What Is Symmetric Psoriatic Arthritis?

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Psoriatic arthritis (PsA) is a type of autoimmune arthritis characterized by stiff, swollen joints. Symmetric psoriatic arthritis is the second most common form of PsA. It affects the joints on both sides of the body at the same time. For example, it affects both the knees or both the wrists.

Keep reading to learn more about symmetric PsA, its symptoms, causes, diagnosis, and more.

Psoriatic disease of the hand

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Symptoms

Symptoms of symmetric PsA can develop slowly with mild symptoms, or they can develop quickly and be severe.

Symptoms might include:

  • Fatigue
  • Tenderness, pain, and swelling of one or more joints on both sides
  • Enthesitis: Tenderness and swelling of the tendons and ligaments
  • Reduced range of motion: Limited movement of a joint. That limited movement might be stiff and painful and restrict the natural motion of the joint’s range (its full movement potential).
  • Joint stiffness in the morning
  • Nail changes: Including pitting or separation from the nailbed
  • Uveitis: Inflammation of one or both eyes
  • Skin symptoms: Including scaly, itchy plaques, similar to what is seen in psoriasis, an inflammatory skin condition linked to PsA
  • Lower back pain: Due to inflammation of the joints between the vertebrae (the small bones forming the spine) and the joints between the spine and pelvis—a symptom called sacroiliitis
  • Dactylitis: Swollen fingers and toes (sausage digits) on both sides of the body

Symptoms of PsA tend to be worse with symmetric joint involvement. Severity increases with the number of affected joints.

Symmetric vs. Asymmetric Psoriatic Arthritis

Joint symmetry in PsA tends to be asymmetric. Asymmetric means joint pain and swelling only affect one side of the body. For example, one knee is affected but the other knee isn’t.

Asymmetric PsA tends to be milder than symmetric PsA, and it affects no more than five joints at once. It usually affects the larger joints, although it can also affect the hands and feet. According to the Cleveland Clinic, asymmetric PsA affects 70% to 80% of people with PsA.

Asymmetric PsA will often occur before symmetric PsA. Not everyone with asymmetric PsA will go on to develop the symmetric type.

Causes

PsA is caused by a combination of genetic, environmental, and lifestyle risk factors. Risk factors include psoriasis, a family history of psoriasis or psoriatic arthritis, age, obesity, smoking,

Psoriasis

Having psoriasis is the biggest risk factor for the development of PsA. People with severe psoriasis have a higher risk than people who experience mild symptoms. PsA affects up to 30% of people with psoriasis.

Family History and Genes

Studies have shown that people with a close relative with psoriasis have an up to 40% risk for developing psoriatic arthritis. Several genes may contribute to psoriasis and psoriatic arthritis, including HLA-B27, which has been linked to PsA. HLA-B27 has also been linked to more severe PsA.

Having HLA-B gene markers doesn’t mean that you will go on to develop PsA or that you will have a more severe disease course. In fact, there is no way to predict whether a person will go on to develop PsA or their disease course just by family history or having certain genes.

Age

PsA can start at any age, but it tends to occur in adults ages 30 to 50. For many people, PsA starts 5 to 10 years after their psoriasis diagnosis.

According to the National Psoriasis Foundation, about a third of the people with PsA are under age 20. And every year, there are 20,000 new diagnoses in children under the age of 10.

Obesity

Obesity has been recognized as a risk factor for psoriasis and psoriatic arthritis. Fortunately, obesity is a modifiable risk factor, which means you can do something about it. If you are diagnosed with PsA, maintaining a healthy weight or losing weight if you are overweight can help to reduce your risk for a more severe disease course.

Smoking

Numerous studies have found that smoking is a major risk factor for the development of PsA. A 2011 study found that women who smoked were more likely to develop PsA than those who had never smoked. Past smokers had a 50% increased risk, and the greatest risk was based on the frequency and the number of years smoked.

Alcohol

Alcohol can have negative effects on your health. Studies also have found that excessive alcohol consumption can increase the risk for PsA. It can also reduce the effectiveness of your PsA treatments and may negatively interact with some of these treatments.

Environmental Factors

Exposure to certain infections can contribute to your development of PsA. Some experts believe there is a link between strep infections and the development of PsA. Physical trauma has also been identified as a risk factor for PsA, as well as emotional stress, stressful life events, and skin infections like staph.

Diagnosis

PsA can be challenging to diagnose. This is because the classic symptoms of the condition, such as pitting of the fingernails and swollen fingers, are not always present.

Symmetric PsA is sometimes confused with another inflammatory condition called rheumatoid arthritis (RA). The symmetric pattern mimics RA but PsA is known for distal interphalangeal (DIP) joint involvement (affecting the first knuckles from the top of the fingers).

In addition, PsA does not cause rheumatoid nodules, and rheumatoid factor (RF) testing with PsA will be negative.

No one blood test can diagnose symmetric PsA. It is often a diagnosis of exclusion. This means your doctor will need to rule out other conditions, including RA.

In making an assessment, your doctor will want to look at your medical history, conduct a physical exam, and request medical imaging and lab work.

Part of your medical history includes asking about specific characteristics of symmetric PsA.

This might include:

  • Joint pain and swelling on both sides of the body
  • Joint pain that improves with the use of the affected joints
  • Morning stiffness that lasts more than 30 minutes
  • Swelling of fingers and toes
  • Back pain that wakes you up at night
  • Changes to the nails of the fingers and toes

Your doctor will also examine you for specific signs of PsA, including:

  • Psoriasis on the elbows, scalp, palms of the hands, and the soles of the feet
  • Changes to finger and toenails
  • Tenderness, redness, and swelling in the joints
  • Tendon and ligament problems, including at the Achilles tendon
  • Back mobility
  • Inflammation and pain in the sacroiliac joints, the area where the spine connects to the pelvis

Psoriatic Arthritis Doctor Discussion Guide

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

Doctor talking to patient in hospital room

Treatment

The goals of treatment for PsA are to reduce symptoms, improve and maintain joint function, keep inflammation down, slow down the disease’s progression, and maximize your quality of life.

Treatment for symmetric PsA is the same as it would be for asymmetric PsA. But since symmetric PsA is more severe, your treatment plan is based on your pain levels, disease severity, age, overall health, and current quality of life.

Your treatment options for PsA might include:

Some people with PsA will need surgery to repair damaged joints. Surgery can help to restore function, relieve pain, and improve mobility.

Treatment Options

There are effective medicines for PsA. Research has led to treatment options including many new biologic drugs and a newer class of drugs called JAK inhibitors. That means people with PsA can feel better and have a great quality of life.

Progression

PsA progresses differently for each person affected and it can progress quickly if it is not properly treated. Worsening of symptoms and more frequent flare-ups are signs your PsA has progressed, and that more aggressive treatment might be needed.

This is especially true if you are experiencing flares every couple of months and need corticosteroids to manage symptoms and reduce inflammation.

Significant loss of joint mobility is a sign of worsening PsA. The goals of PsA treatment are to prevent joint damage and reduce your pain. But if you are having difficulty walking, moving, or using your joints, including your hands, you should talk to your doctor about updating your treatment plan.

Additional signs of disease progression are:

  • Bone erosion (loss of bone)
  • Bone spurs at the areas where tendons attach to bone

Both bone erosion and bone spurs can be seen on X-rays. Once you have these kinds of bone changes, you may already be experiencing limited mobility and pain.

Flare-Ups

Most people with PsA will go through periods of flare-ups. This means that their symptoms will get worse for some time. These periods may be linked to specific triggers. Avoiding these triggers may help prevent a flare.

Stress: Most people with PsA report flare-ups during stressful times. A 2015 study found people with PsA were more vulnerable to increased joint pain, skin symptoms, and fatigue at times when they are dealing with the psychological factors of PsA.

For stressful times, consider exercise and meditation to manage your stress, or talk to a therapist who can suggest better ways to cope with PsA. 

Lack of sleep: Studies have shown a link between poor sleep and worsening PsA symptoms. One 2020 review of studies found sleep disturbances affected up 38% of people with PsA and fatigue affected around 45% of people with the condition.

Both of these add to the burden of disease and are associated with increased skin and joint symptoms, and disease flare-ups.

Not following your treatment plan: If you don’t stick to your treatments, your PsA will flare up. Don’t stop, skip, or take the wrong dosage of medicine. Always follow your doctor’s advice and instructions for taking your medications. 

Being inactive: PsA causes swelling and stiffness of the joints, and the best way to counteract this effect is by being active. Stretching and light exercise makes it easier to get joint symptoms under control. Lack of activity can send you in the opposite direction and trigger flare-ups.

Diet: Some types of foods can lead to inflammation and trigger flare-ups. This includes saturated fats, simple carbohydrates, sugar, and alcohol. Replace foods from these categories with healthy options, including fresh fruits and vegetables and foods that high are in omega-3 fatty acids, such as walnuts and oily fish.

Alcohol intake: Drinking too much alcohol can lead to increased inflammation. This can lead to more fatigue and pain, and make it harder for you to get around. If you notice your PsA gets worse after drinking, cut back or stop consuming alcohol altogether.

Smoking: Smoking comes with a variety of health problems. It also makes PsA worse and triggers flare-ups. Quitting smoking will likely lessen skin and joint symptoms. It could also improve your overall health.

Weather changes: Dry and cold weather can both trigger PsA flares. Dry weather can dry out the skin, which worsens skin symptoms. Cold, damp weather and barometric pressure changes have been linked to joint pain, swelling, and stiffness.

Researchers have not been able to find any solid connections between weather and PsA flares, but many people with PsA do report flares based on weather conditions. If the weather is a trigger for you, take the necessary precautions to protect your skin and joints from dry weather or cold, damp weather.

Frequently Asked Questions

How bad can psoriatic arthritis get?

Ongoing inflammation puts you at an increased risk for joint damage and disability. In addition to bone and joint damage, inflammation PsA can cause damage to other organs in the body. This might include your heart, eyes, and inner ear.

What are the five types of psoriatic arthritis?

The five types of PsA are classified by the parts of the body that are affected, the extent of symptoms, and severity. They can overlap and it is possible to have two or more types as the disease changes over time.

  • Symmetric PsA affects the same joints on both sides of the body.
  • Asymmetric PsA doesn’t affect the same joints on both sides of the body.
  • Distal interphalangeal predominant (DIP) PsA primarily affects the small joints of the fingers and toes closest to the nails.
  • Psoriatic spondylitis causes inflammation of the spine and movement problems in the neck, low back, pelvis, and sacroiliac (SI) joints.
  • Arthritis mutilans (AM) is a severe type of PsA that damages the hands and feet, eventually leading to deformity and disability.

What causes psoriatic arthritis flare-ups?

Flare-ups are associated with specific triggers and avoiding some of these can help to prevent flares. Common triggers for PsA are stress, lack of sleep, not following your treatment plan, being inactive, diet, excessive alcohol intake, smoking, and weather changes.

What is the best treatment for psoriatic arthritis?

The main goal of treatment in PsA to control the inflammation that causes joints to swell and skin to overgrow. But there is no one-size-fits-all approach to treating the condition and treatment will depend on how severe your PsA is.

You may need to try more than one treatment before you and your doctor find what works best. You will also need to make lifestyle adjustments, such as watching your diet, being active as much as possible, and getting rid of bad habits like smoking and drinking too much alcohol.

Summary

Symmetric psoriatic arthritis is an autoimmune condition that affects the joints on both sides of the body at the same time. Symptoms include joint pain and swelling. Treatment aims to slow progression and maintain joint function. Options include medications, lifestyle modifications, and possibly surgery.

A Word From Verywell

Living with psoriatic arthritis can very challenging. PsA affects the body inside and out, and it can have profound effects on both your physical and mental well-being.

Early diagnosis and treatment are vital to keeping you mobile, regardless of the type of PsA you have. And with so many new treatment options available, the outlook for people with PsA has never been better. 

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