Treatments for the arthritis

Drugs

Non-steroidal anti-inflammatory drugs (NSAIDs)Anti-inflammatory drugs act by blocking the inflammation that occurs in the lining of your joints. They can be very effective in controlling pain and stiffness. Usually you’ll find your symptoms improve within hours of taking these drugs but the effect will only last for a few hours, so you have to take the tablets regularly.Some people find that NSAIDs work well at first but become less effective after a few weeks. In this situation, it sometimes helps to try a different NSAID. There are about 20 available, including ibuprofen, diclofenac, indometacin and naproxen.Like all drugs, NSAIDs can sometimes have side-effects, but your doctor will take precautions to reduce the risk of these, for example, by prescribing the lowest effective dose for the shortest possible period of time.NSAIDs can cause digestive problems (stomach upsets, indigestion or damage to the lining of the stomach) so in most cases NSAIDs will be prescribed along with a drug called a proton pump inhibitor (PPI), which will help to protect the stomach.NSAIDs also carry an increased risk of heart attack or stroke. Although the increased risk is small, your doctor will be cautious about prescribing NSAIDs if there are other factors that may increase your overall risk, for example, smoking, circulation problems, high blood pressure, high cholesterol or diabetes.Read more about NSAIDs.Disease-modifying anti-rheumatic drugs (DMARDs)Disease-modifying drugs help by tackling the causes of inflammation. They change the way the condition progresses and hopefully will stop your arthritis from getting worse. It may be several weeks before DMARDs start to have an effect on your joints, so you should keep taking them even if they don’t seem to be working. Sometimes these drugs are given by injection.DMARDs aren’t usually used as a first-choice treatment, and the decision to use them will depend on a number of factors, including how much effect NSAIDs have had, how active your arthritis is and how likely it is that you’ll have further joint damage.Examples of DMARDs include:

methotrexate sulfasalazine hydroxychloroquine ciclosporin

Biological therapies are a newer group of disease-modifying drugs that may be used if other DMARDs aren’t working well enough. These are given either by injection or through a drip into a vein. Biological therapies used for treating psoriatic arthritis include:

adalimumab etanercept infliximab

When taking almost all DMARDs you’ll need to have regular blood tests and in some cases a urine test. The tests allow your doctor to monitor the effects the drug has had on your condition but also to check for possible side-effects, including problems with your liver, kidneys or blood count.

You can take NSAIDs along with DMARDs, and sometimes you might need to take more than one DMARD.Steroid injectionsYour doctor might recommend steroid injections if your joints are particularly painful or your ligaments and tendons have become inflamed.Read more about steroid injections.Surgery

You probably won’t need surgery, although very occasionally a damaged tendon may need surgical repair. Sometimes, after many years of disease, a joint that has been damaged by inflammation is best treated with joint replacement surgery.If your psoriasis is bad in the skin around the affected joint, your surgeon may recommend a course of antibiotic tablets to help prevent infection. Sometimes psoriasis can appear along the scar left by the operation, but this can be treated in the usual way.Treatments for the skin

Your skin will usually be treated with ointments. There are 5 main types: tar-based ointments dithranol-based ointments (it’s very important not to let these come into contact with

normal skin) steroid-based creams and lotions vitamin D-like ointments such as calcipotriol and tacalcitol vitamin A-like (retinoid) gels such as tazarotene

If the creams and ointments don’t help your psoriasis, your doctor may suggest: light therapy, involving short spells of exposure to high-intensity ultraviolet light carried out

in hospital retinoid tablets

Many of the DMARDs used for psoriatic arthritis will also help your skin condition. Similarly, some of the treatments for your skin may help your arthritis.- See more at: http://www.arthritisresearchuk.org/arthritis-information/conditions/psoriatic-arthritis/treatments.aspx#sthash.CrEYA2Ty.dpuf

Psoriasis Causes and Known Triggers

Scientists believe that at least 10 percent of the general population inherits one or more

of the genes that create a predisposition to psoriasis. However, only 2 percent to 3

percent of the population develops the disease. Researchers believe that for a person to

develop psoriasis, the individual must have a combination of the genes that cause

psoriasis and be exposed to specific external factors known as "triggers". Read more

about the science of psoriasis »

Psoriasis triggers are not universal. What may cause one person's psoriasis to become

active, may not affect another. Established psoriasis triggers include:

Stress

Stress can cause psoriasis to flare for the first time or aggravate existing psoriasis.

Relaxation and stress reduction may help prevent stress from impacting psoriasis.

Injury to skin

Psoriasis can appear in areas of the skin that have been injured or traumatized. This is

called the Koebner [KEB-ner] phenomenon. Vaccinations, sunburns and scratches

can all trigger a Koebner response. The Koebner response can be treated if it is caught

early enough.

Medications

Certain medications are associated with triggering psoriasis, including:

Lithium: Used to treat manic depression and other psychiatric disorders. Lithium

aggravates psoriasis in about half of those with psoriasis who take it.

Antimalarials: Plaquenil, Quinacrine, chloroquine and hydroxychloroquine may

cause a flare of psoriasis, usually 2 to 3 weeks after the drug is taken.

Hydroxychloroquine has the lowest incidence of side effects.

Inderal: This high blood pressure medication worsens psoriasis in about 25

percent to 30 percent of patients with psoriasis who take it. It is not known if all

high blood pressure (beta blocker) medications worsen psoriasis, but they may

have that potential.

Quinidine: This heart medication has been reported to worsen some cases of

psoriasis.

Indomethacin: This is a nonsteroidal anti-inflammatory drug used to treat

arthritis. It has worsened some cases of psoriasis. Other anti-inflammatories

usually can be substituted. Indomethacin's negative effects are usually minimal

when it is taken properly. Its side effects are usually outweighed by its benefits in

psoriatic arthritis.

Other triggers

Although scientifically unproven, some people with psoriasis suspect that allergies, diet

and weather trigger their psoriasis. Strep infection is known to trigger guttate psoriasis.

Treatment

Traditional Systemic Medications

Systemic medications are prescription drugs that work throughout the body. They are

usually used for individuals with moderate to severe psoriasis and psoriatic arthritis.

Systemic medications are also used in those who are not responsive or are unable to

take topical medications or UV light therapy.

systemic Medications: Soriatane (Acitretin)

What is Soriatane (acitretin)?

Soriatane is an oral retinoid, which is a synthetic form of vitamin A. Acitretin is the only

oral retinoid approved by the FDA specifically for treating psoriasis.

The exact way Soriatane works to control psoriasis is unknown. In general, retinoids

help control the multiplication of cells including the speed at which skin cells grow and

shed.

How is Soriatane used?

Soriatane comes in 10 mg and 25 mg capsules. The prescribed dose is taken once a

day with food. Several factors determine the dosage for each individual, including the

type of psoriasis present.

Doses may be reduced after symptoms improve, depending on the person's response.

Ordinarily, retinoid treatment is stopped when lesions have cleared significantly. When

lesions or other symptoms reappear, the drug may be taken again.

Soriatane tends to work slowly for plaque psoriasis. Psoriasis may worsen before

individuals start to see clearing. After eight to 16 weeks of treatment, the skin lesions

usually will improve. It may take up to six months for the drug to reach its peak effect.

Soriatane is indicated for use in adults with severe plaque, guttate, pustular,

erythrodermic, or palmoplantar psoriasis.

Do not take Soriatane if:

You are pregnant, planning to become pregnant, or breastfeeding:

You have severe liver or kidney disease:

You have high triglycerides;

You are allergic to retinoids.

Soriatane causes serious birth defects. Because of this risk, women of childbearing

potential must have two negative pregnancy tests before starting Soriatane. They must

use two effective forms of birth control at least one month before beginning treatment,

while on the drug and for three years after stopping treatment. Progestin-only birth

control pills may not work while taking Soriatane, so women should avoid using them as

a primary form of birth control.

Individuals should not donate blood during treatment and for three years after stopping

treatment. Donated blood could expose pregnant women to acitretin.

What are the possible side effects?

Hair loss

Chapped lips and dry mouth

Dry skin and eyes

Bleeding gums and nose bleeds

Increased sensitivity to sunlight

Peeling fingertips and nail changes

Changes in blood fat levels

Depression

Aggressive thoughts or thoughts of self-harm

Headache

Joint pain

Decreased night vision

Elevated liver enzymes

These side effects, and others, tend to go away after stopping the medication or lowering the dosage.

What are the potential drug interactions?

Your doctor should always be aware of any other medications, therapies or supplements

you are using. Avoid dietary supplements with vitamin A. Soriatane is related to vitamin

A, and taking vitamin could add to the unwanted effects of Soriatane.

Women of childbearing potential who use Soriatane must not drink or eat any substance

containing alcohol during treatment and for two months after treatment is stopped.

Alcohol can cause Soriatane to convert to a form that is very slowly removed from the

body, which increases the risk of birth defects if the woman becomes pregnant.  

Soriatane can reduce the effectiveness of phenytoin, a common drug for epilepsy, when

given at the same time. Soriatane should not be combined with tetracycline (an

antibiotic), since both medications can cause increased pressure on the brain, which can

have serious consequences.

Can Soriatane be used with other treatments?

Soriatane is most effective for treating psoriasis when it is used with phototherapy.

Soriatane is sometimes used with Amevive (alefacept), Enbrel (etanercept), or

Remicade (infliximab), and may also be prescribed in rotation

with cyclosporine or methotrexate.

Accutane (isotretinoin) is another oral retinoid that is sometimes used in place of acitretin

to treat psoriasis.

cyclosporine

What is cyclosporine and how does it work?

Cyclosporine is an immunosuppressive drug that was first used to help prevent rejection

in organ transplant patients. In 1997, the Food and Drug Administration (FDA) approved

Neoral for adults with severe psoriasis and otherwise normal immune systems.

Cyclosporine suppresses the immune system and slows down the growth of certain

immune cells.

How is it used?

Cyclosporine is taken daily by mouth in capsule or liquid form. The liquid form must be

diluted for use, preferably mixed with room temperature orange or apple juice. Do not

mix with grapefruit juice. Cyclosporine must be taken on a consistent schedule.

Cyclosporine can provide rapid relief from symptoms. You may see some improvement

in symptoms after two weeks of treatment, particularly with stronger doses. However, it

may take from three to four months to reach optimal control.

Extended use of cyclosporine by transplant patients is well-established. However, long-

term use as a treatment for psoriasis is more limited. The FDA recommends

cyclosporine not be used for longer than one year. However, there are no specific

guidelines for how long you should stay off of cyclosporine before resuming treatment.

Some doctors may prescribe the drug for more than one year.

Who should not take cyclosporine?

Do not take cyclosporine if you have:

A compromised immune system

Abnormal kidney function

High blood pressure

Cancer, or a history of cancer (other than basal or squamous cell skin cancers)

Severe gout

Additionally, do not take cyclosporine if you are:

Pregnant or breastfeeding

Undergoing radiation treatment.

What are the risks?

Individuals previously treated with PUVA, methotrexate or other immunosuppressive

agentsUVB, coal tar, or radiation therapy are at an increased risk of developing skin

cancer when taking cyclosporine. Additional risks with cyclosporine include kidney

damage. This increases with length of time and amount of cyclosporine taken. Your

doctor will monitor your kidney function before and during treatment. Patients can also

develop hypertension on this medication so frequent blood pressure checks are

important.

Vaccinations may be less effective if taken while on cyclosporine. Talk to your doctor if

you plan to get any kind of vaccination.

What are the side effects?

Decreased kidney function

Headache

High blood pressure

High cholesterol

Excessive hair growth

Tingling or burning sensation in the arms or legs

Skin sensitivity

Increased growth of gum tissues

Flu-like symptoms

Upset stomach

Tiredness

Muscle, bone or joint pain

Potential drug interactions with cyclosporine

Your doctor should always be aware of any other medications, treatments or dietary

supplements you are using. Many medications interact with cyclosporine. These include

certain antibiotics, anti-inflammatory drugs, anti-fungals, gastrointestinal agents, calcium

channel blockers, and anti-convulsants. OTC medications such as aspirin and ibuprofen.

Also, talk to your doctor if you are taking St. John's Wort while on cyclosporine.

Avoid grapefruit while taking cyclosporine and talk to your doctor about the amount of

potassium-rich foods such as bananas, tomatoes, raisins and carrots you may have in

your diet. Cyclosporine can raise the levels of potassium in your blood.

Can cyclosporine be used with other treatments?

Cyclosporine can be used with the topical drugs Dovonex and Vectical. When using

these topicals, lower doses of cyclosporine may be given, lessening the risk of side

effects.

Systemic Medications: Methotrexate

Approved by the FDA in the 1970s for treatment of severe psoriasis, methotrexate was

initially used to treat cancer. The drug is also highly effective in reducing the painful

symptoms of psoriatic arthritis.

In a person with psoriasis, methotrexate binds to and inhibits an enzyme involved in the

rapid growth of skin cells and slows down their growth rate.

Do not take methotrexate if:

You are an alcoholic or have alcoholic liver disease, cirrhosis or other chronic

liver diseases;

You have an immunodeficiency syndrome or an active infectious disease;

You are trying to conceive (applies to both men and women), pregnant or

nursing;

You have an active peptic ulcer;

You have significant liver or kidney abnormalities;

You have underdeveloped bone marrow, a low white blood cell count, low

platelets or significant anemia.

The less common side effects of long-term methotrexate treatment include liver damage

and reversible living scarring developing reversible liver scarring. The risk of liver

damage increases if a person drinks alcohol, has abnormal kidney function, is obese,

has diabetes or has had prior liver disease. Years after the drug, in rare occasions,

certain types of cancer, such as lymphoma, and bone marrow toxicity have occurred.

Methotrexate can cause a reduced white blood cell count increasing infection risk.

Individuals taking methotrexate must have regular blood tests to ensure that the drug is

safely processed by the body including the liver, white blood cells and bone marrow.

Additionally, the liver must be biopsied at regular intervals.

Pregnancy should be avoided if either partner is taking methotrexate. Men should be off

methotrexate at least three months before trying to conceive. Women should wait at

least four months after stopping methotrexate to become pregnant.

Moderate to Severe Psoriasis: "Off-label" Systemic Medications

There are additional systemic medications that are not approved by the FDA for treating

psoriasis and psoriatic arthritis. However, some doctors prescribe them off-label—a

common and accepted medical practice.

Hydrea (hydroxyurea) is an oral cancer medication found to be effective for psoriasis in

the late 1960s. Hydrea can produce significant improvement in stable plaque psoriasis,

but it also has potentially dangerous side effect, including bone marrow toxicity. Long-

term use has been associated with skin cancer.

Isotretinoin is an oral retinoid approved as a treatment for severe cystic acne. The most

common side effects of isotretinoin are eye and lip dryness, and nosebleeds. Bone spurs

and hair loss occur to a lesser degree.

Isotretinoin has the potential for severe birth defects if a woman becomes pregnant while

the drug is still in her system. A woman on isotretinoin should use reliable birth control

one month before treatment, during treatment and for at least one month afterward.

Mycophenolate mofetil is used for the prevention of organ transplant rejection, as well

as in the treatment of several inflammatory or autoimmune skin diseases. It has been

used in combination with cyclosporine. Because it is an immunosuppressive agent,

people with compromised immune systems should not take it.

Sulfasalazine is a combination anti-inflammatory and antibiotic commonly used for

treating psoriatic arthritis. Many people cannot tolerate sulfasalazine because of allergy

to sulfa, or because of side effect, including nausea, vomiting and loss of appetite.

6-thioguanine is an oral medication approved for treating certain types of leukemia. 6-

Thioguanine has been reported to be effective for psoriasis, including treatment

of pustular psoriasis. 6-Thioguanine must be used under close supervision due to the

potential side effects associated with suppression of the bone marrow.

PhototherapyPhototherapy or light therapy, involves exposing the skin to ultraviolet light on a regular basis and under medical supervision. Treatments are done in a doctor's office or psoriasis clinic or at home with phototherapy unit. The key to success with light therapy is consistency.

Ultraviolet light B (UVB)/Ultraviolet light A (UVA) Treatments

UVB phototherapy

Present in natural sunlight, UVB is an effective treatment for psoriasis. UVB penetrates

the skin and slows the growth of affected skin cells. Treatment involves exposing the

skin to an artificial UVB light source for a set length of time on a regular schedule. This

treatment is administered in a medical setting or at home.

There are two types of UVB treatment, broad band and narrow band. The major

difference between them is that narrow band UVB light bulbs release a smaller range of

ultraviolet light. Narrow-band UVB is similar to broad-band UVB in many ways. Several

studies indicate that narrow-band UVB clears psoriasis faster and produces longer

remissions than broad-band UVB. It also may be effective with fewer treatments per

week than broad-band UVB.

During UVB treatment, your psoriasis may worsen temporarily before improving. The

skin may redden and itch from exposure to the UVB light. To avoid further irritation, the

amount of UVB administered may need to be reduced. Occasionally, temporary flares

occur with low-level doses of UVB. These reactions tend to resolve with continued

treatment.

UVB can be combined with other topical and/or systemic agents to enhance efficacy, but

some of these may increase photosensitivity and burning, or shorten remission.

Combining UVB with systemic therapies may increase efficacy dramatically and allow for

lower doses of the systemic medication to be used.

Home UVB phototherapy

Treating psoriasis with a UVB light unit at home is an economical and convenient choice

for many people. Like phototherapy in a clinic, it requires a consistent treatment

schedule. Individuals are treated initially at a medical facility and then begin using a light

unit at home.

It is critical when doing phototherapy at home to follow a doctor's instructions and

continue with regular check-ups. Home phototherapy is a medical treatment that

requires monitoring by a health care professional.

All phototherapy treatments, including purchase of equipment for home use, require a

prescription. Some insurance companies will cover the cost of home UVB equipment.

Vendors of home phototherapy equipment often will assist you in working with your

insurance company to purchase a unit.

Sunlight

Although both UVB and ultraviolet light A (UVA) are found in sunlight, UVB works best

for psoriasis. UVB from the sun works the same way as UVB in phototherapy

treatments.

Short, multiple exposures to sunlight are recommended. Start with five to 10 minutes of

noontime sun daily. Gradually increase exposure time by 30 seconds if the skin tolerates

it. To get the most from the sun, all affected areas should receive equal and adequate

exposure. Remember to wear sunscreen on areas of your skin unaffected by psoriasis.

Avoid overexposure and sunburn. It can take several weeks to see improvement. Have

your doctor check you regularly for sun damage.

Some topical medications can increase the risk of sunburn. These

include tazarotene, coal tar, Elidel (pimecrolimus) and Protopic (tacrolimus). Individuals

using these products should talk with a doctor before going in the sun.

People who are using PUVA or other forms of light therapy should limit or avoid

exposure to natural sunlight unless directed by a doctor.

Psoralen + UVA (PUVA)

Like UVB, ultraviolet light A (UVA) is present in sunlight. Unlike UVB, UVA is relatively

ineffective unless used with a light-sensitizing medication psoralen, which is

administered topically or orally. This process, called PUVA, slows down excessive skin

cell growth and can clear psoriasis symptoms for varying periods of time. Stable plaque

psoriasis, guttate psoriasis, and psoriasis of the palms and soles are most

responsive to PUVA treatment.

The most common short-term side effects of PUVA are nausea, itching and redness of

the skin. Drinking milk or ginger ale, taking ginger supplements or eating while taking

oral psoralen may prevent nausea. Antihistamines, baths with colloidal oatmeal products

or application of topical products with capsaicin may help relieve itching. Swelling of

the legs from standing during PUVA treatment may be relieved by wearing support hose.

Laser Treatments

Excimer laser

The excimer laser—recently approved by the Food and Drug Administration (FDA) for

treating chronic, localized psoriasis plaques—emits a high-intensity beam of ultraviolet

light B (UVB). 

The excimer laser can target select areas of the skin affected by mild to moderate

psoriasis. Individual response to the treatment varies. It can take an average of four to

10 sessions to see results, depending on the particular case of psoriasis. It is

recommended that patients receive two treatments per week, with a minimum of 48

hours between treatments.

There is not yet enough long-term data to indicate how long the improvement will last

following a course of laser therapy.

Pulsed dye laser

Like the excimer laser, the pulsed dye laser is approved for treating chronic, localized

plaques. Using a dye and different wavelength of light than the excimer laser or

other UVB-based treatments, pulsed dye lasers destroy the tiny blood vessels that

contribute to the formation of psoriasis lesions.

Treatment consists of 15- to 30-minute sessions every three weeks. For patients who

respond, it normally takes about four to six sessions to clear the target lesion.

The most common side effect is bruising after treatment, for up to 10 days. There is a

small risk of scarring.

Other

Tanning beds

Some people visit tanning salons as an alternative to natural sunlight. Tanning beds in

commercial salons emit mostly UVA light, not UVB. The beneficial effect for psoriasis is

attributed primarily to UVB light. The National Psoriasis Foundation does not support the

use of tanning beds as a treatment option for psoriasis.