Clinical Features of Psoriatic Arthritis

6 Ways That It Differs From Other Types of Arthritis

Psoriatic arthritis
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Psoriatic arthritis is an autoimmune disease that belongs to a group of conditions known as spondyloarthropathies—a family of chronic inflammatory diseases that cause arthritis both in the joints and entheses (the sites where the ligaments and tendons attach to the bone). The predominant symptoms are joint pain and inflammation, often involving the spine. 

A doctor will work to differentiate psoriatic arthritis from other spondyloarthropathies (such as ankylosing spondylitis, reactive arthritis, and nteropathic arthritis), as well as other conditions to which it closely relates, including rheumatoid arthritis, gout (a.k.a. gouty arthritis), and, to a lesser extent, osteoarthritis.

Because there are no lab or imaging tests that can definitively diagnosis psoriatic arthritis, a keen understanding of the following clinical features of the disease—and how they differ from other forms of arthritis—is essential to rendering an accurate diagnosis.

Joint Distribution

Joint pain and stiffness are often the only outward signs of psoriatic arthritis. For some people, these may be the only symptoms they ever develop. Others may present with more "classic" forms of the disease involving the hands, feet, or spine. Fatigue, swelling, joint deformity, and the restriction of joint function is also common.

Unlike some forms of arthritis in which symptoms develop abruptly (e.g., gout, enteropathic arthritis), the symptoms of psoriatic arthritis tend to develop gradually and worsen over time.

The vast majority of cases will be asymmetric, meaning that joints are affected arbitrarily and are not mirrored on the other side of the body. This differs from rheumatoid arthritis, in which the pattern is mainly symmetrical.

With that being said, as psoriatic arthritis progresses, it can sometimes become symmetrical and manifest with severe symptoms (including, in rare cases, a potentially disfiguring condition known as arthritis mutilans).

Bone Damage

Psoriatic arthritis affects bones differently than other types of arthritis. With psoriatic arthritis, cortical bone (the outer protective surface) will begin to thin and narrow, especially on the fingers and toes. At the same time, new bone will begin to form near the margins of a joint.

The bone changes can cause a "pencil-in-cup" deformity on X-ray in which the tip of the finger is narrowed as the adjoining bone develops a cup-like shape. This is a classic symptom of severe psoriatic arthritis as well as scleroderma.

In contrast, ankylosing spondylitis will cause the excessive formation of new cortical bone, while rheumatoid arthritis will manifest with the erosion of cortical bone and the narrowing of the joint space.

Hands and Feet

One characteristic feature of psoriatic arthritis is dactylitis, the sausage-like swelling of the fingers and toes caused by chronic inflammation. Dactylitis only affects a small proportion of people with psoriatic arthritis but is considered a classic presentation of the disease.

Psoriatic arthritis also tends to affect the distal joints (those nearest the nails) of the fingers and toes. Rheumatoid arthritis tends to affect the proximal (middle) joints, while osteoarthritis can affect any joint in the body.

Psoriatic arthritis can sometimes cause the "opera-glass hand" deformity in which the fingers telescope backward and bend irregularly. It mainly occurs with severe psoriatic arthritis and less commonly with rheumatoid arthritis.

Skin, Nails, and Eyes

Psoriatic arthritis is inextricably linked to the autoimmune skin disease psoriasis. In fact, psoriasis will precede the onset of psoriatic arthritis in roughly 80% of cases, oftentimes as early as 10 years prior.

With that being said, as many as 15% to 20% will manifest with arthritis first. Occasionally, arthritis and psoriasis will appear simultaneously.

Unlike other types of arthritis, psoriatic arthritis will present with skin plaques in nearly 80% of cases. Eye problems (such as uveitis) are also distinctive, caused by the formation of plaques on or around the eyelid.

Nail abnormalities can sometimes occur with inflammatory or non-inflammatory arthritis. But, with psoriatic arthritis, the signs tend to be more distinctive and include:

  • "Oil drops" (reddish-yellow spots beneath the nail plate)
  • Spotted lunula (redness in the white arch just above the cuticle)
  • Splinter hemorrhages (vertical black lines under the nail where capillaries have burst)

Psoriatic Arthritis Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Doctor Discussion Guide Woman

Spine

Spondyloarthropathies like psoriatic arthritis can be differentiated from rheumatoid arthritis and gout in that the spine is frequently affected. In fact, the prefix spondylos is derived from the Greek for "spine" or "vertebra." 

Although rheumatoid arthritis can affect the cervical spine of the neck, spondyloarthropathies can involve the axial spine, spanning the torso to the tailbone.

With psoriasis, the major areas of spinal involvement are the lumbar spine of the lower back and the sacroiliac joint where the wing-shaped top of the pelvis (the ilium) attaches to the lower part of the spine (sacrum).

The condition, referred to as psoriatic spondylitis, can affect up to 35% of people with psoriatic arthritis, according to a 2018 review in Current Rheumatology Reports.

Blood Tests

Beyond the physical characteristics of psoriatic arthritis, there are blood tests that can help differentiate it from other forms of arthritis.

One factor associated with spinal spondyloarthropathy is a genetic mutation of the human leukocyte antigen B27 (HLA-B27) gene. Around 90% of white people with ankylosing spondylitis will have the HLA-B27 mutation as well as 60% to 70% of those with psoriatic arthritis.

While useful in diagnosing spondylitis, the mere presence of the HLA-B27 mutation is not considered conclusive since people without arthritis or inflammation can also have it.

The same is not true for antibody tests used to diagnose rheumatoid arthritis. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) are two antibodies commonly used in the diagnosis of rheumatoid arthritis. While the antibodies are sometimes detected in people with psoriatic arthritis, they are almost invariably low and inconsequential.

As inflammatory diseases, blood tests done on those with psoriatic arthritis, rheumatoid arthritis, or gout will reveal elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). These inflammatory markers will not be elevated with osteoarthritis since the disease is not inflammatory.

Differentiation

Because there are no blood or imaging tests that can definitively diagnose psoriatic arthritis, a differential diagnosis may be used to rule out other possible causes. Chief among the investigation are the various forms of arthritis which share similar symptoms.

Psoriatic Arthritis Differential Diagnosis
Condition Differentiating Signs Differentiating Tests
Psoriatic arthritis Asymmetrical arthritis
Psoriasis
Dactylitis 
Nail psoriasis
Negative RF test
Narrowing of cortical bone
 
Ankylosing spondylitis Back pain
Spinal stiffness
Chest expansion poor
 
Positive HLA-B27
Bilateral sacroiliitis
Rheumatoid arthritis Symmetrical arthritis
No dactylitis
Lumbar spine normal
Positive RF test
Positive anti-CCP
Bone erosion
Narrowed joint space
No bone spurs
Gout Rapid acute episodes
(lasting 7 to 14 days)
Pain in foot joints
Big toe mainly affected
Tophi on X-ray
Urate crystals in joint fluid
Osteoarthritis Develops over years
Starts asymmetrically
Pain but little swelling
Normal CRP and ESR
Bone spurs
Narrowed joint space
 
Reactive arthritis Recent chlamydia
Recent bowel infection
Urethritis common
Positive STD screen
Positive HLA-B27
Enteropathic arthritis Limbs mostly affected
Concurs with IBD
Positive diagnosis of
Crohn's diease or
ulcerative colitis
Juvenile spondylitis Occurring under the age of 16 Negative RF test
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