How Effective Is Methotrexate for Psoriatic Arthritis?

Psoriatic arthritis (PsA) is an inflammatory joint disease associated with psoriasis, with a psoriasis rash accompanied by pain, swelling, tenderness, stiffness, and dyskinesia of the joints and surrounding soft tissues. Some patients may have sacroiliitis and / or spondylitis, with a prolonged course and easy relapse. Late stage may have joint stiffness. About 75% of patients with rash appear before arthritis, while about 15% of patients have rash, and about 10% of patients with rash appear after arthritis. The disease can occur at any age, with a peak age of 30 to 50 years. There is no gender difference, but there are more men with spinal involvement.

Basic Information

English name: psoriaticarthritis
Visiting department: orthopedics

Multiple groups: 30 to 50 years old
Common causes: Genetic factors

Causes of psoriatic arthritis

Genetic factor

The disease often has a tendency to gather in families. The prevalence of first-degree family members is as high as 30%, and the risk of single egg twins is 72%. Family history is reported in 10% to 23.8% in China, and 10% to 80% in foreign countries. The disease is autosomal dominant, with incomplete penetrance, but some people think it is autosomal recessive or sex linked.

2. Infectious factors

(1) Viral Infection: Some people have performed antiviral treatment on patients with psoriasis accompanied by viral infection, and the condition of psoriatic arthritis also eased.

(2) Streptococcal infections: It is reported that about 6% of patients have a history of pharyngeal infection and upper respiratory symptoms, and their anti- "O" titer is also increased.

(3) Endocrine dysfunction: The correlation between psoriasis and endocrine gland function has long attracted people's attention.

(4) Neuropsychiatric disorders: Previous literature often reports that mental factors are related to the disease. For example, trauma can cause the disease to worsen or worsen the condition, and it is believed that this is due to increased vascular motor nerve tension after mental stimulation.

(5) Others Most patients have recurrence and aggravation in winter, remission or spontaneous subsidence in summer, but those with chronic illness disappear regularly in season. There are also women who get worse before and after menstruation, rash subsided during pregnancy, and relapse after delivery.

Clinical manifestations of psoriatic arthritis

Most of them develop slowly, and about one-third of the patients may have more rapid onset, with systemic symptoms such as fever.

Joint

In addition to peripheral joint disease of the limbs, some can involve the spine. Sometimes it can turn into chronic arthritis and severe disability. According to clinical characteristics, arthritis is divided into five types, 60% of which can be transformed into each other, and exist together.

(1) Single arthritis or less arthritis type accounts for 70%, mainly the joints between the distal or proximal fingers (toes) of the hands, feet, and knees, ankles, hips, and wrists. Accompanied with distal and proximal interphalangeal joint synovitis and tenosynovitis, damaged fingers (toes) can present typical sausage sausages (toes), often accompanied by finger (toe) lesions. About 1/3 or even 1/2 of patients with this type of disease can develop into polyarthritis.

(2) Symmetric polyarthritis type accounts for 15%. The lesions are mainly proximal interphalangeal (toe) joints, which can involve distal interphalangeal (toe) joints and large joints, such as wrist, elbow, knee and ankle .

(3) Destructive joint type accounts for about 5%, which is a severe type of psoriatic arthritis. Occurs in 20 to 30 years of age. The affected fingers, palms, and sacrum may have osteolysis. The knuckles often have telescopic "telescope" phenomenon. The joints may be rigid, deformed, and often accompanied by fever and sacroiliitis. This type of skin psoriasis is often widespread and severe, and is pustular or erythrodermic.

(4) Distal interphalangeal joint type accounts for 5% to 10%. The lesion involves the distal interphalangeal joint, which is a typical psoriatic arthritis, which is usually associated with psoriasis nail lesions.

(5) Spondylosis type About 5% are older men with spinal and sacroiliac joint lesions (often unilateral or segmental). Symptoms such as lower back pain or chest wall pain may be absent or mild. Spondylitis manifests as ligament osteophyte formation, which can cause spinal fusion, blur of the sacroiliac joints, narrowing of the joint space, and even fusion, which can affect the cervical spine and lead to atlantoaxial and subaxial incomplete dislocation.

Recently, some scholars have classified psoriatic arthritis into three types: single joint and oligoarthritis types similar to reactive arthritis with tendonitis; polysymmetric arthritis types similar to rheumatoid arthritis; similar Ankylosing spondylitis is predominantly associated with central axis arthropathy (spondylitis, sacroiliitis, and hip arthritis), with or without spondylosis of the surrounding joints.

Skin

Psoriasis of the skin is common in the scalp and the extremities of the extremities, especially in the elbows and knees. Pay special attention to skin lesions in hidden areas, such as hair, perineum, hips, and umbilicus. Appears as pimples or plaques, round or irregular. There are abundant silvery white scales on the surface. After removing the scales, it becomes a shiny film. When the film is removed, spot-shaped bleeding can be seen. This feature has diagnostic significance for psoriasis. The existence of psoriasis is an important difference from other inflammatory joint diseases. The severity of skin lesions and the degree of arthritis are related in 35% of patients.

3. Finger (toe) nail performance

About 80% of patients with psoriatic arthritis have finger (toe) nail lesions, while those with no arthritis have only 20% of nail lesions. The most common nail lesion is a thimble-like depression. Other manifestations are nail detachment, hyperkeratosis, thickening, diaphragm, and discoloration of the nail.

4. Other

(1) Systemic symptoms: Few have fever, weight loss, and anemia.

(2) Systemic damage: 7% to 33% of patients have ocular lesions, such as conjunctivitis, uveitis, iritis, and dry keratitis; <4% of patients have aortic valve insufficiency, which is common in the late stage of the disease. In addition, cardiac hypertrophy and conduction block, etc., the upper lung fibrosis can be seen; gastrointestinal tract may have inflammatory bowel disease, rare amyloidosis.

(3) Achilles tendonopathy Heel pain is a manifestation of tendonitis, especially at the end of Achilles tendon and patellar aponeurosis.

The onset of this disease is insidious, about 1/3 of which is an acute attack, and there is often no incentive before the onset.

Psoriatic Arthritis Exam

Laboratory inspection

There is no specific laboratory test for this disease. Erythrocyte sedimentation speeds up during disease activity, C-reactive protein increases, IgA and IgE increase, and complement levels increase. Synovial fluid showed a non-specific response, with a slight increase in white blood cells, mainly neutrophils. Rheumatoid factor is negative, and low titers of rheumatoid factor occur in 5% to 16% of patients. Low titers of antinuclear antibodies were positive in 2% to 16% of patients. About half of the patients were HLAB-27 positive and were significantly associated with sacroiliac joint and spinal involvement.

2. Imaging examination

(1) Peripheral arthritis shows signs of destruction and hyperplasia. The small joints of the hands and feet are bony and rigid, the interphalangeal joint is destroyed with widening of the joint space, the osteoproliferation of the terminal phalangeal styloid process and the absorption of the terminal phalanx, the proximal phalanx destruction and the distal phalangeal osteogenesis Changed, causing "hat pencil" deformity. The joint space between affected fingers narrows, fuses, ankyloses, and deformities. Long bones and villous periostitis.

(2) Axillary arthritis is mostly unilateral iliac arthritis, and the joint space is blurred, narrowed, and fused. The intervertebral space is narrowed, rigid, asymmetric ligament osteophyte is formed, and the vertebral ossification is characterized by the ossification of the ligaments between the middle of adjacent vertebral bodies to form a bone bridge, which is asymmetrically distributed.

Diagnosis of psoriatic arthritis

Skin manifestation

Skin psoriasis is an important diagnostic basis for PsA. Skin lesions appear in the diagnosis of arthritis, which is difficult to diagnose, a detailed medical history, a family history of psoriasis, drip psoriasis in childhood, and checking for psoriasis in hidden areas (such as Scalp, umbilical, or perianal) and characteristic radiological findings (especially "pen-cap" bone changes in the hand joints) can provide important clues, but should exclude other diseases and regular follow-up.

(1) Manicure of fingernails (> 20), nail detachment, discoloration, thickening, roughness, diaphragm, and hyperkeratosis of the nail. Fingernail (toe) lesions are the only clinical manifestations that psoriasis may develop into PsA.

(2) Joint manifestations Involving one or more joints, mainly hand and foot joints such as knuckles, metatarsophalangeal joints, etc. The distal interphalangeal joints are the most susceptible, often with asymmetry, joint stiffness, swelling and tenderness.

(3) Spine manifestations Spine lesions may have symptoms such as low back pain and spinal rigidity.

2. Diagnosis basis

Psoriasis patients can be diagnosed with inflammatory arthritis. Because some patients have psoriatic lesions after arthritis, the diagnosis of these patients is more difficult. Pay attention to clinical and radiological examinations, such as family history of psoriasis, find hidden areas of psoriasis, and pay attention to the affected joints. With or without spinal arthropathy. However, other diseases should be excluded before making a diagnosis.

Differential diagnosis of psoriatic arthritis

Rheumatoid arthritis

Both have minor arthritis, but psoriatic arthritis has psoriatic skin lesions and special nail lesions, finger (toe) inflammation, starting and ending point inflammation, invasion of the distal interphalangeal joints, and rheumatoid factor is often negative. Special X manifestations, such as cap-like changes, some patients have spine and sacroiliac joint disease, and rheumatoid arthritis is mostly symmetrical minor arthritis, with proximal interphalangeal and metacarpophalangeal joints, and wrist joint involvement. There may be subcutaneous nodules, rheumatoid factor positive, X-rays are mainly invasive changes in the joints.

2. Ankylosing spondylitis

Psoriatic arthritis that invades the spine, asymmetric spine and sacroiliac joint lesions, can be "jumping" lesions, usually in older men, with milder symptoms, psoriasis skin lesions and nail changes. Ankylosing spondylitis is younger, without skin and nail lesions, and spinal and sacroiliac joint lesions are often symmetrical.

3. Osteoarthritis

Psoriatic arthritis with only distal interphalangeal joint involvement needs to be distinguished from osteoarthritis. Osteoarthritis is free of psoriatic skin lesions and nail lesions, and may include Heberden nodules and Bouchard nodules. There is no typical X-ray change of PsA. The age of onset is more than 50 years old. people.

Psoriatic arthritis complications

This disease can be complicated by muscle atrophy and idiopathic consumption, extensor tendon effusion, gastrointestinal amyloidosis, aortic valve insufficiency, myopathy, Sjogren's syndrome, and inflammatory changes in the eye. Can also overlap with other serum-negative polyarthritis. According to reports, this disease can be combined with other sero-negative polyarthritis diseases to constitute the following overlapping syndromes: psoriatic arthritis-Behcet syndrome; psoriatic arthritis-Ritt syndrome; Psoriatic arthritis-Crohn's disease; Psoriasis arthritis-Ulcerative colitis. It can also cause fatal complications such as severe infections, peptic ulcers and perforations.

Psoriatic Arthritis Treatment

The purpose of this disease treatment is to relieve pain, delay joint destruction, and control skin damage. Individual treatment plans.

General treatment

Take appropriate rest, avoid excessive fatigue and joint damage, pay attention to joint function exercise, avoid tobacco, alcohol and irritating food.

2. Drug treatment

Drug selection is similar to rheumatoid arthritis except that antimalarial is still controversial.

(1) Non-steroidal anti-inflammatory drugs (NSAIDs) are suitable for patients with mild to moderate active arthritis, and have anti-inflammatory, analgesic, antipyretic and swelling effects, but have no effect on skin lesions and joint damage. The therapeutic dose should be individualized and only changed to another NSAIDs after 1 to 2 weeks of ineffectiveness. Avoid taking two or more NSAIDs at the same time. The elderly should choose NSAIDs with short half-life. For patients with a history of ulcers, they should take selective COX-2 inhibitors to reduce gastrointestinal adverse reactions.

(2) Slow-acting antirheumatic drugs (DMARDs) prevent disease progression and delay the destruction of joint tissues. If a single DMARD is ineffective, it can also be used in combination, such as methotrexate as a basic drug, plus sulfasalazine. The following is a brief description of several commonly used DMARDs: Methotrexate is effective for skin lesions and arthritis, and can be used as the first choice. Can be taken orally, intramuscularly and intravenously, starting once a week. If there are no adverse reactions and exacerbations, the dose can be gradually increased once a week. After the condition is controlled, the dose is gradually reduced and the maintenance amount is once a week. Blood medication and liver function should be checked regularly during the medication. Sulfasalazine is effective for peripheral arthritis. Gradually increasing the dosage from small doses can help reduce adverse reactions. Usage: Start with a small daily dose and increase the appropriate dose every week. If the effect is not obvious, it can be increased to the maximum amount (need to follow the doctor's advice). Blood tests should be performed regularly during medication And liver function. Penicillamine is suitable for oral administration. After oral administration, it can be gradually reduced to the maintenance amount. Penicillamine has many adverse reactions. Renal damage (including proteinuria, hematuria, nephrotic syndrome) and bone marrow suppression can occur in large doses over a long period of time. Most of them can be recovered if the drug is stopped in time. During treatment, blood, urine routine and liver and kidney function should be checked regularly. Azathioprine is also effective for skin lesions. Take it from the usual daily dose and give a maintenance amount after the effect. Blood medication and liver function should be checked regularly during medication. Cyclosporine The FDA has been effective in treating psoriasis of the skin and joints by using it for the treatment of severe psoriasis. The FDA believes that maintenance treatment for one year and longer-term use are prohibited for psoriasis. The usual amount starts from the maintenance amount (as directed by your doctor). Blood medication, blood creatinine and blood pressure should be checked during medication. Leflunomide is used for moderate to severe patients.

(3) Etratide is an aromatic retinoic acid. Orally appropriate dose (as directed by your doctor). Gradually reduce the amount of disease after treatment, 4 to 8 weeks of treatment, liver and kidney function is abnormal and hyperlipidemia, pregnant women, lactating women are prohibited. Due to its potential teratogenicity and long-term retention in the body, patients should not become pregnant during the medication and for at least one year after discontinuation. Pay attention to liver function and blood lipids during medication. Long-term use can cause spinal ligament calcification, so the use of central axis disease should be avoided.

(4) Glucocorticoids are used in severe cases and those that cannot be controlled by general medical treatment. Due to many adverse reactions, sudden discontinuation can induce severe psoriasis types and disease recurrence, so it is generally not recommended, and it should not be used for a long time. However, some scholars believe that low-dose glucocorticoids can alleviate the symptoms of patients and can serve as a "bridge" before DMARDs take effect.

(5) Phytopharmaceutical preparation ( triple tripter) Tripterygium glycosides are taken 3 times a day after meals (dosage is in accordance with the doctor's order).

(6) Local application Joint cavity injection of long-acting corticosteroids can be considered in acute single joint or less arthritis type, but it should not be used repeatedly. It should not be used more than 3 times in a year, while avoiding skin lesions. In addition to susceptibility to concurrent infections, crystalline crystal arthritis can also occur. Topical medication for psoriasis skin lesions Different medications are selected according to the type of skin lesions and the condition. For example, topical glucocorticoids are generally used for mild to moderate psoriasis. Improper use or abuse, especially at high doses, can cause skin relaxation, thinning and atrophy. Tar preparations are prone to contaminate clothing and have an unusual smell, so they can be taken during sleep. Apart from causing skin irritation, there are few other adverse reactions.

Anthracene is effective for mild and moderate psoriasis, but its inconvenience and adverse reactions limit its widespread use. Topical vitamin D3 and calcipotriol are used for the treatment of moderate psoriasis, but have certain side effects, but no pollution and odor. It is not recommended for facial and genital skin and pregnant women and children. Salicylic acid preparations are commonly used in combination therapy with glucocorticoid, anthracene or coal tar preparations to increase the effectiveness of these drugs.

Tazarotene (Tazorac) is a topical retinal or vitamin A derivative used in the treatment of psoriasis. The most obvious adverse reaction is to make the skin bright red, which is often mistaken for the worsening of the condition. It is generally not used on skin wrinkles, such as Around the groin and eyes. Others include black distilled oil ointment, camptothecin solution and so on.

3. Surgical treatment

Surgical treatment, such as arthroplasty, is used for patients who have developed joint deformities with dysfunction.

Prognosis of psoriatic arthritis

The general course is good, and only a few patients (<5%) have joint destruction and deformity. Family history of psoriasis, onset before the age of 20 years, HLA-DR3 or DR4 positive, aggressive or multiple joint disease, and poor prognosis of extensive skin lesions.

The course of the disease is long, can last for decades, and can even be extended for life and easy to relapse. Patients with psoriasis generally have a better prognosis. A few patients have extensive joint involvement, severe skin lesions, and high disability rates. Acute arthritis itself rarely causes death, but glucocorticoids and cytotoxic drugs can cause fatal complications such as severe infections, peptic ulcers, and perforations.

Psoriatic Arthritis Prevention

Primary prevention

(1) Remove all possible inducing factors, such as prevention and treatment of tonsillitis or upper respiratory tract infection, avoid trauma and mental trauma, irritation, excessive tension and other mental factors, maintain good eating habits, and avoid spicy and spicy food.

(2) Strengthen physical exercise and improve immunity.

(3) The law of life, maintain a comfortable mood, pay attention to hygiene, and prevent skin infections.

(4) Increase awareness of psoriasis. The disease is not contagious and can be alleviated by active treatment.

2. Secondary prevention

(1) Early diagnosis of psoriatic arthritis is characterized by both arthritis and psoriasis, and most patients have psoriasis first. In particular, about 80% of patients have deformed and damaged fingernails, such as horny hyperplasia under the nails, thickened decks, turbidity, tarnishing, blood nails, and uneven surface heights. This is only 20% of patients with psoriasis alone. For those who only have arthritis and no history of psoriasis, they should carefully check the scalp and elbow joints, such as the extensor skin, and the skin that is not easily found, which is meaningful for the early diagnosis of the disease.

(2) Early treatment of this disease is chronic recurrent and joint disease. The cause is not completely clear. So far, there are many treatments, but there is still no satisfactory treatment. Therefore, comprehensive therapy, integrated traditional Chinese and western medicine should be adopted to give play to their respective strengths, so that the disease can be effectively controlled at an early stage.

3. Tertiary prevention

(1) Pay attention to clean and hygienic skin to prevent recurrence of psoriasis infection.

(2) Avoid stress and keep your mood comfortable.