What Is Psoriatic Arthritis Remission and Is It Possible?

In recent years, psoriatic arthritis (PsA) remission has become an important topic for medical research. Researchers have found that earlier diagnoses, better management of symptoms, and advances in treatments are making it easier for people with PsA to live normal and pain-free lives. 

Read about how PsA remission is defined and what it looks like so that you manage your expectations and work towards keeping disease symptoms from coming back.

Psoriatic arthritis is a type of autoimmune arthritis associated with joint and skin inflammation. PsA affects joints and surrounding structures. It inflames the tendon area that inserts in a bone (a symptom called enthesitis) and causes tenosynovitis (inflammation the tendon area where muscle connects to bone) of the all the digits, (a symptom called dactylitis).

PsA also affects the nails, causing pitting (small indents in the nail surface). Further, it is often connected to psoriasis, a condition where skin cells build and form scales and dry, itchy patches. These symptoms help to distinguish it from other types of inflammatory arthritis, such as rheumatoid arthritis (RA), another autoimmune disease where an overactive immune system mistakenly attacks the joints and in severe cases, the organs.

According to data from the Cleveland Clinic, PsA prevalence varies from 0.3% to 1%, and people with pre-existing psoriasis have the highest risk for developing PsA. It is often diagnosed in middle age (ages 30 to 50) but anyone of any age can develop PsA. Women and men are equally affected, and people of Northern European descent have an increased risk. Genetics also play a role, especially family history of PsA or psoriasis. 

Severity and course of PsA varies from person-to-person. Some people have mild symptoms while others have severe disease activity that eventually causes joint damage and/or disability. Aggressive disease is more common in people who have more joint involvement early on, extensive skin involvement, strong family history of psoriasis, or disease onset before age 20.

Rheumatologists (doctors who specialize in arthritic conditions) define PsA remission as “minimal disease activity” status. In general, there are two types of remission in PsA: drug-induced and drug-free.

• Drug-induced remission indicates minimal disease activity while on medication.
• Drug-free remission, while rare, is complete relief from joint tenderness and swelling without the help of medication.

Determining remission is based on specific criteria, which involves five clinical domains: synovitis, enthesitis, dactylitis, spondylitis, and nail and/or skin involvement.

• Synovitis refers to inflammation of the synovial membrane, the membrane that holds the joint cavities. This condition is painful, especially with movement. Joints swell due to synovial fluid retention.
• Enthesitis causes inflammation of tendons and ligaments that attach to bone.
• Dactylitis causes severe inflammation in the finger and toe joints. The swelling causes the digits to resemble sausages. If swelling is severe, the fingers can become so stiff that a person can no longer form a fist.
• Spondylitis refers to inflammation of the spine and large joints.
• Nail and/or skin involvement: According to the National Psoriasis Foundation, up to 86% of people with PsA have nail psoriasis, which includes pitting (indents in the nails), deformation in the shape of nails, nail thickening, onycholysis (separation of the nail from the nail bed), and discoloration, usually appearing like a fungal infection. More than 80% of people with PsA have both joint and skin involvement. These people tend to have overall severe disease state, worse outcomes, and increased need for medical care. Skin problems caused by PsA include psoriasis plaques that appear on skin, especially on the knees, elbows, hands, feet, low back, and scalp. Plaques may be itchy and painful and bleed.  They will vary in size and join together to cover large areas of the skin.

The significant reduction of these symptoms—or minimal disease activity—is considered remission from PsA.

In addition to helping with making a confirmation of remission, these clinical domains are important in both diagnosis and treatment.

In the last decade, a target-to-treat (T2T) has become the recommended approach for treating PsA. Target-to-treat in PsA means setting specific testing goals—either remission or low disease activity. In addition, numerous new treatment therapies have become available to people with PsA. 

One 2018 study reported in the journal, Arthritis Research & Therapy looked at clinical disease status of people with PsA treated in an outpatient clinic setting during the years 2008 to 2017. The Norwegian study involved the collection of data, including demographics, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) blood work to check inflammation levels, and clinical measures of disease activity based on severity, disease activity, and modified disease activity, researcher assessments, patient-reported outcomes of function, pain, and disease-modifying antirheumatic drug (DMARD) use. What the researchers found was that biologic treatment was a necessary component of targeting remission. Further, newer treatment options and the development of attainable and valid measures help to improve remission odds.

An earlier study from 2010, also reported in Arthritis Research & Therapy, examined remission rates in people with PsA who were treated with anti-tumor necrosis factor alpha (TNFα) therapy. TNF inhibitors suppress response to tumor necrosis factor (TNF), a protein that is part of the inflammatory process.

The study from researchers out of University College Dublin, Ireland analyzed a group of people attending a biologic clinic from November 2004 to March 2008. Patients had rheumatoid arthritis or PsA. Criteria for assessment included demographics, previous DMARD use, tender and swollen joint counts, morning stiffness, pain score, patient assessment, CRP blood work, and health assessment questionnaires. After 12 months of treating with TNF inhibitor therapy, 58% of the PsA patients achieved remission, this compared to only 44% of the RA patients. CRP levels also were checked, and researchers noted inflammation levels were much less for the people with PsA.

Remission in PsA means there is an absence of signs of disease activity, which can include symptoms and inflammation blood markers. In people who have long-standing disease, low disease activity, or few disease signs, it is a reasonable goal.  

The standard treatment approach for PsA is T2T. The goal of T2T in PsA is remission or inactive disease. Psoriatic arthritis T2T involves medication adjustment over time to achieve a pre-determined goal, usually remission.

Depending on a person’s overall health and level of disease activity, monitoring can be as frequent as every month or every few months. At each visit, your doctor will evaluate to see if you are meeting the targeted goal. If the goal is not met, medication dose may be increased, new drugs may be added, or medication may be switched out to a different class of drugs. The process is ongoing and involves increasing aggressive therapy to come as close to the goal of remission or low disease activity.

One study reported in the December 2015 publication of The Lancet put the T2T approach to the test.  In this trial, 206 patients with early PsA were randomized to receive standard care or tight control management for 48 weeks. The tight control group was seeing their doctors once a month and had pre-determined targets and a specific treatment protocol that included DMARDs. The ultimate goal was minimal disease activity. Those in the standard care group were seen by their doctors every 12 weeks and were treated as their doctors deemed appropriate with no set protocol or treatment goal.

Results from the tight control group showed joint and skin symptoms were significantly improved far exceeding those in the standard group. Those in the tight control group were meeting at least five of seven criteria, which included few or no swollen and tender joints, and very little skin involvement, pain, or disability. 

While only a few recent studies have addressed PsA remission, most researchers agree starting PsA treatment as early as possible increases the chance of remission and could potentially make lasting remission more likely. However, drug-free remission is more unlikely and relapse rates are much higher when PsA treatment is discontinued. Findings from a 2015 study reported in the Annals of the Rheumatic Diseases have confirmed this. 

The German study observed 26 PsA patients for six months who were on methotrexate or a TNF inhibitor. These patients did not have joint pain or musculoskeletal symptoms and some skin involvement.  The researchers found incidence of disease relapse was high after treatment discontinuance, affecting 20 of the patients. 

The researchers concluded stopping treatment—even in people with remission for more than six months—was not realistic because the rate for flare-ups (periods of high disease activity) in PsA is higher when a person is not taking medications. 

These is no cure for psoriatic arthritis. If you are lucky enough to experience remission, your doctor will likely want you to keep taking medications. Making lifestyle changes can also help prevent symptoms from returning. This may include joint protection, weight management, a healthy diet, and joint-friendly exercises, such as swimming, walking and biking.

Starting treatment as early as possible will slow down the disease and make remission possible. Additionally, early, aggressive treatment prevents joint damage and disability and leads to a better long-term outlook. You can increase your odds of remission by working closely with your rheumatologist and taking all treatments as prescribed.

PsA remission can last weeks, months, or even years. But remission will not be permanent and your symptoms may suddenly return. If this happens, talk to your doctor as soon as you can.