Patients with PsA may benefit from new medications and surgeries

Early, aggressive treatment may help reduce symptoms and improve joint function

Medications or biologic agents that target T-cells, white blood cells involved in the body's immune system, appear to offer significant benefit to patients suffering from psoriatic arthritis (PsA), a type of arthritis that affects up to 48 percent of patients with the skin disease psoriasis, according to a new review article in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). About 7.5 million Americans - roughly 2.2 percent of the population - have psoriasis, an autoimmune disease that causes red, flaky skin.

"Although these new immunosuppressive agents are expensive, they are the only agents that have demonstrated a decrease in radiologic progression of peripheral arthritis, and can be used to manage associated types of inflammation, as well as skin and nail disease," said lead study author Michael S. Day, MD, MPhil, a resident orthopaedic surgeon with the Department of Orthopaedic Surgery at NYU Hospital for Joint Diseases.

PsA can range in intensity from mild, involving only a few joints, to severe, where more joints are affected and pain may be significant. In about 15 percent of patients with PsA, skin lesions appear before arthritic symptoms; however, patients with more severe psoriasis are not necessarily at greater risk for developing PsA, Dr. Day said.

"When patients in dermatology clinics are screened for evidence of inflammatory arthritis, many have evidence of joint inflammation that they did not report, suggesting that many of these patients are undiagnosed and untreated," said study co-author, Dr. Susan M. Goodman, an assisting attending rheumatologist and internist at Hospital for Special Surgery.

Currently, initial treatments for PsA include nonsteroidal anti-inflammatory drugs (NSAIDs) that reduce inflammation, pain and fever. In the near future, drugs aimed at providing more targeted therapy will allow more PsA patients to avoid progressing to end-stage arthritis and joint destruction, she added.

Similarities between PsA and rheumatoid arthritis (RA) have spurred PsA researchers to consider early, aggressive treatment, an approach that has proved to be successful in RA patients.

Surgery may also be considered for patients who have joint deformities as a result of PsA, but so far there have been few large-scale, high-quality clinical trials, Dr. Day said. "The disease typically follows a moderate course, but up to 48 percent of cases develop into destructive arthritis in which the inflammatory process leads to bone erosion and loss of joint architecture," he said.

"Initially, it was believed that PsA had a more benign course than does RA, but this belief has been disproven," said Dr. Goodman.

Orthopaedic surgeons play a key role on the PsA treatment team. Dr. Day added that collaboration with dermatologists, rheumatologists, internists and family physicians is essential to the successful surgical treatment of PsA.

"PsA is a systemic inflammatory disease with multi-organ system effects," said Dr. Day. "As such it should be treated with a multi-disciplinary approach."

"Those who do progress to joint destruction may benefit from surgery, and may provide researchers with insights and further data regarding outcomes as well as the risks of surgery in this population," Dr. Goodman said.