Psoriatic Arthritis Progression and Stages

Psoriatic arthritis (PsA) is a type of inflammatory arthritis that often affects people who already have psoriasis. PsA will get worse with time and a person can have periods of remission, where they won’t have any symptoms, and periods of flare-ups, where skin and/or joint symptoms are active and progressive. 

When you are first diagnosed, your rheumatologist will want to determine the stage of the disease—mild, moderate or severe. Determining the seriousness of PsA, helps your healthcare provider figure out the best treatment course and how to best monitor progress.

Mild PsA, often seen in early PsA, will cause pain and stiffness, but it will not affect your ability to perform daily activities. Moderate PsA, seen within a few years of diagnosis, will affect your quality of life, as pain and limited range of motion can make it harder to perform some activities of daily living. Last, severe PsA, seen in people who have lived with PsA for a long time, will have the greatest impact on your quality of life as it will drastically restrict day-to-day activities. 

Early PsA

The majority of the time, PsA begins years after the presentation of psoriasis symptoms. Up to 40 percent of people with psoriasis eventually go on to develop PsA.  

There are several risk factors that make it more likely for a person with psoriasis to develop PsA. These include:

• Psoriasis on fingernails
• A family history of PsA
• Being between ages 30 and 50
• Having psoriasis of the scalp

Much like other types of inflammatory arthritis, PsA usually starts with pain and swelling in one or more joints, usually the smaller joints, such as the fingers and toes. You may also have swelling in larger joints, including the knees, ankles, shoulders. PsA almost always causes enthesitis, which is inflammation of where tendons insert into bone (such as at the Achilles' tendon). PsA can also cause a condition called dactylitis, where a finger or toe is so swollen it looks like a sausage.

Additional signs a person may experience in the early phases of PsA include:

• Pitted nails or nail separation
• Lower back pain
• Eye inflammation
• Foot pain
• Elbow pain
• Reduced range of motion
• Fatigue

Disease Progression

PsA will progress differently for each person. Without appropriate treatment, the disease will worsen and affect more joints on both sides of the body.  As the disease progresses, you will experience periodic flare-ups of disease symptoms. 

Extended periods of inflammation may eventually cause bone erosion (loss of bone). Joint space may also begin to narrow, which will make it harder to move. In the small joints of the fingers and toes, it is possible to see clear joint damage.

Later Stages of PsA

Joint problems are not the only symptoms associated with progressing PsA.  As the disease progresses, PsA can start to impact your daily life and cause severe fatigue and debilitating skin symptoms. In addition, PsA is associated with a number of complications all related to inflammation.

Fatigue: Up to 50 percent of people with PsA live with some fatigue and at least 30 percent complain of severe fatigue that affects them on a daily basis. 

Skin Symptoms: PsA rash presents as thick, red, silvery patches of skin. Patches are usually dry, itchy and sore, and can develop anywhere on the body—but the knees, elbows, low back, hands and feet are usually the most affected. 

Spine Symptoms: As many as 40 percent of people with PsA have spine involvement, this according to a 2017 study reported in the medical journal, Annals of the Rheumatic Diseases.  Pain results when there is inflammation of the joints between the vertebrae, a condition called psoriatic spondylitis. Inflammation may also affect the joints between the spine and pelvis, called sacroiliitis.

Eye Inflammation: A condition called uveitis that affects the eye’s middle layer can cause pain, floaters (dark specks or strings drifting across the eyes), and blurry vision from long-standing PsA inflammation. According to the Arthritis Foundation, 7 percent of people with PsA will have uveitis.

Arthritis Mutilans: Up to 5 percent of people will develop arthritis mutilans, a severe form of the disease that affects the joints of the hands and feet. The condition will cause the joints to erode and shorten and the skin around those joints to contract, causing permanent damage. Biologic drug treatment can prevent this type of joint damage. 

Hearing Loss: Research reported in The Journal of Rheumatology finds strong evidence for inner ear damage in people with PsA. The 2017 study of mostly men PsA patients found 60 percent of the patients were experiencing hearing loss related to damage in the inner ear and/or the auditory nerve. Such damage eventually leads to hearing loss and balance problems.

Slowing Down PsA

There is no cure for PsA and joint damage cannot be reversed. However, the disease can be slowed down, and treatment works best when it is started in the early stages of the disease.  

The first step to slowing down the disease’s progress is by controlling inflammation. Several medications can help, including:

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs, such as Advil (ibuprofen) and Aleve (naproxen), are over the counter (OTC) NSAIDs that can reduce inflammation throughout the body. They also help manage joint pain. When OTC NSAIDs don’t help, your healthcare provider can prescribe stronger NSAIDs, such as Voltaren-XR (diclofenac) and Celebrex (celecoxib). 
• Cortisone Injections: Cortisone injections can target inflammation in a single joint to help reduce pain and swelling quickly.
• Disease-Modifying Antirheumatic Drugs (DMARDs): DMARDs, such as Trexall (methotrexate) and Azulfidine (sulfasalazine), work to slow down PsA’s progression. These drugs are helpful in preventing joint damage, but they are known for their harsh side effects, including the potential for liver and blood problems and increased susceptibility to infection. However, their benefits often outweigh the risks, and many patients tolerate these medications with no adverse effects.
• Biologic Drugs: Biologic drugs use genetically engineered proteins originating from human genes to target specific parts of the immune system so as to slow down disease progression and prevent joint damage.

In addition to drug therapy, you will want to avoid putting stress on joints. The following things can help:

• Losing Weight: Losing weight can reduce stress on your joints.
• Exercise: Low-impact exercise, such as biking, swimming, and yoga, can help with weight loss, strengthen muscles and increase range of motion.
• Heat and Cold Therapy: A heating pad can help to relax tense muscles, which reduces joint stress. Ice therapy can reduce in inflammation, swelling, and pain in affected joints. Just don’t apply ice directly to the skin. Wrap an ice pack in a towel before applying it to skin.

A Word From Verywell

Pain and inflammation can be difficult to manage and living with both can have an effect on your emotional health. When emotional health is left unchecked, PsA eventually leads to depression, anxiety, and difficulties in coping with day-to-day life. Ask your healthcare provider about locating a PsA support group or a therapist who can help you to learn coping skills especially if you find you are struggling with the emotional challenges of your health.