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 youll 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 dont seem to be working. Sometimes these drugs are given by
injection.
DMARDs arent 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 youll 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 arent 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 youll 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 injections
Your 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 wont 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 (its 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 dont 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/arthritisinformation/conditions/psoriaticarthritis/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, longterm 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-labela
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. Longterm 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. 6Thioguanine 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.

Phototherapy
Phototherapy 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 laserrecently approved by the Food and Drug Administration (FDA) for
treating chronic, localized psoriasis plaquesemits 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.