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About six years ago, Mike Braucher, 58, had to stop playing basketball with his sons because of joint pain. After a few pain medications didn’t work, he was eventually referred to a rheumatologist who provided a more accurate diagnosis: Psoriatic arthritis, a chronic condition marked by joint pain and skin symptoms.
Braucher, like many with psoriatic arthritis, experienced an inability to do what he loved because of his symptoms. Fortunately, his rheumatologist provided the right diagnosis and psoriatic arthritis treatment plan, allowing Braucher to return to his regular routine. “We're in an amazing era of treatment with options that were not available 10 years ago,” says Julius Birnbaum, M.D., a professor of medicine at the University of Pittsburgh and author of Living Well with Autoimmune Diseases. The pathway to that initial psoriatic arthritis diagnosis and finding the right treatment can be difficult, but not impossible, to navigate.
What is psoriatic arthritis?
Psoriatic arthritis occurs when someone has both inflammatory arthritis and psoriasis, says Lawrence Brent, M.D., associate director of rheumatology at Temple University. Inflammatory arthritis is a group of conditions that occur when the immune system is overactive. Psoriasis is an inflammatory skin condition which often manifests as erythematous plaques, a type of red or flat red skin lesions.
Researchers are unsure what causes psoriatic arthritis, though there seems to be a genetic component. Other risk factors include obesity and severe psoriasis. Trauma to the joint or bones often triggers this condition.
Psoriatic arthritis symptoms
Symptoms can vary greatly, but common ones include:
- Joint swelling and inflammation: This occurs in the spine, neck, lower back or hips. Pain is usually worse in the morning or after rest.
- Back pain: Birnhaum notes that back pain occurs more often in younger patients. Older patients’ back pain is more likely related to degenerative changes in the spine than psoriatic arthritis.
- Rash: A rash or skin inflammation, particularly in the elbows, knees or scalp.
- Sausage fingers and toes: Psoriatic arthritis may cause sausage-like swelling of toes or fingers that’s often painful.
- Tenderness: Many patients experience tenderness in areas where ligaments or tendons attach to bones.
- Psoriatic arthritis nails: A tell-tale sign of psoriatic arthritis is when there’s nail pitting, dips or depressions in the nail plates.
- Mental health symptoms: A lack of energy as well as anxiety or depression often accompanies psoriatic arthritis.
- Uveitis: As the disease progresses, some patients will also develop uveitis, inflammation of the eye which can cause light sensitivity and decreased vision.
Psoriatic arthritis is also associated with a higher prevalence for other conditions, such as diabetes, hypertension, heart disease and obesity.
Difficulty in diagnosing
“Patients with psoriatic arthritis could have psoriasis first and then go on to develop the musculoskeletal complications afterwards,” explains Birnbaum, who notes other patients experience the opposite: They develop arthritis before skin symptoms develop. He adds, “Then, there are patients who develop psoriasis skin disease at the same time that they develop arthritis.”
These three different presentations make it difficult to diagnose psoriatic arthritis, an experience familiar to Tim Clepper, 68. Clepper was an avid cyclist until about five years ago, when he began experiencing fatigue and joint pain. He went to every doctor he could think of, but none could diagnose his symptoms. About two years ago, he finally was referred to a rheumatologist who diagnosed him with psoriatic arthritis.
“One of the issues with psoriatic arthritis is that diagnosis can be very difficult and very time consuming,” says Klepper, “I've been volunteering with the Arthritis Foundation for 25 years, yet the last thought in my mind was that I had some sort of arthritis.”
Clepper isn’t alone in a long path to diagnosis. Braucher mentioned a similar journey, and nationwide, about 15 percent of psoriatic arthritis cases are currently undiagnosed.
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