Psoriasis arthropathica L40.50

Psoriasis that simultaneously affects the skin (see psoriasis) and joints(psoriatic arthritis).

Form of chronic rheumatoid factor-negative polyarthritic syndrome characterized by psoriasis with involvement of the DIP and PIP on the hands and feet. In 25% of cases, psoriatic arthritis progresses as destructive arthritis and causes permanent disability. The arthritis(psoriatic arthritis) can precede the skin symptoms by years and vice versa.

• Psoriasis in the population: 1-3%
• Arthritis psoriatica in patients with psoriasis: 5-20%
• Psoriatic arthritis in the population as a whole: 0.1-0.2%
• Men and women are equally affected.

see below Psoriatic arthritis

Frequently infestation of the knee joint, then finger, ankle and toe joints; so-called "transverse infestation": Inclusion of the finger end joints as well as the toe joints or "infestation in the beam": Basic, middle and end joints affected (so-called dactylitis) with swelling of a finger or toe.

• Preferential involvement of the finger end joints and nail changes
• Severe deformity with ossifications/articular stiffness and joint changes leading to mutilation.
• Symmetrical infestation of several joints (comparable to rheumatoid arthritis without rheumatoid factors)
• Infestation of one or less joints in the course of psoriasis (see below psoriasis vulgaris).
• Psoriatic arthritis with spinal manifestation.

Uric acid (a strong increase in uric acid is said to correlate with a severe course of the disease). Negative rheumatoid factors. 10-15% of patients with psoriatic arthritis show antibodies against cyclic citrullinated peptides ( CCP-AK). In spondylarthritis often positive association with HLA-B27.

Cooperation with the rheumatologist. Protecting the joints during flare-ups, endurance training between flare-ups. In addition to movement exercises, movement baths (34 °C) and connective tissue massages , supplementary occupational therapy (joint protection, self-help training, functional training).

Remember! No tablets without physiotherapy!

As a decongestant measure in acute attacks, ice packs provide relief, in other cases heat packs with fango or mud. Supplementary short-wave treatment, interferential current treatment or ultrasound. Vitamin E in a dosage of < 300 mg/day is helpful, as is selenium (200 mg/day) and zinc supplementation. The intake of eicosanoids, e.g. omega-3 fatty acids, has proved extremely effective.

Remember! The medication does not cure the disease, but enables the patient to live with it as symptom-free as possible!

Non-steroidal anti-inflammatory drugs in ointment or gel form (e.g. Target Gel, Voltaren Emulgel).

Glucocorticoids: Intra-articular glucocorticoid injections such as triamcinolone crystal suspension (e.g. Lederlon) under the usual aseptic conditions. For finger and toe joints 1.5-3 mg, hand and ankle joints 10-20 mg intra-articularly is sufficient. Infiltration of the peritendinous tissue and painful tendon insertions.

Step-by-step therapy see below. Tab. 2 "Stepwise therapy for psoriasis arthropathica".

• Non-steroidal anti-inflammatory drugs: Indometacin (e.g. Amuno) 100-150 mg/day, diclofenac (e.g. Voltaren Drg.) 100-200 mg/day or ibuprofen (e.g. ibuprofen Klinge Drg.) 800-1200 mg/day p.o. Therapy to be used as needed or regularly.
• Glucocorticoid shock therapy: For intermittent relapse activity, glucocorticoid shock with prednisone equivalent (e.g. Decortin) 40 mg/day p.o., reduce by 5 mg every 3 days. Caveat. Gastric protection with e.g. Riopan gel.

Reminder. Every moderately severe or severe, clinically active psoriatic arthritis requires a basic therapy!

• Methotrexate: In severe cases methotrexate (e.g. Lantarel tbl.) 10-20 mg/week p.o. or i.m. (total dose max. 1.5 mg/week). (total dose max. 1.5 g!).
• Fumaric acid esters: Alternative trial with fumarates 1000-1200 mg/day p.o. (e.g. Fumaderm), gradual dosage. Improvement of symptoms after about 2-3 months.
• Combination therapy: The combination of MTX and fumarates has proven to be effective, especially in acute relapses. After about 3-4 months, after the acute attack has subsided, MTX can be discontinued and the Fumaderm therapy is continued. Close laboratory monitoring is a matter of course.

In case of a refractory relapse, "pulse therapy" with high-dose glucocorticoids i.v. such as prednisolone (e.g. Solu Decortin H) 500-1000 mg/day on 3 consecutive days.

Notice. Glucocorticoids are not successful in all cases!

• Basic therapy: Peroral gold therapy (e.g. Auranofin) 6 mg/day p.o. If there is no improvement after 4-6 months, the dose may be increased to 9 mg/day p.o.
  Alternative: Sulfasalazine (e.g. Azulfidine): Initial 500 mg/day p.o., weekly increase by 500 mg up to max. 2-3 times 1000 mg/day.
• Ciclosporin A (Sandimmun): Very effective and indicated in severe forms (dosage: 2.5 mg/kg bw/day p.o.).
• Etanercept (e.g. Enbrel): In refractory cases.
• Leflunomide (e.g. Arava): initially 100 mg/day for 3 days, then 20 mg/day. Comparable results exist with sulfasalazine with regard to efficacy and safety (TOPAS study). Therapeutic effect is expected after 4-6 weeks.
• Golimumab (Simponi): 1 time/month 50 mg s.c. (on the same day of each month), if necessary in combination with the individually required dose of MTX.

• Upadacitinib is a selective and reversible JAK inhibitor. In human cell-based assays, upadacitinib preferentially inhibits JAK1 or JAK1/3 signaling pathways compared to other cytokine signaling pathways mediated via JAK2. Dosage 15 mg alternatively 30 mg/day.

Notice. Basic therapy must be avoided in pregnancy and infertility. Anticonception is indicated with all basic therapeutics, with cytotoxic substances also in men.

Forms of psoriatic arthritis (according to Moll and Wright)

Step-by-step therapy for psoriasis arthropathica

For skin involvement, see psoriasis, for psoriatic arthritis, depending on the stage of inflammation, cold application for severely inflamed joints, including cold chambers. In the case of reactive muscle tension, the application of heat(mud bath or pack, heat bath) or sauna has proved effective.

Anti-inflammatory phytotherapeutic agents are indicated for joint and skin manifestations of psoriasis, and phytotherapeutic agents for infection prophylaxis are indicated for patients undergoing immunosuppressive or immunomodulating therapy.

Anti-inflammatory ph ytotherapeutics: Omega-3-rich vegetable oils (e.g. linseed oil, hemp oil, evening primrose oil), turmeric(Curcuma longa rhizoma), devil's claw(Harpagophyti radix), willow bark(Salicis cortex), frankincense(Boswellia serrata), ginger(Zingiberis rhizoma) and the three-winged fruit(Tripterygium Wilfordii HOOK.F./TwHF).

Bromelain has an anti-inflammatory and cartilage-protective effect and should be included in the treatment of arthritis.

Infection-preventing phytotherapeutics: these include above all preparations containing mustard oil(isothiocyanates) and at the same time symptom-relieving preparations such as eucalyptus oil (eucalypti aetheroleum/cineole).

Antioxidants such as vitamins C and E (< 300 mg/day), trace elements selenium (<200 mg/day) and zinc.

See also under psoriatic arthritis and with regard to skin involvement under psoriasis and the respective variants.