Psoriatic Arthritis

What is Psoriatic Arthritis?

Psoriatic arthritis is a chronic inflammatory arthritis associated with psoriasis. It develops in roughly one in five to three in ten adults with psoriasis, depending on the source, and the joint disease can appear before, with or after the skin disease.^{[1, 2]} It is a medical condition that needs ongoing care from a physician, usually a rheumatologist.

Common symptoms

Symptoms vary and can change over time. The disease can involve peripheral joints, the places where tendons attach to bone (enthesitis), tendon sheaths, whole fingers or toes (dactylitis), and the spine, along with skin and nail psoriasis in most patients.^[2]

• Joint pain, swelling and stiffness, often worse in the morning or after rest
• A sausage-like swollen finger or toe
• Heel, sole or other tendon-attachment pain
• Low back and buttock pain with stiffness
• Red, scaly skin patches and nail pitting or lifting
• Tiredness

Causes and risk factors

The cause is not fully understood. Research points to an interplay of genetic predisposition, environmental triggers and activation of the immune system, with inflammatory signals such as TNF, IL-23 and IL-17 playing central roles.^[3] Having psoriasis is the main risk factor, and a family history of psoriasis or psoriatic arthritis also raises risk.^[1]

People with psoriatic arthritis are also more likely to have other health problems, including heart disease, diabetes, metabolic syndrome, gout, anxiety and depression.^{[2, 4]}

How it is diagnosed and treated conventionally

Diagnosis is made by a physician from the pattern of symptoms, an examination of the joints, skin and nails, blood tests and imaging. The blood test for rheumatoid factor is usually negative, which helps separate it from rheumatoid arthritis.^[1]

Treatment is tailored to which parts of the body are affected. Anti-inflammatory pain relievers are used alone only for mild disease and for a short time, and methotrexate or a similar drug is usually started early for joint inflammation. Biologic medicines that block TNF, IL-17 or IL-23 are the next step, and targeted drugs called JAK inhibitors are generally used after those.^[5] Education, lifestyle changes, physiotherapy and occupational therapy are part of care.^[2]

Why Psoriatic Arthritis calls for a whole-person approach

Psoriatic arthritis involves the skin, joints, tendons, mood, sleep and general health at the same time. Treating only one of these can leave others unaddressed, which is why rheumatology guidance includes screening for related conditions and lifestyle support.^[2]

Complementary care is aimed at some of these surrounding factors. It is not aimed at the immune process, which is managed with prescribed medicines.

Immune-driven inflammation

Psoriatic arthritis is considered an immune-mediated disease in which signaling pathways involving TNF, IL-23 and IL-17 drive inflammation in both skin and joints.^[3] This is the target of modern biologic drugs and is the reason medical treatment should not be interrupted.

Pain, sleep and mood

Chronic pain and poor sleep often go together. In psoriasis, a systematic review found that insomnia symptoms were mediated by itch and pain, and that treating skin symptoms eased the insomnia.^[6] Depression and anxiety are among the common comorbidities of psoriatic arthritis.^{[2, 4]}

Weight, diet and heart health

Cardiovascular disease, diabetes and metabolic syndrome are more common in psoriatic arthritis.^[2] A review of dietary research in inflammatory arthritis, including psoriatic arthritis, suggests that patterns such as the Mediterranean diet may help reduce disease activity, although these findings are preliminary.^[7]

Acupuncture for Psoriatic Arthritis

What the research shows

There are no controlled trials of acupuncture for psoriatic arthritis itself. A 2020 review of complementary medicine in the condition noted that studies of commonly used therapies such as acupuncture and massage were conspicuously absent.^[8] The evidence we can describe comes from related areas, and it should not be read as proof that acupuncture helps psoriatic arthritis.

For psoriasis skin disease, a review of 13 trials with 1,060 participants reported better outcomes with acupuncture-related acupoint stimulation (including acupressure and catgut embedding) than with non-acupoint stimulation in the short term, but the trial quality was not rigorous.^[9] A review of mind-body therapies for psoriasis concluded that evidence to support acupuncture was lacking, and that cupping often worsened the skin through the Koebner phenomenon (new lesions appearing at sites of skin injury).^[10] People with active psoriasis should therefore be cautious about cupping.

For chronic pain more generally, an individual patient data meta-analysis of 39 trials with adequate allocation concealment (20,827 patients) found acupuncture better than sham or no acupuncture for musculoskeletal pain, osteoarthritis, headache and shoulder pain. That analysis did not include inflammatory arthritis.^[11]

How acupuncture may work

No study has shown how acupuncture might act in psoriatic arthritis. In chronic pain generally, the authors of the analysis above concluded that pain relief from acupuncture cannot be explained by placebo effects alone, and that factors beyond needling at specific points also contribute.^[11] How it might act in psoriatic arthritis is unknown.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the body, usually left in place for about 20 to 40 minutes. A course of several visits is followed by reassessment of pain, stiffness, sleep and stress. Because there are no trials in this condition, there is no research-based schedule to report.

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[12] Tell the practitioner first if you take a blood thinner, have a bleeding disorder, are pregnant, have a pacemaker (relevant to electroacupuncture), or take medicines that lower immune defenses, because needle sites need to be kept clean.

Ayurvedic medicine for Psoriatic Arthritis

The Ayurvedic view

Classical Ayurveda does not describe psoriatic arthritis as a single condition. Practitioners may relate the skin disease to the Kushta group of skin disorders and the joint disease to patterns such as Vatarakta or Amavata, in which impaired digestion (agni), accumulated metabolic residue (ama) and aggravated Vata and other doshas are thought to be involved. These are traditional frameworks for choosing therapies, not biomedical diagnoses.

Therapies that may be used

Ayurvedic care is individualized. It traditionally includes:

• Dietary guidance, such as favoring freshly cooked, easily digested food and a regular daily routine
• Stress-reducing practices such as breathing exercises and gentle yoga within your physical limits
• Herbs such as turmeric, prescribed individually by a qualified practitioner
• Gentle warm oil massage over comfortable areas, avoiding inflamed skin

Panchakarma cleansing procedures are not appropriate during pregnancy, acute illness or frailty, and they are generally not advised when someone is taking immune-suppressing medicines or has active skin lesions, unless the treating physician agrees. We would not use them in place of any prescribed treatment.

What the research shows

There are no clinical trials of Ayurvedic treatment programs for psoriatic arthritis. A PubMed search found none, and a 2020 review of complementary medicine in psoriatic arthritis did not identify any.^[8] One Ayurvedic-related ingredient with trial data in related conditions is turmeric or curcumin, covered in the next section.

What we can offer is supportive care for stress, sleep and daily routines. In psoriasis, a review found that stress-management approaches such as meditation, hypnosis and psychotherapy showed promising results as complementary treatments.^[10] These findings are for the skin condition, not for psoriatic arthritis.

Herbal medicine for Psoriatic Arthritis

Herbs and formulas that have been studied

Research on herbs in psoriatic arthritis is thin, so most evidence comes from psoriasis or from inflammatory arthritis in general. Studied products include curcumin from turmeric, and total glucosides of paeony, an extract of the Chinese peony root.^{[13, 14]} Chinese herbal prescriptions have also been tested in plaque psoriasis.^[15]

What the research shows

The evidence is limited and mostly of low quality. A review of 31 trials of curcumin across 10 autoimmune diseases included two in psoriasis, which reported improvement in at least some clinical outcomes. The authors said larger trials are needed.^[13] A systematic review of complementary therapies for psoriasis found curcumin supported by three small trials with 118 participants in total.^[16]

A meta-analysis of 63 trials of total glucosides of paeony across five types of inflammatory arthritis found that, in psoriatic arthritis, the extract may improve a skin severity score and lower an inflammation marker. The authors noted the low quality and small number of trials.^[14] A separate meta-analysis of 30 trials in psoriasis found that adding the extract to other treatments improved response, while the extract alone did not differ from other single treatments, and the studies were generally of low methodological quality.^[17]

A meta-analysis of 16 trials of traditional Chinese medicine in plaque psoriasis found better results than a comparison tablet, with the authors calling for placebo-controlled trials.^[15] These findings concern skin disease, not joint disease.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. People with psoriatic arthritis often take methotrexate, other immune-suppressing drugs or anti-inflammatory pain relievers, and herbs can add to side effects or change how drugs act.^[18] Herbal and dietary supplements are also a recognized cause of liver injury, which matters when methotrexate is also being taken.^[19] Please tell us about every medicine and supplement you use, and tell your rheumatologist about any herb you start.

About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, plan surgery, or have liver or kidney disease.

Translating traditional medicine into modern biological language

This section is interpretation, not equivalence. Chinese medicine may describe psoriatic arthritis through patterns such as wind-dampness, heat or blood stasis, and Ayurveda through aggravated Vata with ama. Researchers study ideas that loosely parallel these pictures, such as immune signaling by TNF, IL-17 and IL-23 and chronic inflammation.^[3]

No study has shown that a traditional pattern or dosha matches a particular biological process in psoriatic arthritis. Traditional assessment is used to individualize supportive care, not to replace diagnosis or monitoring by your rheumatologist.

How this care fits with your medical care

Our care is complementary. Keep your rheumatologist and dermatologist, and do not stop or change prescribed medicines, including methotrexate and biologics, without talking with your prescriber. Ongoing monitoring by your rheumatologist matters.

Please bring your diagnosis, your medication list including any injections, recent blood test and imaging results, and a list of supplements you take. We do not diagnose or manage the disease itself. New or worsening joint swelling, skin flares or eye symptoms should be reported to your physician.

When to seek urgent medical care

Some symptoms need prompt medical assessment, and psoriatic arthritis is linked to eye inflammation and bowel disease.^[3]

• A red, painful eye, blurred vision or sensitivity to light
• A single hot, swollen joint, especially with fever, which can be a joint infection
• Fever, chills or signs of infection while taking immune-suppressing medicines
• Sudden worsening of joint pain or swelling, or new inability to move a joint or the neck
• Persistent diarrhea with blood or severe abdominal pain
• Chest pain, shortness of breath or weakness on one side of the body

If you have any of these emergencies, call 911 or go to the nearest emergency department.