What causes psoriatic arthritis flare? Related conditions and treatments

What does psoriatic arthritis flare feel like?

Psoriatic arthritis flares are experienced by some people with psoriasis, a chronic inflammatory disease. During psoriasis flares, the immune system attacks healthy tissues in the body. The skin is primarily affected, but other parts of the body can also be involved, such as the nails, eyes, or joints. Psoriatic arthritis, or PsA, occurs when active psoriasis affects the joints. It’s not a separate condition from psoriasis, but just one aspect of disease activity. Healthcare professionals aren’t sure how many people with psoriasis also experience psoriatic arthritis. Estimates range between 6% and 41%. People with more severe psoriasis are more likely to develop psoriatic arthritis. For many, the development of PsA may not occur for up to ten years after first noticing psoriasis.

When active psoriasis attacks the joints, the affected joints get stiff, swollen, and painful. Fingers and toes might swell up like sausages during a PsA flare, a unique arthritis symptom called dactylitis. Tendons around the joints might also swell and stiffen. People may have other symptoms besides joint problems, such as skin problems and nail disorders. When psoriatic arthritis first manifests, it usually only strikes a few joints in the hands or feet. As it develops, more joints are involved, including wrists, ankles, larger joints, and the spine (spondylitis). Psoriatic flares damage the joints. Some of this damage heals, but some of the injuries may never recover.  Over time, progressive joint injuries build up and can result in deformity and debilitation.

What causes psoriatic arthritis flares?

Psoriasis is the cause of psoriatic arthritis flares. Psoriatic arthritis flares can be triggered by external or internal factors, including:

• Stress

• Skin injuries such as sunburn

• Infections

• Allergies

• Alcohol

• Cold or warm weather

These are not psoriatic arthritis causes. Instead, many of them activate the immune system. That immune system activity may cascade into an autoimmune attack on healthy tissues in the skin or joints.

Should I be worried about a psoriatic arthritis flare?

See a healthcare provider when experiencing psoriasis or psoriatic arthritis symptoms. Active psoriasis disease activity must be brought under control. Psoriasis flares progressively injure the body’s tissues, including the joints. Eventually, psoriatic arthritis can lead to severe joint damage, deformity, and disability.

Emergency or immediate medical treatment may be needed in some cases of a psoriatic arthritis flare. Symptoms that require emergency medical treatment include severe PsA symptoms, high fever, hot and swollen joints, unusual pain or swelling in a joint, severe abdominal pain, or bone fractures. Severe side effects from psoriasis medications, such as serious infections, blood clots, heart attack, or stroke, also require emergency treatment.

How is the cause of psoriatic arthritis flare diagnosed?

For people who haven’t been diagnosed with psoriatic arthritis, diagnosis is based on a history, physical examination, and tests. People may start with a primary care physician, but psoriatic arthritis is definitively diagnosed and treated by a doctor of rheumatology. A dermatologist usually treats skin and nail symptoms. The care team will also include a primary care physician.

The clinician will start with a medical history and a review of the symptoms. The physician will ask about any patient or family history of psoriasis or arthritis. Symptoms of psoriatic arthritis include swollen and painful joints but need to include finger swelling, as well. Lower back pain is an indication that the spine may be involved. The healthcare provider will look for other active psoriasis symptoms such as skin conditions (skin lesions, rashes, plaques, or bumps), nail changes (nail discoloration, nail pitting, or separation from the nail bed), or eye problems (uveitis). Other nonspecific symptoms include fatigue, morning stiffness, and reduced range of motion.

There are no specific blood tests for psoriatic arthritis, but a probable diagnosis can be made based on various findings from a blood test. X-rays are another essential tool for distinguishing psoriatic arthritis from other joint problems. An MRI can help identify important distinguishing features of psoriatic arthritis, such as ligament swelling or tendonitis.

How long does psoriatic arthritis flare last?

Psoriasis flares are unpredictable in their duration and severity. Treatment can help reduce both duration and severity, but even with treatment, flares can last for weeks or months.

How to stop psoriatic arthritis flares

Most people with psoriatic arthritis want the pain and stiffness to go away. That is only one goal of treatment. The main goal is to prevent or minimize damage to the joint. Each PsA flare could do permanent damage to the joints, so treatment aims to block or slow that gradual worsening of joint function.

In addition to joint problems, people experiencing a psoriatic arthritis flare usually have other parts of the body affected. These other manifestations of active disease may have separate treatments.

For psoriatic arthritis, symptom relief for pain, swelling, and stiffness is usually managed with nonsteroidal anti-inflammatory drugs (NSAIDs). Over-the-counter NSAIDs like ibuprofen or naproxen may be sufficient to handle mild pain, but a healthcare provider can prescribe stronger NSAIDs. In more severe cases, corticosteroid injections may be needed, as well.

To control the flare itself, a rheumatologist will use drugs that suppress or modify the immune system’s attack on the joints and other tissues. These include:

• Oral disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate or sulfasalazine

• JAK inhibitors such as Xeljanz (tofacitinib)

• Biologic DMARD injections (antibodies) such as Orencia (abatacept)

Nonmedical treatments used to preserve or restore joints include surgery, joint replacement, physical therapy, assistive devices, orthotics, dietary supplements, and splints.

RELATED: Everything you need to know about biologics for psoriasis

Living with psoriatic arthritis flare

Psoriatic arthritis is a lifelong condition, but preventing and managing psoriatic arthritis flare-ups involves more than just doctors and medicines. There are several things people can do to help prevent flare-ups and minimize their severity:

• Lose weight.

• Engage in low-impact exercise regularly.

• Eat a healthy diet that is low in trigger foods like fried foods or red meat and high in anti-inflammatory foods like leafy vegetables and fatty fish.

• Consider taking daily dietary supplements such as glucosamine, chondroitin, omega-3 fatty acids, gamma-linolenic acid (GLA), or antioxidant vitamins (A, C, E, and D). To prevent osteoporosis due to arthritis, inactivity, or corticosteroid treatment, consider taking daily calcium supplements. Get medical advice from members of the care team before starting supplements.

• Ask for medical advice about assistive devices or other ways to improve functioning at home and on the job.

When a flare-up does occur, and joints become stiff and painful, the pain and swelling can be helped with self-care as well as medications:

• Rest—take it easy and stop using the joint. This reduces the metabolic demands on the tissues and reduces blood flow, the first step to reducing swelling.

• Exercise—although rest provides pain relief, healthcare providers may suggest simple and gentle range-of-motion exercises to help relieve pain and stiffness during a flare and improve joint flexibility between flares. These are also effective at reducing morning stiffness.

• Heat (warm baths, warm showers, and heating pads) is best for stiffness, particularly morning stiffness.

• Ice is best for acute pain, especially if tendons are involved. It lowers the temperature of the tissues, reducing the metabolic demands and greatly reducing blood flow. It also numbs the nerves in the joints.

Keep in mind that living with psoriasis may involve other medical conditions such as depression, other autoimmune conditions (e.g. inflammatory bowel disease), metabolic syndrome, obesity, infection, injuries, and heart attack. It’s important to exercise, eat healthily, join support groups, get regular checkups, and see a mental health professional if necessary.

RELATED: 15 treatments and remedies for arthritis pain relief

What’s next? Additional resources for people with psoriatic arthritis flare

Test and diagnostics

• Psoriasis, American Family Physician

• Psoriatic arthritis, StatPearls

• What are the early signs of psoriasis?, SingleCare

Treatments

• Everything you need to know about biologics for psoriasis, SingleCare

• Know when to go to the emergency room, Arthritis Foundation

• Psoriasis treatments and medications, SingleCare

• Psoriatic arthritis, StatPearls

• Your care team, National Psoriasis Foundation

Scientific studies and clinical trials

• Incidence and prevalence of psoriatic arthritis in patients with psoriasis stratified by psoriasis disease severity: Retrospective analysis of an electronic health records database in the United States, Journal of the American Academy of Dermatology

• The epidemiology of psoriatic arthritis, Rheumatic Diseases Clinics of North America