Questions and Answers

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Q. I have been told that although the arthritis is connected to psoriasis, if you can get rid of the psoriasis it does not follow the arthritis will go. Is this the case?

A. Whether the arthritis gets better following improvement in the skin depends on whether you are one of those patients in whom the skin and joints wax and wane together. If so, treatment of the skin condition, or the avoidance of factors which make it worse, or the affects of sunshine on the skin may all be followed by improvement in the joints. In patients who have this sequence of events it is usually consistent over time and improvements can be expected in the joints each time the skin improves. In other patients arthritis can be troublesome with the most minimal area of the skin involved, the treatment of the skin has no noticeable effect on the joints.

Q. I recently went in to hospital for an arthroscopy on my left knee. Three weeks later I went to see the orthopaedic surgeon for the results. He informed me that although as yet there was no joint inflammation, I asked him that if there was no joint damage WHY were my knees so painful? His answer was "good question" and left the room. Please could you enlighten me more?

A. When a joint is examined by arthroscopy, the degree of magnification of the tissues is quite small and fine detail, as would be seen down a microscope, is not obtained, so that it is entirely possible for inflammation to be present in a degree to cause pain which would not be visible by this method. Also in psoriatic arthritis the inflammation can be intense over a short period of time and then subside, leaving no visible trace by the time arthroscopy is performed.

Q. How do doctors treat patients with Ankylosing Spondylitis and Psoriasis?

A. Ankylosing Spondylitis, or a condition very similar to it, does indeed occur in a proportion of people with psoriasis, and in particular in those who have B27 tissue type. The treatment of the spondylitis is essentially similar to that for ordinary Ankylosing Spondylitis in people who have no psoriasis, and consists of the prescription of anti-inflammatory medicines and a programme of hydrotherapy and physiotherapy to maintain spinal mobility.

In some patients, individual joints as well as the spine are involved, and it may well be that psoriasis and the infective agents which trigger the arthritis in an individual, also trigger the Spondylitis, joint involvement in either condition will respond to the same medication, e.g. sulphasalazine? which has slower, but more fundamental effect on the condition than non-steroidal anti-inflammatory drugs. Recently there has been evidence that ordinary Ankylong Spondylitis in which the spinal condition does not respond to sulfasalazine may respond favourably in that respect to methotrexate which of course is already widely used for patients both with psoriasis and psoriatic arthritis.

Q. Could you tell me why I feel so tired with PsA?

A. Tiredness is a feature common to all the forms of inflammatory arthritis, and for a long time it was put down to psychological causes and to the effects of chronic pain. There is now evidence that chemical substances that the body produces during inflammation, known as interleukin may be directly responsible for this effect and so when the disease comes under better control, particularly with medicines which suppress these substances the tiredness begins to improve.

Q.I would like to know why my left knee swelled up with blood and after 7 aspirations, six weeks rest and an arthroscopy (which didn't reveal why) it is still swollen, although I am now using it and back at work. The treatment I am on is Methotrexate – intra muscular injection once weekly and one Indomethacin 75mg nightly?

A. When a knee is very intensely inflamed, as can be the case in psoriatic arthropathy, there is a great increase in the bloodflow in the lining of the joint, and it becomes congested and bleeds very easily with the most minimal trauma and this is probably what happened in your case. Because there are other serious cases of bleeding into a joint, which requires careful investigation, arthroscopy was a reasonable thing to do. If the case was simply the intensity of the inflammation, this would tend to have subsided after rest and aspiration, so that by the time an arthroscopy was done, it probably would not show anything. You do not say whether anything was injected into your joint, such as steroid, in any of the seven aspirations performed. It is very unusual to have to do as many aspirations as seven and It may be that the reason the fluid kept returning was that the inflammation continued, although not as intensely as when the bleeding occurred, and was not brought under control, either by steroid injection or with the dose of Methotrexate which you were receiving at that time. Methotrexate takes a considerable time to achieve its maximum effect and different patients need widely differing doses.

Q. Can acupuncture help with easing the pain of psoriatic arthritis? If so, where do I go, or how can I find out the best place/practitioner to consult? Is it available on the NHS?

A. Acupuncture may help to ease the pain of any type of arthritis and psoriatic arthritis is no exception. Its effect is not very predictable and overall only about 80% of people can expect any lasting help. If your arthritis is very “active” and even if you have done well with acupuncture in the past, you may only get a few day’s relief. It is always worth trying if you don’t mind needles.

Acupuncture is far more widely available on the NHS than people realise. Many general practitioners practice it and so do some physiotherapists. Your local pain specialist may well be able to provide treatment in the hospital clinic. The first port of call is always your own GP who will advise you.

Q. a. I would very much like to know whether diet can cure psoriatic arthropathy or whether sunshine is the greater factor and b. what foods/drinks other than tomatoes and strawberries are best to avoid?

A. First of all it is important to say that neither diet nor sunshine will cure psoriatic arthropathy because, sadly, there is no cure, neither may they even affect the symptoms. The two factors cannot be compared. Sunshine may help by warming stiff muscles and joints and in some people may relieve psoriasis. Tomatoes and strawberries do not necessarily worsen arthritis. There are three types of dietary manipulation that needs consideration. The first is food elimination, where certain foods are cut out of the diet to see if joints get better. They are then added in one at a time to see if the joints become inflamed. Some people do find that certain foods make their joints worse but every person is different. However, elimination of these foods will merely dampen and not remove the symptoms.

The second “diet” tried is where certain things are added – either because there is a belief that the sufferer is deficient in one thing eg a vitamin, or because it is thought that food balance has been upset. Extra vitamins, cod liver oil and amino acids are examples of this type of food change. Again there are no more than individual stories that this might help psoriatic arthritis and few trials have been published.

The third type of diet, which has even less evidence that it works, is one where the way in which food is prepared or the time at which it is given is altered.

The problem with all diets is that there is no firm evidence that they work, they are often pushed as universal cures for all types of arthritis and there is a great need for proper scientific evaluation. Judgment that diet plays any part or a great part in the treatment of psoriatic arthritis, cannot be made at this time.

Q. a. How can physiotherapy help with joint mobility and reduction in permanent joint damage? B. are there any positive treatments for my joints – shoulders, elbows, hands, wrists? C. exercise routines – any comments.

A. These are frequently asked questions and very important ones to answer because arthritis will not only damage and stiffen joints, it will also lead to muscle weakness and wasting so that walking is made doubly difficult. Although it is not possible to prevent this happening entirely and joint damage will continue by way of inflammation there is a lot that you can do keep mobile and prevent the disability becoming any worse.

The general principles are:

Seek the advice of a specialist physiotherapist as to what you should or should not do.
Little and often is better than short and sharp.
Exercises should treat and prevent joint contracture and stiffness, and give strength and stamina to weak muscles.
A regular routine is a good idea but if a joint is very hot and swollen some exercises should be avoided.

The answers to these questions have been provided by members of our mediclal advisory team. Always consult your own doctor or health care provider.