer the term: psoriatic disease.

For example, at the III International Symposium on Psoriasis in 1987, prof. Novotny from Czechoslovakia made a report entitled “Visceral psoriasis” and presented a classification in which forms such as psoriatic nephritis, endocrinopathic form of psoriasis, etc. were identified. And of course, in our time it is no longer possible to consider psoriasis only as a dermatosis limited to damage to the skin and nails. It follows that we must be critical of the definition of psoriasis made in most textbooks, where it is considered as an isolated lesion of the skin.

An autopsy study of the condition of the internal organs of patients with psoriasis revealed alterative changes in the walls of the vessels of the main substance, depolymerization of fibrillar structures of connective tissue, the appearance of perivascular cellular infiltrates and macrophage nodules in the myocardium, kidneys, etc. Reversible and irreversible changes in nerve cells have also been identified (Buharovich M.N. et al. - in the collection: Systemic dermatoses. - Gorky, 1990).

It should be emphasized that the etiology and pathogenesis of psoriasis remains poorly understood, and that the most likely causes of psoriasis are a complex relationship of genetic and many other influences. But this definition still says little about the pattern of articular and visceral lesions in psoriasis.

What psoriatic rashes on the skin look like, what psoriatic changes in the nails look like, what methods confirm the diagnosis of skin psoriasis, what purely morphological changes in the skin underlie the so-called “psoriatic triad”, how psoriasis progresses, what complications there are - you have studied all this in detail or you will study it in practical classes, and we will not touch on this issue in the lecture.

I’ll just say why you need this, at first glance, purely dermatological knowledge and diagnostic techniques. The fact is that a family doctor, local therapist, surgeon, or traumatologist in their practical work often has to meet with patients with psoriatic arthritis. And in order to recognize this form of joint damage, you need to be able to recognize the skin manifestations of psoriasis. By the way, the ability to diagnose psoriatic arthritis is provided for by the qualification characteristics of a general practitioner approved by the Ministry of Health.

Joint diseases are one of the most common types of human pathology, and there are up to 100 nosological forms. Apparently, at least 20 million people in the world suffer from these diseases. Among patients with various forms of chronic inflammatory diseases of the joints, rheumatoid arthritis undoubtedly ranks first in frequency at present. However, psoriatic arthritis, which, according to the modern classification, is classified as a group of rheumatoid diseases, also occupies an important place due to the incidence rate, resistance to therapy, the complexity of diagnosis and often unfavorable prognosis.

According to the All-Union Arthrological Center (Abasov E.M., Pavlov V.M., 1985), in patients with chronic monoarthritis, psoriatic arthritis is more common (7.1%) than ankylosing spondylitis - ankylosing spondylitis (5.3%), yersinia arthropathy (2.7), tuberculous synovitis (3.1) and other joint diseases. The actual incidence of psoriatic arthritis is undoubtedly much higher, since many patients, especially those with widespread skin rashes, are treated in dermatological hospitals and are not taken into account by statistics. In addition, psoriatic arthritis is often not recognized and not registered in a timely manner, since it can occur for a long time without characteristic skin rashes. And then, as many famous rheumatologists noted at the All-Union Conference in 1988, patients are mistakenly diagnosed with rheumatoid arthritis, infectious-allergic polyarthritis, etc.

It is believed that psoriatic arthritis develops on average in 7% (according to the American rheumatologist Rodnan G.P., 1973) or even in 13.5% of patients with psoriasis (according to Moscow rheumatologists). But psoriasis itself is a very common disease. Using mathematical analysis, it was found that the probability of developing psoriasis during one’s lifetime is 2.2% (Mordovtsev V.N. et al., 1985). Thus, the probability of developing psoriatic arthritis during a person's lifetime (up to 75 years) is approximately 0.1-0.15 (i.e. 100-150 per 100,000 population). This is a fairly high frequency: according to this calculation, in the city of Chelyabinsk with a population of 1 million people, one can expect from 1000 to 1500 patients with psoriatic arthritis. This calculation is confirmed by information from Erdes and Benevolenskaya, employees of the Institute of Rheumatology of the Academy of Medical Sciences, who in 1987 cited the figure of 0.1% as an indicator of the incidence of psoriatic arthritis among the population of Moscow.

Since today we will talk about joint diseases, we need to get acquainted with some general information.

Firstly, articular syndrome is a combination of joint(s) pain, swelling, stiffness and limited function. Joint swelling can be caused by intra-articular effusion (increased volume of synovial fluid), thickening of the synovial membrane of the joint, thickening of periarticular (extra-articular) soft tissues, intra-articular fatty growths, etc. Consequently, articular syndrome may be due to both intra-articular and periarticular changes.

The term arthritis(synovitis) refers to inflammatory lesions of the synovial membrane, accompanied by its hypertrophy and effusion into the joint.

The term arthrosis(or osteoarthritis) denotes degenerative damage to cartilage in the underlying bone, primary or secondary, accompanying inflammation and other factors.

Psoriatic arthritis belongs to the so-called seronegative arthritis: rheumatoid factor, as a rule, RF is not detected in patients with psoriatic arthritis - rheumatoid factor is antibodies to the Fc fragment of IgG, which are found in the blood serum of most patients with rheumatoid arthritis and some other diseases). But what kind of disease is psoriatic arthritis? Ailbert, who first described arthritis in a patient with psoriasis in 1882, believed that this was a random combination. However, it has now been proven that psoriatic arthritis is a special nosological form that naturally occurs in patients with psoriasis.

On etiology and pathogenesis There is no point in stopping at psoriatic arthritis, since it is simply not known, like the etiology and pathogenesis of psoriasis. Those interested can look at the collection “PSORIASIS” (M., 1980). There they will find various assumptions about the role of the CEC and cellular immunity, cyclic nucleotypes and lipid metabolism disorders, changes in the intestinal mucosa and nervous system, etc. The viral theory of the etiology of psoriasis will not be forgotten. But in the end it turns out that psoriasis is a multifactorial disease and the discovery of its pathogenesis is a matter of the future.

True, it is of interest that in patients with vulgar psoriasis and psoriatic erythroderma, HLA B13 and B17 antigens are found approximately 4 times more often than in the population. It is estimated that carriers of the B13 antigen have a risk of developing psoriasis almost 9 times greater than those who do not have this antigen (Erdes S. et al., 1986). But in patients with psoriatic arthritis, the frequency of detection of the HLA B27 antigen is 2-3 times higher than in the population: in patients with psoriatic arthritis, this antigen occurs in approximately 20-25%, and among the population in 7-10%. In patients with uncomplicated psoriasis (without symptoms of arthritis), the B27 antigen occurs with the same frequency as in healthy individuals, i.e. at 7-10%. The diagnostic significance of the HLA B27 antigen in psoriatic arthritis is due to the fact that it is found in 80-90% of patients with psoriatic arthritis with damage to the spine (“central arthritis”) and sacroiliac joints, but when only peripheral joints are affected, this antigen is found with such the same frequency as in healthy individuals (Brewerton et. al. 1974; Lambert et. al. 1976).

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The degree of activity characterizes the inflammatory process both in the joints and in other organs and systems and is determined according to the criteria proposed for rheumatoid arthritis.

I. The minimum degree of activity is manifested by minor pain when moving. There is no morning stiffness or its duration does not exceed 30 minutes. ESR is not increased (no more than 20 mm/h), body temperature is normal. Exudative manifestations in the joint area are absent or slightly pronounced. No other inflammatory symptoms are detected.

II. A moderate degree of activity involves pain at rest and with movement. Morning stiffness lasts up to 3 hours. Moderate, unstable exudative symptoms are detected in the joint area. ESR within 20-40 mm/h, significant leukocytosis and band shift. Body temperature is often subfebrile.

III. The maximum degree of activity is characterized by severe pain at rest and during movement. Morning stiffness lasts more than 3 hours. Severe exudative phenomena are observed in the area of periarticular tissues. ESR is above 40 mm/h. High body temperature. Significant increase in the level of biochemical laboratory parameters (sialic acids, SRV, fibrinogen, etc.). The development of remission of the inflammatory process is possible, especially with the monooligoarthritic variant of the articular syndrome and limited vulgar psoriasis.

Laboratory indicators. Laboratory changes when psoriatic arthritis are nonspecific and reflect the degree of activity of the inflammatory process. With a moderate and maximum degree of inflammation activity, anemia, accelerated ESR, leukocytosis are determined, the appearance of SRV is noted, dysproteinemia with an increase in globulins due to α- and γ-fractions, etc. In 20% of patients, hyperuricemia is determined, which shows the severity of skin changes and almost never accompanied by clinical symptoms of gout. In 5-10% of cases of psoriatic arthritis, a positive test for RF is detected in small (not higher than 1/64) titers.

In patients with osteolytic variant of joint damage a violation of the aggregation properties of erythrocytes is detected, leading to an increase in blood viscosity and a decrease in hematocrit).

In case malignant form of psoriatic arthritis very pronounced deviations from the norm of nonspecific signs of inflammation and significant changes in immunological parameters are revealed: hypergammaglobulinemia above 30%, an increase in the concentration of immunoglobulins of classes A, G and E, circulating immune complexes, the appearance of nonspecific (antinuclear factor, rheumatoid factor) and specific (to the cells of the horn and granular layers of the epidermis) antibodies, etc. When examining the synovial fluid, high cytosis is detected (up to 15-20 x 104 / ml) with a predominance of neutrophils. The mucin clot is loose and disintegrating.

X-ray signs of psoriatic arthritis. The X-ray picture of psoriatic arthritis has a number of features. Thus, osteoporosis, characteristic of many joint diseases, in the case of psoriatic arthritis is detected only in the mutilating form. Psoriatic arthritis is characterized by the development of erosive changes in the area of the distal interphalangeal joints. Erosion, having formed at the edges of the joint, subsequently spreads to its center. In this case, the apices of the terminal and middle phalanges are worn down with simultaneous thinning of the diaphyses of the middle phalanges, and the second articular surface is deformed in the form of a concavity, which creates the radiological symptom “pencils in a glass”, or “cup and saucer”.

X-ray of fingers with psoriatic arthritis

Pathognomonic for psoriatic arthritis is the development of an erosive process with ankylosis in several joints of the same finger (“axial lesion”). Characteristic radiological signs are proliferative changes in the form of bone growths around bone erosions at the base and apex of the phalanges, as well as in the area of attachment of ligaments, tendons and joint capsules to the bones (periostitis). Osteolysis of the bones that make up the joint is a distinctive feature of the mutilating form of psoriatic arthritis. Not only the epiphyses are subject to resorption, but also the diaphyses of the bones of the joints involved in the pathological process. Sometimes the lesion affects not only all the joints of the hands and feet, but also the diaphyses of the bones of the forearm.

X-ray signs of psoriatic spondylitis manifest themselves in the form of vertebral and paravertebral asymmetrical rough ossifications, creating the “jug handle” symptom, ankylosis of the intervertebral joints. Sometimes X-ray changes in the spine do not differ from those characteristic of ankylosing spondylitis. Sacroiliitis in psoriatic arthritis is often asymmetrical (one-sided). If bilateral changes are noted, they usually have varying degrees of severity.

However, the development of sacroiliitis, similar to that of ankylosing spondylitis, is possible.

Radiologically, the stage of damage to peripheral joints is determined according to Steinbrocker, and the sacroiliac joints - according to Kellgren. If spondyloarthritis is present, its signs are indicated (syndesmophytes or paraspinal ossifications, ankylosis of intervertebral joints).

The degree of functional insufficiency of the joints and spine is assessed according to the principle accepted in domestic rheumatology. There are three degrees of joint dysfunction depending on the preservation or loss of the ability to carry out professional activities and self-care.

Various forms of psoriatic arthritis comprehensively reflect the main features of the pathological process, the degree of its severity, the degree of progression of osteochondral destruction, the presence and severity of systemic manifestations, the functional state of the musculoskeletal and other body systems.

The severe form is characterized by generalized arthritis, ankylosing spondylitis with severe spinal deformity, multiple erosive arthritis, lysis of the epiphyses of bones in two or more joints, functional failure of the joints of degree II or III, severe general (fever, exhaustion) and visceral manifestations with dysfunction of the affected organs, progressive course of exudative or atypical psoriasis, maximum degree of activity of the inflammatory process for three consecutive months or more. Diagnosis of this form requires the presence of at least two of the above symptoms.

The usual form is characterized by inflammatory changes in a limited number of joints, the presence of sacroiliitis and (or) damage to the overlying parts of the spine, but without functional insufficiency, destructive changes in single joints, a moderate or minimal degree of activity of the inflammatory process, a slowly progressive course, systemic manifestations without functional insufficiency organs, limited or widespread vulgar psoriasis.

The malignant form develops exclusively in young men (under 35 years of age) with the presence of pustular or erythrodermic psoriasis. It is distinguished by a particularly severe course with prolonged hectic fever, rapid loss of body weight to cachexia, generalized arthritis with a pronounced exudative component, spondyloarthritis, generalized lymphadenopathy and numerous visceritis. This form of psoriatic arthritis is difficult to treat, is characterized by a paradoxical reaction to anti-inflammatory therapy (including glucocorticosteroids) and an extremely unfavorable prognosis, often ending in death.

Psoriatic arthritis in combination with diffuse connective tissue diseases, rheumatism, Reiter's disease, gout. Combined forms of the disease are rare, but the rarest option is the combination of psoriatic arthritis with systemic lupus erythematosus.

Examples of clinical diagnoses:

Psoriatic arthritis, polyarthritic variant with systemic manifestations (renal amyloidosis, end-stage renal failure), severe form. Widespread psoriasis vulgaris, progressive stage. Activity III. Stage III. Functional joint insufficiency degree II.
Psoriatic arthritis, spondyloarthritic variant with systemic manifestations (aortitis, left-sided anterior uveitis), severe form. Palmoplantar pustular psoriasis, progressive stage. Activity III. Stage II B. Bilateral sacroiliitis stage IV, multiple syndesmophytosis. Functional insufficiency of joints of the III degree. Palmoplantar pustular psoriasis, progressive stage.
Psoriatic arthritis, distal variant, without systemic manifestations, usual form. Activity II. Stage III. Functional joint failure of the first degree. Limited vulgar psoriasis, stationary stage.

Diagnostics. Psoriatic arthritis has a number of distinctive features, which were grouped into diagnostic criteria by D. Mathies back in 1974 and remain relevant to this day.

Diagnostic criteria for psoriatic arthritis (Mathies D., 1974):

Damage to the distal interphalangeal joints of the fingers.
Simultaneous damage to the metacarpophalangeal (metatarsophalangeal), proximal and distal interphalangeal joints, “axial damage”.
Early damage to the joints of the feet, including the big toe.
Heel pain (subcalcaneal bursitis).
The presence of psoriatic plaques on the skin or changes in the nails typical of psoriasis (confirmed by a dermatologist).
Psoriasis in close relatives.
Negative reactions to the Russian Federation.
Characteristic radiological findings: osteolysis, periosteal overlays. Absence of epiphyseal osteoporosis.
Clinical (usually radiological) symptoms of unilateral sacroiliitis.
X-ray signs of spondylitis are rough paravertebral ossifications.

Diagnostic rule: the diagnosis is reliable if three criteria are present, one of which must be 5th, 6th or 8th. In the presence of the Russian Federation, five criteria are required, among which the 9th and 10th must be present.

Joint diseases
V.I. Mazurov

This disease belongs to the stages of psoriasis with progressive damage to small peripheral joints. Often, psoriatic arthritis appears before skin lesions of psoriasis.

The disease can appear at any age (most often the age of patients is 30-50 years), it mainly affects women.

Psoriasis is a hereditary chronic disease characterized by epidermal growth, plaque rash, and damage to the musculoskeletal system and internal organs. The exact cause of psoriasis is unknown. There are many theories:

heredity;
autoimmune process;
viral infection;
endocrine pathology.

Active psoriatic arthritis is characterized by the following:

one joint may be affected (monoarthritis), several (oligoarthritis), many (polyarthritis);
appears more often 3-5 years after the rash, sometimes during or before the appearance of the rash;
inflammation affects the lower extremities (knee, ankle, feet), sometimes small joints of the fingers, toes and large joints, rare spine;
the affected joint swells, there is a local increase in temperature, redness, and sometimes pain;
stiffness is typical, especially in the morning;
with damage to the spine (spondylitis) and sacrum, pain and stiffness are detected in the upper and lower back, buttocks;
Dystrophic, destructive and inflammatory changes are observed in the joints (arthralgia - pain in them, osteolysis and osteoporosis - destruction of bone tissue, contractures - restriction of movement), which lead to dislocations, subluxations, ankylosis - immobilization.
inflammation of the tendons may progress - tendonitis (damage to the Achilles tendon leads to painful walking);

sometimes there is damage to the articular cartilage (the process in the cartilage between the ribs and the sternum causes pain, as in costochondritis);
there are changes in the nail plate in the form of depressions and tubercles;
Acne often progresses.

In severe cases, pathological changes in internal organs are observed:

eyes- inflammation of the iris (iridocyclitis), which is accompanied by photophobia, pain, lacrimation;
respiratory system- pneumonia (pneumonia) and pleurisy, which cause pain and shortness of breath;
heart- aortitis, which can block the aortic valve and lead to shortness of breath and heart failure; myocarditis with conduction disturbances; heart defects;
liver- hepatitis and cirrhosis develop.

This creates a syndrome that includes: arthritis, acne on the palms and soles, osteitis (bone inflammation).

Process stages

The disease has three stages:

psoriatic enthesopathy- a pathological process in the periarticular tissues, which is characterized by pain (especially during movements), changes are detected on ultrasound, MRI, scintigraphy;
psoriatic arthritis- the process moves to the synovial membranes, bones (the synovial and synovial-osseous forms are distinguished, respectively);
deforming stage, in which deformities, subluxations, dislocations, osteolysis, osteoporosis, and ankylosis are visible on x-rays.

Clinical forms

Classification of forms of the disease includes:

unilateral mono/oligoarthritis (asymmetrically affects up to three joints);
distal interphalangeal;
symmetrical polyarthritis (similar to rheumatoid);

mutilating (deforming);
spondylitis and sacroiliitis (affects the spine, sacroiliac and hip joints).

Diagnostics

The doctor makes a diagnosis based on examination and identification of a characteristic clinical picture, medical history of the patient and his family members, and special diagnostics.

A general blood test is performed, where anemia and acceleration of ESR can be detected (however, acceleration is also possible with a neoplasm, infection, pregnancy). Equally important is a test for rheumatoid factor (to rule out rheumatoid arthritis). Examine the intra-articular fluid obtained by arthrocentesis (puncture) for uric acid crystals and leukocytes (for differential diagnosis with gout, infections).

On X-rays and MRI, you can see changes in cartilage, damage to bone tissue, osteolysis, bone growths, and deformities. The scan reveals osteoporosis and bone fractures.

There is a method for identifying the genetic marker HLA-B27 (positive in half of the cases in psoriatic spine disease).

The presence of a rash characteristic of psoriasis greatly facilitates the diagnosis.

It is necessary to conduct a test for the Koebner phenomenon: when scraping the surface of the plaque, a light, loose stain similar to stearin appears first, then a wet surface appears, and upon subsequent scraping, a drop of blood is released.

Differential diagnosis is carried out with:

rheumatoid arthritis (a symmetrical process is noted, the presence of RF in the blood and joint fluid, rheumatoid nodules);
Reiter's disease (there is a temporal connection with a urogenital infection, skin changes quickly progress and disappear);
Ankylosing spondylitis with damage to the spine (inherent constant arthralgia, poor posture, X-ray shows the spine as a “bamboo stick”);
gout (with severe pain, bluish-purple skin over the joint, increased levels of uric acid in the blood and joint fluid).

Treatment methods

When treating this pathology, an integrated approach and a quick solution are necessary, since there is a high risk of worsening the condition with the development of disability.

For psoriasis, a hypoallergenic diet with increased potassium levels and reduced fat is prescribed.

The regimen during treatment is gentle on motor movements. Regular exercise will help relieve stiffness and reduce pain. In addition, exercise will maintain the size of movements, increase flexibility and elasticity of muscles, normalize weight and thus reduce the load on joints and increase endurance.

In parallel with the treatment of arthritis, psoriasis is treated with local and systemic medications. Prescribed:

enterosorbents;
hepatoprotectors;
calming;
vitamin products.

The initial stage is treated with non-steroidal anti-inflammatory drugs (for example, ibuprofen, nimesulide, indomethacin, voltaren, naproxen - Advil, Motrin), which are selected individually by the attending physician.

Side effects (stomach irritation, ulcers, gastric bleeding) are prevented with the following drugs: cytotel, omeprazole, lansoprazole, famotidine.

In severe forms, glucocorticosteroids (prednisolone, hydrocortisone) can sometimes be prescribed.

They are used very rarely and only as prescribed by a doctor, as they provoke relapses, a malignant form, and serious side effects (for example, nephropathy).

Intravenous immunosuppressants are widely used:

Methotrexate;
Sulfasalazine;
Chlorbutin.

If absolutely necessary, intra-articular drugs are administered.

In very severe cases, plasmapheresis, hemosorption, and hemodialysis are performed to reduce inflammation and symptoms of psoriasis.

You should not expect quick healing, since improvements will occur only after 3-6 months.
Therapeutic and preventive therapy to prevent deterioration, relapses, complications includes antioxidants (vitamin E), chondrostimulants and chondroprotectors.

Such drugs include:

Chondroitin;
Chondroxide;
Glycosaminoglycans;
Alflutop;
Arthrodar;
Arteparon.

In rare cases, surgical treatment is indicated: arthroplasty, placement of endoprostheses, osteotomy.

In non-acute cases, balneo-, climatic-, physiotherapy (ultrasound, magnetic therapy), and ultraviolet light therapy are indicated.

Psoriatic arthritis is an inflammatory pathology that affects the joints. Its leading clinical manifestations are pain in the spine and muscles, the formation of plaques on the skin, subsequent deformation of the vertebral bodies, bone, cartilage joint structures. Treatment of psoriatic arthritis is conservative with the use of drugs from various clinical and pharmacological groups, physiotherapeutic measures, and exercise therapy.

General description of the disease

Psoriatic arthritis is one of the forms of psoriasis, diagnosed in 5-7% of patients. and spine usually occur after severe skin lesions. Bright pink nodules, covered with silvery scales, form on it. It is this specific symptom that allows you to quickly diagnose the pathology.

The small interphalangeal joints are the first to be involved in the inflammatory process, and then the large joints and the spinal column are damaged. In the absence of medical intervention, after a few years the patient may become disabled due to destructive changes in cartilage, bones, and development.

Classification of pathology

Psoriatic arthritis is characterized by various course options. The forms of the disease differ in the severity of symptoms, the number of people involved in the process, and the order in which they are affected.

Asymmetrical shape

This is the most common clinical form of the disease. Oligoarthritis affects no more than four asymmetrically located joints of the feet or hands. There is severe swelling of the fingers and a purplish-bluish coloration of the skin in the area of inflammation. Often the course of the pathology is complicated. This is the name for inflammation of the flexor tendons, which are equipped with soft tunnels of connective tissue (sheaths).

Arthritis of the distal interphalangeal joints

Arthritis affecting the distal interphalangeal joints is characterized by the most typical clinical picture for this pathology. and swell, the skin turns red and becomes hot to the touch. Painful sensations occur not only during the day, but also at night, further worsening the psycho-emotional state of a person.

Symmetrical shape

With this form of psoriatic arthritis, five or more interphalangeal and metacarpophalangeal small joints are involved in the inflammatory process. The symptoms of the pathology are similar to the clinical manifestations of rheumatoid diseases, which significantly complicates the diagnosis. With symmetrical arthritis, random deformation of the joints and multidirectional axes of the fingers are often observed.

Mutilating

The disease, which occurs in a mutilating form, often causes subluxations, irreversible deformities, and shortening of the fingers and toes. Such destructive-degenerative changes are provoked by osteolysis - complete resorption of bone tissue without the formation of fibrous foci. Mutilating psoriatic arthritis is often accompanied by spondyloarthritis and severe skin symptoms.

Psoriatic spondylitis

Adequate assessment of stressful situations

In group sessions with a psychotherapist, patients are taught to respond adequately to conflict situations in order to prevent stress or depression. They are the ones that most often act as factors that provoke relapses of psoriasis.

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To date, literally tons of medical works and treatises and tons of popular literature have been written about psoriasis. There are not many effective methods for treating psoriasis, and even fewer that are reliably helpful.

For example, most symptoms of psoriasis regress when the climate changes to a maritime one. With moderate insolation, the plaques become faded, many of them disappear, and in some cases, psoriasis is cured. But there are forms in which tanning is contraindicated. In some cases, psoriasis is complicated by psoriatic arthritis, which occurs in 10% - 40% of patients.

The disease itself is common in the population in the region of 2-3%, and this means that at least one person out of five hundred has some signs of psoriatic arthritis.

It should not be confused with psoriatic, despite some similarities in the clinical picture.

The most important criterion for distinguishing them is the presence of a cutaneous form of psoriasis or its history in case of suspected psoriatic arthritis and specific signs of damage in rheumatoid arthritis, for example, seropositive forms in the presence of rheumatoid factor.

Psoriatic arthritis - what is it?

The most interesting thing is that there is no exact connection between the amount and duration of the cutaneous form of psoriasis and joint manifestations. Therefore, the definition of the type “psoriatic arthritis is joint damage as the next stage of rashes” is fundamentally incorrect.

There is a connection with rashes, but it is very conditional. Psoriasis can occur in the form of joint damage quite severely, but its skin manifestations can be insignificant, but still, complete joint damage without skin rashes is a rare occurrence.

The causes of psoriatic arthritis are just as hidden as the causes of psoriasis. There are many theories, ranging from metabolic to hereditary, but none of them can fully explain the cause of autoimmune inflammation.

risk factors (photo 1)

There are several risk factors that increase the likelihood of joint damage:

Presence of nail lesions due to psoriasis. Nail plates are “transitional tissue” between the skin and joints, and if they are affected, the surface of the nail plate becomes covered with small pits, which are clearly visible in reflected light. The nails become like the surface of a thimble (see photo 1);
Presence of skin rashes. And their severity and activity are not even as pronounced as the bright flesh – red around the edges and itchy skin – as evidenced by the length of the disease;
Age. The most often affected is the “blooming period” - from 30 to 50 years. As for gender differences, men and women suffer equally often, but the disease manifests itself in different forms.

Symptoms of psoriatic arthritis by type

The main symptom of psoriatic arthritis of any localization is pain and limitation of movement. The pain intensifies with physical activity, but can also bother the patient at rest. Like all chronic diseases, psoriatic arthritis occurs with exacerbations and remissions.

During the period of remission, joint damage may not be detected at all, and a person may forget about the disease, deciding that everything has passed, but one morning he wakes up with old pains and realizes that the disease has not gone away.

How does psoriatic arthritis progress during exacerbation?

Most often, the joints are affected asymmetrically, for example, in one person the index finger on the left hand, the small joints of the toes on the left, and the temporomandibular joint on the right may be simultaneously affected;
Involvement of the joints of the axial skeleton, for example, the iliosacral joints and temporomandibular joints, may indicate an unfavorable course of the disease;
During exacerbation, the color of the affected joints is bluish and purple. This is most noticeable on the fingers and toes, which become hot, swollen and painful;
Often when fingers are affected, all joints of the finger are affected, and pain begins in the middle of the palm. The entire finger loses its usual shape and swells evenly, resembling a purple-bluish “sausage”. This uniform inflammation of the tissue is called psoriatic dactylitis, or complete damage to the joints of the finger;

Types of psoriatic joint damage

You can identify several types of symptoms of psoriatic arthritis - joint damage due to psoriasis:

Asymmetric arthritis, which affects several joints, including the joints of the hand, foot, wrist, and elbow.

In general, with psoriasis, damage to small joints is more typical than to large ones, but if large joints are involved, then this also does not happen alone.

Thus, isolated psoriatic arthritis of the knee joint is hardly possible; first of all, such a process must be differentiated with a specific lesion, primarily with tuberculous gonitis, as well as with gonococcal and chlamydial chronic infections.

Symmetrical lesion involving axial joints.

As mentioned above, this form is more severe, and general symptoms may occur with it: malaise, mild low-grade fever, muscle pain.

A special type of axial lesion is psoriatic sacroiliitis, which can continue as an inflammatory lesion of small intervertebral joints. The outcome of such a disease can often be a sharp limitation of mobility in the back.

Arthritis that affects only small joints.

Most often, these are the distal joints near the nail phalanges. As mentioned above, changes in the nails appear first, and then the joints are involved. Most often, this variant develops in men.

A special, rare form of the malignant course of the disease is mutilating arthritis, in which deformation and autoimmune inflammation are so pronounced that the hands become disfigured and deformed, lysis of bone tissue occurs with shortening of the phalanges.

If in arthritis there are nodules resembling rheumatoid ones, tophi, there is a connection with the course of a urogenital infection, rheumatoid factor is detected in the blood, and there is no skin evidence of psoriasis, then most likely we are talking about damage to the joints of another etiology (chlamydia, gout ).

Stages of psoriatic arthritis

There is no uniform classification of the stages of psoriatic arthritis. This is judged on the basis of the following data:

whether or not there is concomitant damage to the axial joints, the presence of sacroiliitis;
number of joints involved;
is there a phenomenon of distal osteolysis (destruction of the phalanges);
are there any systemic manifestations (amyloidosis, conjunctivitis, heart defects, uveitis, Raynaud's syndrome, polyneuritis, etc.);
how pronounced the phase of disease activity is, or whether remission has developed.

Based on the overall picture, the stage of the disease is determined. An important criterion is an X-ray examination of the affected joints, which is divided into 4 stages, from mild osteoporosis to complete fusion of the joint space and the development of ankylosis.

Treatment of psoriatic arthritis, drugs

Treatment of psoriatic arthritis continues for many years as a chronic disease. If arthritis is accompanied by rashes (skin manifestations of psoriasis), then with the regression of these rashes the course of the joint syndrome improves.

One of the most reliable non-drug ways to influence articular syndrome is to normalize body weight and give up bad habits, first of all, giving up beer and weak alcoholic drinks.

NSAIDs, basic therapy and cytostatics

Treatment of exacerbations of psoriatic arthritis involves the administration of NSAIDs. Nimesulide (“Nise.” “Nimesil”) has proven itself well as an analgesic and anti-inflammatory agent.

In the event that there is intense autoimmune inflammation involving the axial joints, then the use of cytostatics, such as methotrexate according to a certain scheme together with folic acid, is indicated. Cyclosporine, colchicine, sulfasalazine, leflunomide, and gold preparations are also used.

Monoclonal antibodies

One of the modern and promising methods of treating psoriatic arthritis is the use of monoclonal antibodies, which can suppress the migration of leukocytes to the site of inflammation and prevent the formation of specific antibodies.

Antibodies that inhibit tumor necrosis factor (TNF-alpha) are used - infliximab, adalimumab.

Hormones

In modern treatment of psoriatic arthritis, hormones are rarely used, and all modern treatment regimens prefer to do without them. Their use, although it does not lead to the formation of Cushingoid syndrome, often transfers the course of psoriatic arthritis to a torpid phase, resistant to other drugs.

Of the indications for taking prednisolone, only the malignant course of the disease remains. Intra-articular administration of hormones to relieve local inflammation (Diprospan) is more widely used.

Treatment prognosis

If treatment for the symptoms of psoriatic arthritis is started in a timely manner (that is, before the appearance of radiological signs of severe arthritis), then there is a chance of stabilizing the condition and improving the quality of life.

Unfavorable signs of rapid deterioration of the condition are exudative inflammation, damage to more than 5 joints, including axial ones, the presence of sacroiliitis and systemic manifestations (carditis, amyloidosis, reactive hepatitis), and nail damage. In this case, hormones, basic drugs and cytostatics are used in therapy, and monoclonal antibodies remain reserve drugs.

The prognosis for life with psoriatic arthritis without systemic manifestations is favorable, but the quality of life in severe cases can be reduced, even leading to disability for various groups.