How to diagnose psoriatic arthritis. What is psoriatic arthritis (polyarthritis), what and how to treat it? Non-steroidal anti-inflammatory drugs

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The degree of activity characterizes the inflammatory process both in the area of ​​the joints and from 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 during movement. Morning stiffness is absent 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 area of ​​the joints are absent or slightly pronounced. Other inflammatory symptoms are not detected.

II. Moderate activity suggests pain at rest and on movement. Morning stiffness lasts up to 3 hours. Moderate, unstable exudative symptoms are determined in the area of ​​\u200b\u200bthe joints. ESR within 20-40 mm/h, significant leukocytosis and stab 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. Pronounced exudative phenomena are observed in the area of ​​periarticular tissues. ESR above 40 mm/h. High body temperature. A significant increase in the level of biochemical laboratory parameters (sialic acids, SRV, fibrinogen, etc.). It is possible to develop a remission of the inflammatory process, especially in the mono-oligoarthritic variant of the articular syndrome and limited psoriasis vulgaris.

Laboratory indicators. Laboratory changes at 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 CRV, dysproteinemia with an increase in globulins due to α- and γ-fractions, etc. are noted. Hyperuricemia is determined in 20% of patients, 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, a decrease in hematocrit).

When 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 horny and granular layers of the epidermis) antibodies, etc. When examining the synovial fluid, high cytosis (up to 15-20 x 104 / ml) is found with a predominance of neutrophils. The mucin clot is loose, decaying.

X-ray signs of psoriatic arthritis. The radiological picture of psoriatic arthritis has a number of features. Thus, osteoporosis, which is characteristic of many diseases of the joints, 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. Erosions, formed along the edges of the joint, further spread to its center. In this case, the tops of the terminal and middle phalanges are grinded off with simultaneous thinning of the diaphysis of the middle phalanges, and the second articular surface is deformed in the form of concavity, which creates an x-ray symptom of “pencils in a glass”, or “a cup and a saucer”.

X-ray of the fingers in psoriatic arthritis

1. Psoriatic arthritis, polyarthritic variant with systemic manifestations (amyloidosis of the kidneys, terminal renal failure), severe form. Widespread psoriasis vulgaris, progressive stage. Activity III. Stage III. Functional insufficiency of joints II degree.
2. Psoriatic arthritis, spondyloarthritic variant with systemic manifestations (aortitis, left-sided anterior uveitis), severe form. Palmar-plantar pustular psoriasis, progressive stage. Activity III. Stage II B. Bilateral sacroiliitis stage IV, multiple syndesmophytosis. Functional insufficiency of joints III degree. Palmar-plantar pustular psoriasis, progressive stage.
3. Psoriatic arthritis, distal variant, without systemic manifestations, common form. Activity II. Stage III. Functional insufficiency of the joints of the 1st degree. Limited psoriasis vulgaris, stationary stage.

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

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

1. Damage to the distal interphalangeal joints of the fingers.
2. Simultaneous lesion of the metacarpophalangeal (metasophalangeal), proximal and distal interphalangeal joints, "axial lesion".
3. Early damage to the joints of the feet, including the big toe.
4. Pain in the heels (heel bursitis).
5. The presence of psoriatic plaques on the skin or a change in the nails typical of psoriasis (confirmed by a dermatologist).
6. Psoriasis in next of kin.
7. Negative reactions to RF.
8. Characteristic radiographic findings: osteolysis, periosteal overlays. No epiphyseal osteoporosis.
9. Clinical (usually X-ray) symptoms of unilateral sacroiliitis.
10. X-ray signs of spondylitis are gross paravertebral ossifications.

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

Joint diseases
IN AND. Mazurov

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

The disease can appear at any age (more often the age of patients is 30-50 years), women are predominantly ill with it.

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

1. heredity;
2. autoimmune process;
3. viral infection;
4. endocrine pathology.

Active psoriatic arthritis is characterized by:

• one joint (monoarthritis), several (oligoarthritis), many (polyarthritis) can be affected;
• appears more often 3-5 years after the rash, sometimes during or before the onset of the rash;
• inflammation covers the lower extremities (knee, ankle, feet), sometimes small joints of the fingers, toes and large, rarely the spine;
• the affected joint swells, there is a local increase in temperature, redness, sometimes pain;
• stiffness is characteristic, especially in the morning;
• with damage to the spine (spondylitis) and the sacrum, pain and stiffness are detected in the upper and lower back, buttocks;
• dystrophic, destructive and inflammatory changes are noted in the joints (arthralgia - pain in them, osteolysis and osteoporosis - destruction of bone tissue, contractures - restriction in 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 a lesion of the articular cartilage (the process in the cartilage between the ribs and the sternum causes pain, as in costal chondritis);
• there are changes in the nail plate in the form of depressions and tubercles;
  acne often progresses.

In severe cases, pathological changes in the internal organs are noted:

1. eyes- inflammation of the iris (iridocyclitis), in which photophobia, pain, lacrimation are noted;
2. respiratory system- pneumonia (pneumonia) and pleurisy, which cause pain, shortness of breath;
3. heart- aortitis, which can block the aortic valve and lead to shortness of breath and heart failure; myocarditis with impaired conduction; heart defects;
4. liver- develop hepatitis, cirrhosis.

Thus, a syndrome is formed, which includes: arthritis, acne on the palms and feet, osteitis (inflammation of the bone).

Process steps

The disease has three stages:

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

Clinical forms

The 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 (the spine, sacroiliac and hip joints are affected).

Diagnostics

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

Conduct a general blood test, where you can detect anemia, accelerated ESR (however, acceleration is possible with neoplasm, infection, pregnancy). No less important is the test for rheumatoid factor (to rule out rheumatoid arthritis). Examine the intra-articular fluid obtained by arthrocentesis (puncture) for uric acid crystals, leukocytes (for differential diagnosis with gout, infections).

X-rays and MRIs can show cartilage changes, bone tissue damage, osteolysis, bone growths, and deformities. When scanning, osteoporosis and bone fractures are detected.

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

Significantly facilitates the diagnosis of the presence of a rash characteristic of psoriasis.

It is necessary to test for the Koebner phenomenon: when the surface of the plaque is scraped off, a light, loose spot, similar to stearin, appears first, then a wet surface, with 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 connection in time with a urogenital infection, skin changes quickly progress and disappear);
• ankylosing spondylitis with damage to the spine (permanent arthralgia, impaired posture, x-rays of the spine like 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

In the treatment of this pathology, an integrated approach and a quick solution are required, since there is a high risk of aggravation of the condition with the development of disability.

With psoriasis, a hypoallergenic diet with an increased level of potassium and a reduced amount of fat is prescribed.

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

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

• enterosorbents;
• hepatoprotectors;
• soothing;
• vitamin remedies.

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 (gastric irritation, ulcers, gastric bleeding) are prevented by 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 directed by a doctor, as they provoke relapses, a malignant form, and serious side effects (for example, nephropathy).

Intravenous immunosuppressants are widely used:

1. Methotrexate;
2. Sulfasalazine;
3. Chlorbutin.

In case of emergency, intra-articular drugs are administered.

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

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

These drugs include:

• Chondroitin;
• Chondroxide;
• Glycosaminoglycans;
• Alflutop;
• Artrodar;
• Arteparon.

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

With a mild process, balneo-, climate-, physiotherapy (ultrasound, magnetotherapy), phototherapy with ultraviolet light are indicated.

(psoriatic arthropathy) is an inflammatory lesion of the joints associated with the skin form of psoriasis. Psoriatic arthritis is characterized by the presence of skin plaques, arthralgia, joint stiffness, pain in the spine, myalgia, and subsequent deformity of the vertebrae and joints. Psoriatic arthropathy is diagnosed primarily on clinical and radiological grounds. Treatment of psoriatic arthritis is carried out for a long time and systemically with the help of anti-inflammatory, vascular agents, chondroprotectors, physiotherapy, and rehabilitation measures. The progressive course of psoriatic arthritis leads to disability of the patient.

General information

Psoriatic arthritis accompanies the course of psoriasis in 5-7% of patients; less commonly, an arthritis clinic precedes skin manifestations. The etiology of psoriatic arthritis is unknown. Among the reasons considered are autoimmune and genetic mechanisms, environmental factors, in particular, infections. In favor of the hereditary theory of psoriatic arthritis is the identification of articular syndrome in 40% of the next of kin of patients with psoriasis. The inclusion of immune reactivity mechanisms in psoriatic arthritis is confirmed in laboratory tests. It is assumed that viral and bacterial agents are involved in the development of psoriatic arthritis.

Factors predisposing to the occurrence of psoriatic arthropathy include the presence of confirmed psoriasis, hereditary predisposition, age from 30 to 50 years.

Classification of psoriatic arthritis

Symptoms of psoriatic arthritis

In most patients (70%), articular syndrome develops following skin manifestations of psoriasis; in other cases (about 20%) precedes skin lesions; in the remaining 10%, the appearance of skin and joint symptoms coincides in time. Psoriatic arthritis can develop gradually with general weakness, arthralgia, myalgia, or suddenly - with acute arthritis with sharp pain and swelling of the joints. In the initial period, there is an interest in the interphalangeal joints of the fingers, metatarsal and metacarpophalangeal, knee, and shoulder joints.

Joint pain in psoriatic arthritis is worse at rest and at night; the characteristic morning stiffness and pain are relieved during the day and on movement. Oligoarthritis with asymmetric joint involvement is the most common clinical form of psoriatic arthritis. It is characterized by damage to no more than 4 joints of the feet and hands, "sausage-like" swelling of the fingers, the development of flexor tendovaginitis, purple-bluish coloration of the skin over the joints. Arthritis affecting the distal interphalangeal joints is characterized by the most typical clinic of psoriatic arthritis.

Rheumatoid-like symmetrical arthritis captures from 5 or more joints (interphalangeal, metacarpophalangeal); leads to random deformation of the joints and multidirectional long axes of the fingers. The mutilating form of psoriatic arthritis causes subluxations, irreversible deformity, and shortening of the toes and hands due to osteolysis of small bones. This variant of the course of psoriatic arthritis is often found in patients with severe skin symptoms and is combined with spondyloarthritis. Spondylitis is a form of psoriatic arthritis that affects various parts of the spine. Psoriatic spondylitis can occur alone or in combination with damage to the joints of the extremities.

Various variants of the course of psoriatic arthritis can be accompanied by muscle and fascial pains, damage to the acromioclavicular and sternoclavicular joints, achilles bursitis, eye damage (iridocyclitis, conjunctivitis), less often - kidney amyloidosis. Malignant development of psoriatic arthritis includes severe lesions of the skin and spine, generalized polyarthritis and lymphadenopathy, hectic-type fever, cachexia, involvement of visceral organs, eyes, and nervous system.

Diagnosis of psoriatic arthritis

If psoriatic arthritis is suspected, the patient needs to consult a rheumatologist and a dermatologist.

Specific criteria for the diagnosis of psoriatic arthritis are: interest of the toes and hands with simultaneous damage to several joints; diffuse swelling and deformity of the fingers; defeat of the first toes; thalalgia; psoriatic plaques on the skin and nail changes; cases of family psoriasis; the presence of radiological signs; manifestations of sacroiliitis; negative test for rheumatoid factor. A mandatory criterion is a psoriatic history in the patient or relatives.

In peripheral blood in psoriatic arthritis, leukocytosis, hypochromic anemia, and an increase in ESR are determined; in venous blood - an increase in the level of sialic acids, seromucoid, fibrinogen, γ- and α2-globulins. Psoriatic arthritis is characterized by a negative result of a blood test for the RF, the detection of immunoglobulins in the synovial membranes and skin, an increase in the levels of IgA and IgG in the blood, and the determination of the CEC. In the study of synovial effusion, increased cytosis and neutrophilia, looseness of the mucin clot, low viscosity of the joint fluid are found.

On the x-ray of the joints in psoriatic arthritis, erosion of the articular surface of the interested bone is revealed, a decrease in the width of the joint space; signs of osteoporosis, osteolysis with multiaxial displacement of the bones of the fingers, ankylosis of the joints, paravertebral calcification. If necessary, arthroscopy and diagnostic puncture of the joint are performed.

Treatment of psoriatic arthritis

There is no specific therapy for psoriatic arthritis, and therefore treatment is focused on reducing inflammation, pain, and preventing loss of joint function. The main drugs for psoriatic arthritis are NSAIDs (diclofenac, piroxicam, indomethacin, ibuprofen). In case of their poor tolerance, complications from the kidneys, gastrointestinal tract, exacerbation of skin psoriasis, it is advisable to prescribe selective COX-2 inhibitors (meloxicam, nimesulide, celecoxib). Severe stiffness of the joints is eliminated by the appointment of muscle relaxants (tolperisone hydrochloride, baclofen, tizanidine).

Systemic therapy for psoriatic arthritis includes glucocorticoids. To achieve a quick and pronounced effect (pain reduction, increase in range of motion), intraarticular administration of glucocorticosteroids is possible. The basic drugs that modify the course of psoriatic arthritis include methotrexate, leflunomide, sulfasalazine, colchicine, mycophenolate mofetil, etc. The mechanism of their action is aimed at preventing damage to healthy joints. Basic drugs are used in conjunction with NSAIDs under the control of tolerance. In severe forms of psoriatic arthritis, immunosuppressive therapy with azathioprine, cyclosporine is performed; monoclonal antibodies to TNF-α - infliximab, etanercept. electrophoresis, phonophoresis with glucocorticosteroids, solution of dimethyl sulfoxide, exercise therapy. Gross deformities and ankylosis with irreversible dysfunction of the joints are indications for joint arthroplasty.

Prediction and prevention of psoriatic arthritis

The course of psoriatic arthritis is chronic with a high probability of a disabling outcome. Modern methods of therapy allow achieving remission and reducing the rate of progression of the disease. The development of psoriatic arthritis in childhood and young age, a severe form of skin psoriasis, and polyarticular lesions aggravate the prognosis.

Due to the lack of knowledge of the etiology of psoriatic arthritis, it is impossible to prevent the disease. Secondary prevention measures include systematic anti-relapse therapy and medical supervision in order to preserve the functionality of the joints.

Psoriatic arthritis is considered the second most common inflammatory joint disease after rheumatoid arthritis, it is diagnosed in 7-39% of patients with psoriasis.

Due to the clinical heterogeneity of psoriatic arthritis and the relatively low sensitivity of diagnostic criteria, it is difficult to accurately assess the prevalence of this disease. Evaluation is often hampered by the late development of typical signs of psoriasis in patients with inflammatory joint disease.

Psoriatic arthritis develops between the ages of 25-55. Men and women get sick equally often, with the exception of psoriatic spondylitis, which is 2 times more common in men. In 75% of patients, joint damage occurs on average 10 years (but not more than 20 years) after the first signs of psoriatic skin lesions appear. In 10-15%, psoriatic arthritis precedes the development of psoriasis, and in 11-15% it develops simultaneously with skin lesions. It should be noted that in most patients there is no correlation between the severity of psoriasis and the severity of the inflammatory process in the joints, except for cases of synchronous occurrence of two diseases.

Pathogenesis

It is believed that the disease psoriatic arthritis results from complex interactions between internal factors (genetic, immunological) and environmental factors.

Genetic factors

Many studies point to a hereditary predisposition to the development of both psoriasis and psoriatic arthritis: more than 40% of patients with this disease have first-degree relatives with psoriasis, and the number of cases of these diseases increases in families with identical or dizygotic twins.

To date, seven PSORS genes responsible for the development of psoriasis have been identified, which are localized in the following chromosomal loci: 6p (PSORS1 gene), 17q25 (PSORS2 gene), 4q34 (PSORS3 gene), lq (PSORS4 gene), 3q21 (PSORS5 gene). 19p13 (PSORS6 gene), 1p (PSORS7 gene).

The results of immunogenetic phenotyping of patients with psoriatic arthritis are contradictory. Population studies have found an increased frequency of HLA major histocompatibility complex genes: B13, B17, B27, B38, DR4 and DR7. Patients with psoriatic arthritis and those with x-ray signs of sacroiliitis are more likely to have HLAB27. With a polyarticular, erosive form of the disease - HLADR4.

It should also be noted that non-HLA-associated genes included in the region of the major histocompatibility complex, in particular, the gene encoding TNFa. The study of polymorphism of the TNF-a gene revealed a significant relationship between the alleles of TNF-a-308, TNF-b+252 and erosive psoriatic arthritis. In case of early disease, this fact has a prognostic value for the rapid development of destructive changes in the joints, and the carriage of TNF-a-238 in representatives of the Caucasian population is considered as a risk factor for the development of the disease.

Immunological factors

Psoriasis and psoriatic arthritis are considered disorders of T-cell immunity. The main role is assigned to TNF-a, a key pro-inflammatory cytokine that regulates inflammation processes using various mechanisms: gene expression, migration, differentiation, cell proliferation, and apoptosis. It was found that in psoriasis, keratocytes receive a signal for increased proliferation when T-lymphocytes release various cytokines, including PIO-a,

At the same time, a high level of TNF-a is found in the psoriatic plaques themselves. It is believed that TNF-a promotes the production of other inflammatory cytokines, such as IL-1, IL-6, IL-8, as well as granulocyte-macrophage colony-stimulating factor.

With a high concentration of TNF-a in the blood of patients with psoriatic arthritis, such clinical manifestations are associated as:

• fever;
• enthesopathy;
• osteolysis;
• the appearance of destructive changes in the joints:
• ischemic necrosis.

In early psoriatic arthritis, IL-10 is found in high concentrations in the cerebrospinal fluid. TNF-a and matrix metalloproteinases. A direct correlation between TNF-a levels is shown. matrix metalloproteinase type 1 and markers of cartilage degradation. Synovial biopsy specimens from patients showed intense infiltration with T- and B-lymphocytes, in particular CD8+ T-cells. They are also detected at the sites of attachment of the tendons to the bone at an early stage of inflammation. CD4 T cells produce other cytokines: IL-2, interferon y, lymphotoxin a, which are found in the cerebrospinal fluid and synovium of patients with this disease. Frequent sporadic cases of psoriasis in HIV infection is one of the evidence for the involvement of CD8/CD4 cells in the pathogenesis of psoriatic arthritis.

Recently, the question of the causes of increased bone tissue remodeling in psoriatic arthritis in the form of resorption of the terminal phalanges of the fingers, the formation of large eccentric joint erosions, and a characteristic “pencil in cup” deformity has been discussed. A bone tissue biopsy revealed a large number of multinuclear osteoclasts in the resorption zones. For the transformation of osteoclast precursor cells into osteoclasts, two signal molecules are needed: the first is a macrophage colony-stimulating factor that stimulates the formation of macrophage colonies that are precursors of osteoclasts, the second is the RANKL protein (receptor activator of NF-kB ligand - ligand of the receptor activator NF-kB) , which starts the process of their differentiation into osteoclasts. The latter has a natural antagonist, osteoprotegerin, which blocks the physiological responses of RANKL. It is assumed that the mechanism of osteoclastogenesis is controlled by the ratio between the activity of RANKL and osteoprotegerin. Normally, they should be in balance, if the ratio of RANKL / osteoprotegerin is violated in favor of RANKL, uncontrolled formation of osteoclasts occurs. In synovial biopsy specimens from patients with psoriatic arthritis, an increase in the level of RANKL and a decrease in the level of osteoprotegerin were revealed, and in the blood serum, an increase in the level of circulating CD14-monocytes, precursors of osteoclasts.

The mechanism of periostitis and ankylosis in psoriatic arthritis is not yet clear; suggest the participation of transforming growth factor b, vascular endothelial growth factor, bone morphogenic protein. Increased expression of transforming growth factor b was found in the synovium of patients with psoriatic arthritis. In an animal experiment, a bone morphogenic protein (in particular, type 4), acting in conjunction with vascular endothelial growth factor, promoted bone tissue proliferation.

Symptoms of psoriatic arthritis

The main clinical symptoms of psoriatic arthritis:

• psoriasis of the skin and / or nails;
• spinal injury;
• damage to the sacroiliac joints;
• enthesitis.

Psoriasis of the skin and nails

Psoriatic skin lesions may be limited or widespread, and some patients have psoriatic erythroderma.

The main localization of psoriatic plaques:

• scalp;
• area of ​​elbow and knee joints;
• navel area;
• axillary areas; o intergluteal fold.

One of the frequent manifestations of psoriasis, in addition to rashes on the skin of the trunk and scalp, is nail psoriasis, which can sometimes be the only manifestation of the disease.

The clinical manifestations of nail psoriasis are varied. The most common are:

• thimble-like psoriasis;
• onycholysis:
• subungual hemorrhages, which are based on papillomatosis of the papillae with dilated terminal vessels (synonymous with subungual psoriatic erythema, "oil spots");
• subungual hyperkeratosis.

Peripheral psoriatic arthritis

The onset of the disease can be either acute or gradual. In most patients, the disease is not accompanied by morning stiffness, for a long time it can be limited and localized to one or more joints, such as:

• interphalangeal joints of the hands and feet, especially the distal ones;
• metacarpophalangeal;
• metatarsophalangeal;
• temporomandibular;
• wrist;
• ankle;
• elbow;
• knee.

Less often, psoriatic arthritis may debut with damage to the hip joints.

Often the involvement of new joints occurs asymmetrically, in the joints of the hands randomly (chaotically). Characteristic signs of peripheral inflammation of the joints:

• involvement of the distal interphalangeal joints of the hands and feet with the formation of a "radish-like" deformity; o dactylitis;
• axial psoriatic arthritis with periarticular phenomena (simultaneous damage to three joints of one finger: metacarpophalangeal or metatarsophalangeal, proximal and distal interphalangeal joints with a kind of cyanotic-purple staining of the skin over the affected joints).

In 5% of patients, a mutilating (osteolytic) form is observed - a "calling card" of psoriatic arthritis. Outwardly, this fails by shortening the fingers and toes due to resorption of the terminal phalanges. At the same time, multiple multidirectional subluxations of the fingers are observed, a symptom of “looseness” of the finger appears. The bones of the wrist, interphalangeal joints of the hands and feet, styloid processes of the ulna, heads of the temporomandibular joints are also subjected to osteolysis.

Dactylitis is found in 48% of patients with psoriatic arthritis, in many of them (65%) the toes are involved, followed by the formation of radiological signs of destruction of the articular surfaces. It is believed that dactylitis develops both due to inflammation of the flexor tendons, and as a result of inflammation of the interphalangeal, metatarsophalangeal or metacarpophalangeal joints of one finger. Clinical manifestations of acute dactylitis:

• severe pain;
• swelling, swelling of the entire finger;
• pain limitation of mobility, mainly due to flexion.

In combination with periarticular phenomena, an axial inflammatory process in the joints forms a “sausage-like” deformity of the fingers. Dactylitis can also be not only acute, but also chronic. In this case, there is a thickening of the finger without pain and redness. Persistent dactylitis without adequate treatment can lead to rapid development of flexion contractures of the fingers and functional limitations of the hands and feet.

Spondylitis

It occurs in 40% of patients with psoriatic arthritis. Often, snondylitis is asymptomatic, while an isolated lesion of the spine (without signs of peripheral inflammation of the joints) is a rarity: it occurs only in 2-4% of patients. Changes are also localized in the sacroiliac joints, the ligamentous apparatus of the spine with the formation of syndesmophytes, paravertebral ossificates.

Clinical manifestations are similar to Bechterew's disease. Pain of an inflammatory rhythm and stiffness are characteristic, which can occur in any part of the spine (thoracic, lumbar, cervical, sacral region). In most patients, changes in the spine do not lead to significant functional disorders. However, 5% of patients develop a clinical and radiological picture of a typical ankylosing spondylitis, up to the formation of a "bamboo stick".

Enthesitis (enthesopathy)

Apthesis is a place of attachment of ligaments, tendons and joint capsule to the bone, enthesitis is a frequent clinical manifestation of psoriatic arthritis, manifested by inflammation in the places of attachment of ligaments and tendons to bones, followed by resorption of the subchondral bone.

The most typical localizations of enthesitis:

• posterior-superior surface of the calcaneus directly at the site of attachment of the Achilles tendon;
• the place of attachment of the plantar aponeurosis to the lower edge of the calcaneal tubercle;
• tibial tuberosity;
• the place of attachment of the ligaments of the muscles of the "rotator cuff" of the shoulder (to a lesser extent).

Entheses of other localizations may also be involved:

• 1st costochondral articulation on the right and left;
• 7th costochondral articulation on the right and left;
• Posterior superior and anterior superior iliac spines;
• iliac crest;
• Spinous process of the 5th lumbar vertebra.

Radiographically, enthesitis manifests itself in the form of periostitis, erosions, and osteophytes.

Forms

There are five main clinical variants of psoriatic arthritis.

1. Psoriatic arthritis of the distal interphalangeal joints of the hands and feet.
2. Asymmetric mono/aligoarthritis.
3. Mutilating psoriatic arthritis (osteolysis of the articular surfaces with the development of shortening of the fingers and / or feet).
4. Symmetric polyarthritis ("rheumatoid-like" variant).
5. Psoriatic spondylitis.

Distribution in these clinical groups is carried out on the basis of the following features.

• The predominant lesion of the distal interphalangeal joints: more than 50% of the total articular score is the distal interphalangeal joints of the hands and feet.
• Oligoarthritis/polyarthritis: Involvement of less than 5 joints is defined as oligoarthritis, 5 or more joints as polyarthritis.
• Mutilating psoriatic arthritis: identification of signs of osteolysis (radiological or clinical) at the time of examination.
• Psoriatic spondyloartitis: inflammatory pain in the spine and localization in any of the three sections - lumbar, thoracic or cervical, reduced mobility of the spine, detection of radiological signs of sacroiliitis, including isolated sacroiliitis.
• Symmetric polyarthritis: more than 50% of the affected joints (paired small joints of the hands and feet).

Diagnosis of psoriatic arthritis

The diagnosis is made based on the detection of psoriasis of the skin and / or nails in the patient or his close relatives (according to the patient), characteristic damage to the peripheral joints, signs of damage to the spine, sacroiliac joints, enthesopathy.

When questioning the patient, it is necessary to establish what preceded the disease, especially if there were complaints from the gastrointestinal tract or the genitourinary system, the eyes (conjunctivitis), which is necessary for differential diagnosis with other diseases of the group of seronegative spondyloarthropathies, in particular with reactive post-enterocolitis or urogenic inflammation of the joints, Reiter's disease (the sequence of joint involvement, the presence of complaints from the spine, sacroiliac joints).

Clinical diagnosis of psoriatic arthritis

On examination pay attention to:

• the presence of skin psoriasis of characteristic localization:
• scalp, behind auricles:
• navel area:
• crotch area:
• intergluteal fold;
• armpits;
• and/or the presence of popey psoriasis.

When examining the joints, characteristic signs of psoriatic arthritis are revealed:

• dactylitis;
• inflammation of the distal interphalangeal joints.

Palpate the attachment sites of the tendon.

The presence or absence of clinical signs of sacroiliitis is detected by direct or lateral pressure on the wings of the iliac bones, and the mobility of the spine is determined.

The condition of the internal organs is assessed in accordance with general therapeutic rules.

Laboratory diagnosis of psoriatic arthritis

There are no specific laboratory tests for psoriatic arthritis.

There is often a dissociation between clinical activity and laboratory values. RF is usually absent. At the same time, RF is detected in 12% of patients with psoriatic arthritis, which creates certain difficulties in diagnosis, but is not a reason for revising the diagnosis.

CSF analysis does not give specific results; in some cases, high cytosis is detected.

The activity of peripheral joint inflammation in psoriatic arthritis is assessed by the number of painful and inflamed joints, the level of CRP, the severity of joint pain and disease activity.

Instrumental diagnosis of psoriatic arthritis

Of great help in the diagnosis is the data of an X-ray examination of the hands, feet, pelvis, spine, where characteristic signs of the disease are found, such as:

• osteolysis of the articular surfaces with the formation of changes of the "pencil in a glass" type;
• large eccentric erosions;
• resorption of the terminal phalanges of the fingers;
• bone proliferations:
• asymmetric bilateral sacroiliitis:
• paravertebral ossificates, syndesmophytes.

• confirmed psoriasis of the skin or nails in a patient or his relatives;
• asymmetric peripheral psoriatic arthritis with a primary lesion of the joints of the lower extremities:
  • hip,
  • knee.
  • ankle,
  • metatarsophalangeal,
  • tarsal joints,
  • interphalangeal joints of the toes.
• damage to the distal interphalangeal joints,
• presence of dactylitis
• inflammatory pain in the spine,
• damage to the sacroiliac joints,
• enthesopathy;
• radiological signs of osteolysis;
• the presence of bone proliferation;
• no RF.

In 2006, the International Group for the Study of Psoriatic Arthritis proposed the CASPAR criteria (Classification Criteria for Psoriatic Arthritis) as diagnostic criteria. The diagnosis can be established by the presence of inflammatory joint disease (spinal involvement or entheses) and at least three of the following five features.

• The presence of psoriasis, psoriasis in the past or a family history of psoriasis.
• The presence of psoriasis is defined as a psoriatic lesion of the skin or scalp, confirmed by a dermatologist or rheumatologist.
• Information about past psoriasis can be obtained from the patient, family doctor, dermatologist or rheumatologist, o Family history of psoriasis is defined as the presence of psoriasis in first- or second-degree relatives (according to the patient).
• Typical for psoriasis lesions of the nail plates: onycholysis, "thimble symptom" or hyperkeratosis - recorded during physical examination.
• A negative test result for the presence of RF using any method other than the latex test: solid-phase ELISA or nephelometry is preferable.
• Dactylitis at the time of examination (defined as swelling of the entire finger) or a history of dactylitis recorded by a rheumatologist.
• X-ray confirmation of bone proliferation (ossification of the edges of the joint), excluding the formation of osteophytes, on radiographs of the hands and feet.

Indications for consulting other specialists

Psoriatic arthritis often co-occurs with conditions such as:

• hypertonic disease;
• cardiac ischemia;
• diabetes.

If signs of these diseases occur, patients need to consult the relevant specialists: a cardiologist, an endocrinologist.

With the development of signs of progressive destruction and deformity of the joints of the hands, ischemic necrosis of the supporting (hip, knee) joints, a consultation with an orthopedic surgeon is indicated to resolve the issue of performing arthroplasty,

Diagnosis example

• Psoriatic arthritis, monoarthritis of the knee joint, moderate activity, stage II, functional deficiency 2. Psoriasis, limited form.
• Psoriatic arthritis, chronic asymmetric polyarthritis with a predominant lesion of the joints of the feet, high activity, stage III, functional deficiency 2.
• Psoriatic spondyloarthritis, asymmetric bilateral sacroiliitis, stage 2 on the right, stage 3 on the left. Paravertebral ossification at the level of Th10-11. Psoriasis common, psoriasis of the nails.

To determine the activity, x-ray stage and functional insufficiency, the same methods are currently used as for rheumatoid.

Differential Diagnosis

Treatment of psoriatic arthritis

The goal of therapy is an adequate effect on the main clinical manifestations of psoriatic arthritis:

• psoriasis of the skin and nails;
• spondylitis;
• dactylitis;
• enthesitis.

Indications for hospitalization

Indications for hospitalization are:

• complex differential diagnostic cases;
• poly- or oligoarticular lesions of the joints;
• recurrent psoriatic arthritis of the knee joints; the need for injection into the joints of the lower extremities;
• selection of therapy for DMARDs;
• conducting therapy with biological agents;
• assessment of tolerability of previously prescribed therapy.

Non-pharmacological treatment of psoriatic arthritis

The use of a complex of therapeutic exercises both in a hospital and at home is especially important for patients with psoriatic spondyloarthritis in order to reduce pain, stiffness and increase overall mobility.

Medical treatment of psoriatic arthritis

Standard therapy for psoriatic arthritis includes NSAIDs, DMARDs, and intra-articular HA injections.

NSAIDs

Diclofenac and indomethacin are mainly used in average therapeutic doses. Recently, selective NSAIDs have been widely used in practical rheumatology to reduce adverse effects from the gastrointestinal tract.

Systemic glucocorticosteroids

There is no evidence of their effectiveness based on the results of controlled studies in psoriatic arthritis, except for the opinion of experts and descriptions of individual clinical observations. The use of glucocorticosteroids is not recommended due to the risk of exacerbation of psoriasis.

Intra-articular administration of glucocorticosteroids is used in the mono-oligoarticular form of psoriatic arthritis, as well as in order to reduce the severity of symptoms of sacroiliitis by the introduction of glucocorticosteroids into the sacroiliac joints.

Basic anti-inflammatory drugs

Sulfasalazine: effective against symptoms of joint inflammation, but does not inhibit the development of radiographic signs of joint destruction, is usually well tolerated by patients, is prescribed at a dose of 2 g / day.

Methotrexate: Two placebo-controlled studies have been conducted. The water shows the effectiveness of intravenous pulse therapy with methotrexate at a dose of 1-3 mg/kg of body weight, the other - methotrexate at a dose of 7.5-15 mg/week orally, in the third - a higher efficiency of methotrexate at a dose of 7.5-15 mg /week compared with cyclosporine A at a dose of 3-5 mg/kg. Methotrexate had a positive effect on the main clinical manifestations of psoriatic arthritis and psoriasis, but did not inhibit the development of radiological signs of joint destruction.

When using methotrexate in high doses, one patient died from bone marrow aplasia.

Further management

After discharge from the hospital, the patient should be under the supervision of a rheumatologist and a dermatologist at the place of residence in order to monitor the tolerability and effectiveness of therapy, treat exacerbations of inflammatory processes in the joints in a timely manner, and assess the need for biological therapy.

What should a patient know about psoriatic arthritis?

When the first signs of inflammation in the joints appear, a patient with psoriasis should contact a rheumatologist. If you have been diagnosed with psoriatic arthritis, but with adequate and timely treatment, you can remain active and productive for many years. The choice of a therapy program depends on the clinical form of the disease, the activity of the inflammatory process in the joints and spine, and the presence of concomitant diseases. During treatment, strive to fully comply with all the recommendations of a rheumatologist and dermatologist, regularly see a doctor to monitor the effectiveness and tolerability of all drugs prescribed to you.

In the understanding of most people, psoriasis is a disease of only the skin. In fact, such a judgment is a fallacy. Undoubtedly, its main manifestation is represented by pathological changes in the skin in the form of redness and peeling. But psoriasis is based on immune disorders in the body. Therefore, very often this disease manifests itself in different clinical forms. One of them is psoriatic arthritis, which is an inflammatory lesion of the joints. It will be discussed in this article.

Why does it happen

Scientists have found that the triggers of psoriasis are immune processes. Therefore, the problem does not occur on a specific area of ​​the skin, but in the internal environment of the body. Against this background, there is a potential threat of damage to any tissue, in particular, hyaline cartilage and the synovial membrane of large and small joints. To provoke such an atypical course of psoriasis in the form of arthritis is capable of:

• psycho-emotional factors and stress;
• excessive exposure to the skin of sunlight and radiation;
• infectious lesions of the skin and subcutaneous tissue;
• immunodeficiency states, including HIV infection;
• alcohol and tobacco abuse;
• violation of the hormonal balance of the blood;
• traumatic injury (bruises, intra-articular fractures, ruptures and sprains, etc.);
• influence of certain medications.

All these factors cause an increase in the immune imbalance in the body with the spread and generalization of psoriatic inflammation. First of all, tissues with a powerful microcirculatory bed are affected. Joints are one of them.

Important to remember! Psoriatic arthritis occurs exclusively in patients with psoriasis. This means that in a person without signs of a psoriatic rash, such a diagnosis cannot be established. The exception is cases of primary manifestation of psoriasis not from a skin lesion, but from an articular one. But these symptoms are sure to build up on top of each other!

How to suspect and identify a problem

The first symptoms of psoriatic arthritis may be pain, swelling, redness, stiffness, and deformity of certain joints. Depending on this, the disease has a different course, which determines its clinical variety:

1. Asymmetric arthritis. It affects different articular groups from opposite sides. For example, the hip and hand joints on the left, combined with inflammation of the knee joint on the right.
2. Symmetric arthritis. It is characterized by the involvement of identical joints on both sides in the inflammatory process (for example, the ankle joints on the left and right).
3. Arthritis with a primary lesion of small articular groups. This form of pathology is characterized by the greatest severity of inflammation in the joints of the hand or feet.
4. Psoriatic spondylosis is an inflammatory lesion of the spinal column.
5. deforming form. It characterizes an extremely difficult stage of the pathological process in the joints. Accompanied by their destruction and deformation.
6. Psoriatic polyarthritis and monoarthritis. In the first clinical variant of the disease, several articular groups are affected according to an asymmetric or symmetrical type. With monoarthritis, only one of the large joints is inflamed (knee, hip, ankle, shoulder, elbow).

Diagnosis of psoriatic arthritis is based on clinical, laboratory and instrumental data. The most indicative is the study of rheumatic tests (increased levels of C-reactive protein, sialic acids, seromucoid). Visual changes in the joints are determined during an X-ray examination. In case of inflammation of large joints, for the purpose of differential diagnosis, a puncture is performed with intra-articular fluid sampling for analysis. By its nature and cellular composition, one can judge the approximate nature of inflammation (exclude purulent process, gout, accumulation of blood, etc.).

Important to remember! If patients with psoriasis develop symptoms of inflammation of any joints, this may be a signal of disease progression in the form of psoriatic arthritis. In this case, the number of rashes may increase or signs of damage to internal organs may appear!

Although the ICD-10 (International Classification of Diseases, Tenth Revision) has a separate code for a disease such as psoriatic arthritis, such a diagnosis is extremely rare as an independent one.

Medical therapy

The treatment of psoriatic arthritis involves an integrated approach. This means that it should include drugs in two directions: for the treatment of psoriasis and for the relief of inflammation in the joints. Some of them belong to the same pharmacological groups. They equally stop pathological processes in the skin and hyaline cartilage.

The main directions of therapy are as follows.

Powerful anti-inflammatory therapy with glucocorticoids

The drugs of this group are one of the basic in the treatment of psoriasis and arthritis of various origins. The tactics of using glucocorticoids is determined by the degree of inflammation activity:

• Psoriatic polyarthritis with pronounced inflammatory changes in the joints, in combination with exacerbation of psoriasis or without it - treatment according to the method of pulse therapy with drugs based on methylprednisolone (metipred, methylprednisolone, cortinef), dexamethasone or prednisolone. Doses of these drugs should be as high as possible to suppress inflammation.
• Psoriatic arthritis with moderate inflammatory changes in one or more joints of the limbs or spine. The use of hormones in medium therapeutic doses by injection or tablet administration is shown.

Treatment with non-steroidal anti-inflammatory drugs

Does not affect the course of psoriasis, but reduces inflammatory changes in the joints. Both old-generation drugs (diclofenac, ortofen, nimesil) and selective new drugs (meloxicam, movalis, rheumoxicam) are used.

Use of cytostatics

Treatment with drugs of this group is resorted to exclusively in the case of psoriatic arthritis occurring against the background of widespread psoriasis. The criterion for the need to use cytostatics is the defeat of internal organs. The most commonly used drug is called methotrexate.

Manipulations on the affected joints

Treatment is represented by two types of effects:

• Immobilization. Inflamed joints are subject to fixation in a normal anatomical position. The exclusion of movements in them for the period of exacerbation of the process will significantly reduce the duration of treatment. Plaster splints and orthoses are suitable for immobilization.
• Intra-articular administration of drugs. Short-acting or long-acting glucocorticoids (hydrocortisone, kenalog, dipospan) can be injected into large joints. Sometimes they resort to the introduction of cytostatics (methotrexate).

Exercise therapy and therapeutic exercises

It is prescribed from the first days of illness. Its meaning is that against the background of immobilization of the joint, the remaining segments of the limb continue to move. As the process stops, the gradual development of the diseased articulation begins.

Important to remember! With psoriatic arthritis, it is unacceptable to try to defeat the disease on your own, using only folk remedies. Refusal of timely complex treatment will lead to the progression of the disease or its spread to several joints!

Possibilities of traditional medicine

Psoriatic arthritis, like any chronic disease, can not always be successfully treated with medication. Patients who have lost hope of recovery are looking for any alternative methods by which to treat this disease. Usually, alternative treatment and alternative medicine come to the rescue. Of course, such techniques have the right to life, but you should not rely only on them. It is best to combine drug treatment with folk remedies.

Here are some effective recipes:

1. Raw carrots as a compress on the affected joint. To prepare it, one medium-sized carrot needs to be finely grated. Add five drops of turpentine and any vegetable oil to the carrot puree. After thorough mixing, the resulting mass is laid out on gauze, which wraps the diseased joint. The duration of the compress is about 8 hours (it is possible at night).
2. Lotions from aloe. Prepared by analogy with a carrot compress. The difference is only in the main ingredient: aloe is used instead of carrots. It is best to alternate with carrot compresses.
3. Tincture based on lilac buds. Raw materials are harvested in the spring. The required number of kidneys per serving of tincture is 2 cups. Fresh kidneys are poured 500 gr. alcohol. Within ten days, the infusion should be in a dark place. After this period, the product is ready for use. It is used exclusively for external application in the form of rubbing on the skin in the area of ​​the affected joints.

On the importance of proper nutrition

One of the theories of the origin of psoriasis, and hence psoriatic arthritis, is intestinal. Therefore, proper nutrition is so important for the successful treatment of these diseases. The right diet for psoriatic arthritis involves:

• Exclusion of allergenic foods: sweets, citrus fruits, chocolate, eggs.
• Exclusion of irritating foods: marinades, seasonings, smoked meats, spices, alcoholic beverages.
• The basis of the diet are vegetables, fruits and berries. But the diet excludes currants, strawberries, tomatoes, blueberries, plums, eggplant, coconut.
• The use of a sufficient amount of purified or melt water (about 1.5 liters per day). Non-carbonated alkaline mineral waters (Borjomi, Essentuki) are also useful.
• Dishes based on cereals: buckwheat, rice, barley. It is best to fill them with vegetable (olive, linseed, sunflower) or butter.
• Meat products. Preference is given to dietary meats: chicken, turkey, rabbit. It is better to refrain from fish at the time of exacerbation.
• Sour-milk products of low fat content.
• Bread made from wholemeal flour and bran.
• Ways of cooking: fried and smoked dishes are strictly prohibited. Products can be boiled, steamed, baked.

Features of the disease in childhood

The prevalence of psoriasis among children is much lower than in adults. The likelihood of psoriatic arthritis in a child is small, which is confirmed by statistical data. Among all patients with this diagnosis, no more than 6% are children under 16 years of age. In persons of this age group, against the background of psoriasis, there are often ordinary arthralgias (joint pains), which pass without a trace. The peculiarity of the course of the disease in children is such that most often it is of a generalized nature (like polyarthritis).

Prevention

Predicting and preventing psoriatic arthritis is very difficult. Prevention comes down to timely adequate treatment of classical forms of psoriasis, adherence to a dietary regimen (strict diet), giving up bad habits, proper hygienic skin care, and preventing injuries. The price for non-compliance with preventive measures is the progression of the disease and even disability.

Psoriatic arthritis has much in common with arthritis of a different origin. Its main difference is the mandatory presence of skin manifestations of psoriasis. This feature of the disease serves as the basis for diagnosis and selection of the optimal method of treatment.

• Description of the disease
• Symptoms
• Diagnostics
• Treatment

According to medical statistics, in about 40% of people diagnosed with psoriatic arthritis, the pathological process extends to the spine, which is called psoriatic spondylitis. In this case, most often it is combined with inflammation of the peripheral joints of the extremities.

Most often this happens when there is a change from one form of psoriasis to another, for example, vulgar can change to exudative. And only in 5% of all cases, an isolated lesion of the spine is detected in psoriasis without the presence of psoriatic arthritis.

However, one should not think that with psoriasis, a person’s back will necessarily suffer. The defeat of the vertebrae will occur only if the course of the psoriasis itself exceeds 10 years.

Description of the disease

The peculiarity of the disease is that there is a violation of the fibrous ring of the intervertebral discs, where osteophytes begin to form, and then syndesmophytes. In this case, an incorrect diagnosis is often made, and instead of spondylitis, the patient may begin to be treated for spondylosis.

Most often, in psoriatic spondylitis, the sacroiliac part of the spine, sternocostal and sternoclavicular joints are affected. At the same time, pathological changes in such spondylitis are practically no different from those changes that are detected in Bechterew's disease.

But still, some differences exist. The thing is that with psoriatic lesions, the pathological process gradually covers all parts of the spine, which leads to the appearance of scoliosis, a violation of posture, and other skeletal disorders. And if there are no skin manifestations, and there is no arthritis of the joints of the extremities, then instead of the correct diagnosis, an erroneous diagnosis is made - Bechterew's disease.

Symptoms

The clinical picture of this type of spondylitis is similar to the clinic of other spondyloarthritis. The main symptom is pain that occurs in any part of the back. At the same time, painful sensations can last for several weeks, or several months, sometimes even years. They are especially pronounced at night and in the morning immediately after waking up. At rest, the pain does not decrease, but subsides slightly after prolonged physical activity.

On examination, the doctor may note the smoothness of the lumbar spine and a slight stoop. At the same time, Forestier's syndrome is observed only in men, and even then in rare cases.

As for the severity of the pathological process in the spine, this indicator is closely related to the person's age, the course of psoriasis, the patient's sex and the degree of skin damage. In this case, it is the articular syndrome that is most often observed, and not the skin manifestation of the disease. Moreover, it can begin either from the peripheral joints or immediately from the spine. If the back was affected from the very beginning of the disease, then the disease will proceed with vivid symptoms and rapid progression. If it began with a skin form, then the course of spondylitis will be benign.

As for gender binding, pronounced psoriatic spondyloarthritis with severe damage to the spinal column is typical only for young men. As for women, spondylitis is incredibly rare in them. Most often, inflammation is caused by such types of psoriasis as exudative, erythrodermic and pustular. It is these pathologies that give a high percentage of involvement of the vertebrae in the pathological process.

Diagnostics

The disease is well detected on radiographs. In 50% of all cases, there is neck deformity, osteoporosis of the vertebrae, and calcification of the ligaments. Erosions on the intervertebral joints and deformation of the vertebral bodies can be detected. In the thoracic region, scoliosis is usually detected, and vertebral deformity is most common here. In the lumbar region, pathological changes in the vertebrae are less common, but here these changes are well expressed.

It is worth noting that at an early stage these pathologies cannot be detected, since they are simply invisible on the x-ray. In order for the disease to be detected at the very beginning, it is necessary to undergo studies such as CT or MRI. However, it often happens that a person turns to doctors too late, when pronounced changes have already occurred and medicine is powerless to do anything here.

Treatment

To date, no treatment has been developed that could help patients with this diagnosis. As drug therapy, such drugs are used that belong to the group of anticytokines. It is also necessary to prescribe corticosteroids and cytostatics. As for anti-inflammatory therapy, it is carried out only according to strict indications and only according to an individual scheme. Also, gymnastics can be added to the treatment, which, in case of psoriatic spondylitis, will help to maintain mobility longer.

The symptoms and treatment of psoriatic arthritis are two related concepts. The therapeutic regimen is developed taking into account the clinical picture and the prevailing symptoms. The main goal of treatment is to improve the patient's condition and prevent further progression of the disease.

Main symptoms

Symptoms of the disease are characterized by a fairly large variety. Psoriatic arthritis in children begins with skin manifestations of the disease. Erythematous papules develop, characterized by silvery scales. These signs are localized in the elbows, knees, groin and on the head. In adults, the disease begins with articular manifestations.

The first clinical signs of psoriatic arthritis appear gradually. Patients note a slight stiffness of movements, especially in the morning. With physical activity, discomfort disappears without a trace. Over time, pain appears. At first, very slight and characterized by a constant increase in intensity, especially at night.

Psoriatic polyarthritis is characterized by multiple lesions of the joints. The first signs are a change in their shape, which eventually develops into deformation. The color of the skin over the affected joints is modified, the epidermis acquires a burgundy hue.

In psoriatic arthritis, the symptoms of the disease may vary depending on the type of disease. For example, the osteolytic form is characterized by shortening of the fingers.

The progression of the disease leads to a significant weakening of the ligamentous apparatus of the joints. As a result, there is a high probability of spontaneous dislocations.

Psoriatic polyarthritis begins with the defeat of small joints on the phalanges of the fingers and toes. Over time, larger joints are involved in the pathological process - knee and elbow.

The transition of inflammation to the tendons and cartilaginous surfaces provokes the development of dactylitis. This condition leads to a significant deterioration in the patient's well-being. The main manifestations of dactylitis:

• severe and constant pain;
• pronounced swelling of tissues in the area of ​​the affected joint;
• the spread of edema to the entire finger;
• impaired mobility of the joint due to deformity and severe pain.

Involvement in the pathological process of the ligamentous apparatus of the spine leads to the development of complications. The consequences of this are manifested in the form of the formation of syndesmophytes and paravertebral ossificates. The condition is accompanied by severe pain and stiffness of movements.

Pathology gradually spreads to all joints. Not only tendons are involved in the inflammatory process, but also bone tissue in the area of ​​ligament attachment. This pathology is mainly localized in the region of the calcaneus and tubercle, tuberosity of the upper surface of the tibia and humerus.

Psoriatic polyarthritis affects not only the joints and nearby tissues, but also the nail plates. The main manifestation is the occurrence of pits or grooves on the surface of the bed. The nail changes color over time due to the deterioration of blood supply.

Diagnostic criteria for the disease

Photo of psoriatic arthritis

Psoriatic arthritis (pictured) is characterized by severe clinical manifestations. However, it is almost impossible to trace a clear chronology. After all, each person reacts differently to diseases.

Conducting an additional examination of the patient will help confirm the diagnosis. For this, laboratory and instrumental methods are used.

If psoriatic arthritis is suspected, diagnosis necessarily includes an x-ray. With its help, you can determine the presence of specific signs of the disease.

Radiographic signs of psoriatic arthritis include:

• reduction of joint space;
• signs of osteoporosis;
• the presence of numerous patterns;
• manifestations of ankylosis of joints and bones;
• development of sacroiliitis;
• occurrence of paraspinal ossifications.

However, x-rays are not the only method for diagnosing a disease. The patient must take blood tests. A sign of the inflammatory process is an increase in the amount of seromucoid, fibrinogen, sialic acids and globulins. In the blood, there is an increase in the level of immunoglobulins of groups A and G, circulating immune complexes appear. For the purpose of differential diagnosis with rheumatoid arthritis, the patient must undergo a study for the presence of rheumatoid factor.

If necessary, the attending physician may refer the patient to a joint puncture in order to obtain synovial fluid. Psoriatic polyarthritis is manifested by an elevated level of neutrophils. The viscosity of the liquid is reduced, while the mucin clot is loose.

Conservative therapy of the disease

How to treat psoriatic arthritis? Unfortunately, there are no medications that can completely cure this unpleasant ailment. The main goal of therapy is to improve the patient's condition by relieving symptoms and stabilizing the pathological process. With the help of an integrated approach, it is possible to prevent further progression of the disease, prevent the development of complications and achieve stable remission.

Treatment of arthritis includes the use of the following groups of drugs:

1. NSAIDs. They have anti-inflammatory, analgesic and antipyretic effects. They help to improve the patient's condition by eliminating the main signs of the disease (severe pain and inflammation). NSAIDs are used as symptomatic therapy because they do not affect the course of psoriatic arthritis. Most often, drugs based on Diclofenac or Ibuprofen are used. Depending on the clinical manifestations of psoriatic arthritis, it is prescribed as an ointment, gel, tablet or injection. The necessary form of drug administration, dosage and duration of treatment is determined by the doctor.
2. Glucocorticosteroids. Hormonal agents have strongly pronounced anti-inflammatory and analgesic effects. They should be taken very carefully due to the high risk of complications. Glucocorticosteroids are prescribed for the ineffectiveness of nonspecific anti-inflammatory drugs. In some cases, it is advisable to use the drug intraarticularly. This will provide a quick and powerful therapeutic effect directly in the focus of inflammation. The introduction of hormones into the joint capsule is possible only in a hospital, since this requires certain knowledge and skills. For this purpose, use Dexamethasone, Prednisolone.
3. Basic anti-inflammatory drugs. The gold standard in the treatment of arthritis of various etiologies. With their help, it is possible to achieve remission during the course of the disease, however, the therapeutic effect begins to appear only a few months after the start of administration. This group of drugs includes Methotrexate, Sulfasalazine, Leflunomide, Cyclosporine-A and others.
4. Bioagents. They have the ability to inhibit a specific protein - tumor necrosis factor. Thanks to this, inflammation is eliminated at the molecular level. These are Remicade, Humira and other means.

Treatment of a patient with psoriatic arthritis, especially if it is a child, should be under medical supervision. In the absence of a positive result from the therapy, the specialist will be able to timely adjust the appointments and select other medications.

Therapy of the disease with the help of physical therapy

After the removal of the acute inflammatory process, exercise therapy should be included in the complex treatment of psoriatic arthritis. Conducting classes is possible only after achieving a stable remission and in agreement with the attending physician.

A specialist in exercise therapy will help develop a suitable set of exercises. The level of physical activity and the necessary movements are selected taking into account the course of the disease, the presence of complications and the initial preparation of the patient.

With the help of exercise therapy, you can effectively get rid of excess weight, which will reduce the load on sore joints. Regular exercise will strengthen the ligamentous apparatus, ensure the flexibility and elasticity of muscle fibers. It relieves pain and the feeling of morning stiffness. It will increase or at least maintain the range of motion in the affected joints at the same level.

In psoriatic arthritis, the exercise therapy complex includes general strengthening exercises aimed at preserving the natural functions of the joints. Regular exercise will make the healing process much more successful.

Non-traditional therapy of the disease

Alternative methods of treatment of psoriasis arthritis can provide effective assistance in the drug therapy of the disease.

First of all, the patient must strictly adhere to the diet. Frequent but small meals are recommended. When developing a daily menu, simple carbohydrates and animal fats should be excluded. Remove fried, spicy, smoked and salty foods. Dairy and vegetable products must be present in the daily diet. An important role is played by fruits and vegetables, especially apples, blueberries, currants, mountain ash, sea buckthorn, asparagus beans. Psoriasis arthritis and alcohol are incompatible concepts. Therefore, alcohol should be avoided. The ban includes coffee and sweet soda.

Good results show old recipes based on medicinal herbs:

1. Burdock root tincture. Grind the fresh plant and put it in a glass container. Pour in vodka so that the liquid covers the contents of the jar by 2-3 cm. Infuse the medicine for 3 weeks in a dry and dark place. Healing tincture can be used orally 10-15 drops three times a day 10-20 minutes before meals or used as rubbing of the affected joints.
2. A decoction of lingonberry leaves. 2 tsp dry grass pour 200 ml of boiling water, put on fire and bring to a boil. The product must be boiled for 15 minutes, and after cooling, drink. The duration of treatment is several weeks and continues until the patient's condition improves.
3. Decoction based on medicinal plants. St. John's wort, coltsfoot, dandelion are mixed in equal proportions. 1 - 2 tbsp mixture pour 200 ml of hot water, insist and drink 0.5 cup twice a day.
4. Infusion of birch buds. The preparation is very easy. It is necessary to pour 5 g of kidneys with a glass of hot water and boil for 15 minutes over low heat. Wrap the container and infuse the product for 1 hour. Ready drink to drink 50 ml 20-30 minutes before meals at least 3-4 times a day.

Alternative methods of therapy are most often absolutely safe, but they must also be agreed with the attending physician. This will allow you to quickly achieve an improvement in the patient's condition and achieve remission, as well as prevent the development of complications.