How Psoriatic Arthritis Is Treated

Given the nature of psoriatic arthritis (PsA)—a chronic disease that combines inflammatory arthritis and the skin condition psoriasis—PsA treatment typically involves a combination of therapies to address painful joints and itchy, scaly, discolored patches of skin.

While there is no cure for psoriatic arthritis, symptoms are often manageable with medications, good lifestyle habits, and specialized approaches like phototherapy. Surgery may be considered if there's significant joint damage.

Treatment of psoriatic arthritis is ideally overseen by both a rheumatologist (a healthcare provider who specializes in arthritis and like diseases) and a dermatologist (a healthcare provider who focuses on skin disorders). PsA is a progressive disease that, if not properly treated, can lead to a reduced quality of life and possible disability.

This article reviews the various treatment options for PsA, such as over-the-counter (OTC) medications, prescription medications, surgical procedures, and more.

Over-the-Counter Therapies

OTC therapies may be the only treatment needed to manage PsA symptoms. These include medications taken by mouth or applied to the skin for pain, inflammation, and rashes.

NSAIDs

For pain, OTC nonsteroidal anti-inflammatory drugs (NSAIDs) are usually tried first. That's especially true for people with mild arthritis symptoms, such as achy hands, wrists, or knees. 

NSAIDs work by blocking enzymes involved in the production of prostaglandins, compounds involved in inflammation. This results in less swelling and pain.

OTC NSAIDs include:

• Advil/Motrin (ibuprofen)
• Aleve (naproxen)
• Aspirin (acetylsalicylic acid)

Side effects typically include gastrointestinal symptoms. Possible risks include kidney problems, high blood pressure, and allergic reactions.

OTC Creams

Hydrocortisone cream is a common OTC topical used for PsA. It is a corticosteroid that decreases inflammation of the skin and joints.

Other OTC creams used for skin itchiness contain the active ingredients salicylic acid and coal tar. Salicylic acid helps soften and remove psoriasis scales, while coal tar reduces inflammation and slows down the excessive cell growth of skin cells that causes scales and dry, itchy patches of skin.

For some, OTC creams may irritate the skin, making it important to test a topical product before using it regularly. When trying a new OTC cream, first apply a small amount on a small area of the skin for several days to see if any reddening or irritation occurs.

Medicated Shampoos

While regular shampoo is used to remove dirt, residue, and excess sebum (an oily substance) from the scalp and hair, medicated shampoo takes it a step further. These products contain ingredients that help treat skin conditions—typically the same ones found in OTC creams, such as hydrocortisone, coal tar, and salicylic acid.

Some people may have a harder time clearing up psoriasis on the scalp than others. This is particularly true in Black people, who may need to use a medicated shampoo twice a week.

If that's not enough, a topical medicine may be recommended. Your dermatologist can help you manage this and provide you with instructions on how frequently to use a medicated shampoo.

Prescriptions

Sometimes these options are not effective enough to treat more severe cases of PsA. Prescription medications are typically introduced into the treatment regimen if OTC options fail.

Your rheumatologist and dermatologist will determine your course of prescription treatment based on the severity of your symptoms, potential risks of treatments, and other diseases you may have.

Psoriasis Treatments

Psoriasis patches appear pink or red on people with light skin tones and purplish or darker brown on brown or black skin. Treatment is the same for everyone despite these differences.

Creams and ointments are used to treat the scaly, itchy patches associated with psoriasis.

These include:

• Topical corticosteroids: Topical corticosteroids are used for inflammation and itching. There are many potencies available. Cordran (flurandrenolide), Topicort (desoximetasone), and Lidex (fluocinonide) are a few common prescription drugs that are used.
• Synthetic vitamin D: Vitamin D helps slow skin cell growth. Medications include Dovonex (calcipotriene) and Vectical (calcitriol), both of which may irritate the skin.
• Anthralin: Anthralin can help slow skin cell growth, remove scales, and make the skin smoother. Sold under the brand name Dritho-Scalp, it may irritate skin and shouldn't be left on for long stretches. 
• Retinoids: Retinoids are vitamin A derivatives that may decrease inflammation. Common brands include Tasorac or Avage (tazarotene). Retinoids may irritate skin and increase sensitivity to sunlight.
• Calcineurin inhibitors: Calcineurin inhibitors reduce inflammation and plaque build-up. Prograf (tacrolimus) and Elidel (pimecrolimus) are two common brands. Long-term or continuous use of these inhibitors may increase the risk of skin cancer. 
  

DMARDs

Disease-modifying anti-rheumatic drugs (DMARDs) are used to treat inflammatory conditions and slow the disease process.

They come in three varieties and are believed to halt the underlying disease process by suppressing the immune system.

• Conventional synthetics (csDMARDs) have been in use for more than 40 years and work by broadly suppressing your immune system. They include Methotrexate, Arava (leflunomide), and Azulfidine (sulfasalazine).
• Targeted synthetics (tsDMARDs) are newer drugs that work by suppressing specific mechanisms that occur in immune cells. Common tsDMARDs include phosphodiesterase inhibitors and JAK inhibitors, such as Xeljanz (tofacitinib).
• Biologics (bDMARDs) are useful for treating prominent skin symptoms along with joint damage. These drugs decrease inflammation by targeting certain molecules on immune system cells that can promote inflammation. Some common bDMARDs include Enbrel (etanercept), Remicade (infliximab), Humira (adalimumab), Simponi (golimumab), and Cimzia (certolizumab pegol).

Newer drugs for PsA include:

• Otezla (apremilast): A DMARD that inhibits phosphodiesterase-4 (PDE4), an enzyme that regulates inflammation in the body
• Cosentyx (secukinumab) and Stelara (ustekinumab): Injectable monoclonal antibody DMARDs that block specific groups of small proteins known as cytokines that help promote inflammatory responses.
  

Pain Medication

Prescription pain relief can take several forms.

NSAIDs

Prescription NSAIDs are stronger than OTC versions and may work better when symptoms do not improve after trying them.

More than a dozen are on the market, including:

• Celebrex (celecoxib)
• Mobic (meloxicam)
• Toradol (ketorolac)
• Zorvolex (diclofenac)

Side effects typically include gastrointestinal symptoms. Similar to OTC NSAIDs, taking prescription NSAIDs carries risks of heightened blood pressure and kidney damage.

Steroids

Steroids can help relieve inflammation. They're often prescribed to treat a flare-up of arthritis or psoriasis. They can be given orally or by injection. Common steroids include:

• Cortisone
• Prednisone
• Methylprednisolone
• Triamcinolone

Side effects of steroids include irritability and mood changes, increased blood sugar levels, high blood pressure, insomnia, and weight gain.

Opioids

Opioids (also called opiates) are narcotic painkillers. They include:

• Percocet (oxycodone and acetaminophen)
• Vicodin (hydrocodone/acetaminophen)
• Demerol (meperidine)
• OxyContin (oxycodone)

These medications are for short-term relief of serious or debilitating pain. Opioids can be highly addictive and should not be taken for extended periods of time.

Side effects include constipation, mental fog, nausea, and drowsiness.

Surgeries and Specialist-Driven Procedures

Sometimes, surgeries or specialized approaches may help relieve symptoms and improve quality of life. One specialized approach is phototherapy, which involves exposing the skin to UV light to help heal skin patches. You do this by standing in a light box two or three times a week.

Special devices that emit UVB light can be used at a healthcare provider's office or in your home. However, for treating psoriasis, you need a prescription from your healthcare provider to use these devices. A session of phototherapy typically lasts around 15 to 30 minutes.

If you use medications that make your skin sensitive to UV light, you should not use phototherapy. Also, note that phototherapy can make your skin tan or darken where it's treated.

In people of color, it can make dark spots from psoriasis even more pronounced. If this concerns you, tell your dermatologist you'd rather try a different treatment option.

When Joints Are Damaged

Although rare, some with PsA opt for surgical treatment when the condition causes significant damage to the joints. However, surgery is typically a last resort. Research shows that fewer than 10% of people with PsA need surgical treatment.

Some common PsA surgical procedures include:

• Joint fusion: Joint fusion (arthrodesis) is a procedure that fuses the ends of two joints together to a fixed position. The procedure can offer pain relief by stabilizing the joint and preventing movements that may be causing pain. However, the procedure can also limit the mobility of a joint.
• Synovectomy: Sometimes, the synovial membrane (joint lining) becomes inflamed and does not respond to medication, resulting in persistent pain. With synovectomy, all or part of the joint lining is removed. The procedure is typically considered when joint inflammation doesn't respond to drugs.
• Joint replacement: Joint replacement surgery involves replacing part or all of a joint with an artificial one to restore joint function. This procedure is commonly done on large joints, such as the hips and knees.

Lifestyle

Being proactive in your treatment and practicing self-care is important for people with psoriatic arthritis.

In addition to taking medications as prescribed, here are some ways you can help manage the condition and ease symptoms:

• Get regular exercise: Physical activity, such as walking and stretching, can help keep affected joints flexible and improve health and well-being. 
• Lose weight: Excess weight puts added stress on joints, so losing weight may help relieve joint symptoms.
• Manage stress: Stress can increase inflammation. Deep breathing, meditation, yoga, tai chi, or a support group may help reduce stress. If you need more help, you may want to consider counseling.
• Keep skin protected: Although sunlight is beneficial for psoriasis, too much of it can cause sunburn and make skin symptoms worse. Controlling your exposure to sunlight and applying sunscreen (on areas that are free from psoriasis plaques) can help prevent sunburn. Also, be sure to moisturize the skin with lotions, avoid hot baths or showers, and use prescription or over-the-counter topical treatments regularly if needed.
• Use gentle clothing detergents: Stick to fragrance-free detergent and fabric softeners to reduce skin reactions.
• Shampoo frequently: If you get psoriasis on your scalp, shampooing often can help remove scales.
• Stop Smoking: Although smoking can cause different health problems, it may also reduce the effectiveness of PsA medications Stopping smoking can lead to better overall health outcomes.

Complementary Medicine

Several complementary treatments can help treat symptoms of PsA along with the options described above. These include:

• Massage
• Acupuncture and acupressure to reduce pain
• Chiropractic (manipulation of the spine)
• Moist heat
• Icing affected joints

Be sure to consult your healthcare team before trying any of these, however, as some may not be appropriate if you are experiencing a flare-up.

Cannabis

Cannabis, in the form of cannabidiol (CBD) or tetrahydrocannabinol (THC), has received little attention as a PsA treatment.

However, CBD has been shown to relieve pain and inflammation from some other types of arthritis pain. Research shows that THC alone may not reduce or prevent inflammation as CBD can.

CBD is legal at the federal level and doesn't get you "high" like THC. CBD is commonly taken orally through tinctures or applied topically with cream or oils.

Talk with your healthcare provider to ensure that any CBD product you want to try is suitable for you and your condition.

Summary

Psoriatic arthritis treatment usually involves several strategies, since you need to not only manage joint symptoms but skin symptoms as well.

Over-the-counter NSAIDs are usually the first choice of treatment for psoriatic arthritis pain. Prescription medications, like DMARDs and steroids, are used if these aren't enough. Topical medications can help ease skin discomfort and reduce plaques.

Phototherapy may be considered to reduce psoriasis plaques. And lifestyle and non-drug therapies, like losing weight, stopping smoking, and applying ice packs, may help you better manage your symptoms.

Surgery is rarely used for PsA but may be appropriate if there is significant joint damage.