Psoriasis arthritis (PA), also known as arthropathic psoriasis, is an inflammatory joint disease associated with psoriasis. The disease is prolonged and prone to recurrence, and in the late stages it forms joint ankylosis, leading to disability. Psoriasis is more common in patients with arthritis, which is two to three times more common than in the general population.
In a 10-year survey, Leczinsky found that the incidence of arthritis in psoriasis was 6.8%, which greatly exceeded the incidence of arthritis in the non-psoriatic population. Women are more likely to develop it than men. According to Nobol, PA accounts for approximately 1% of patients with psoriasis [5]. Since the disease is associated with HLA-B27 and is rheumatoid factor negative with similar clinical presentation as Reiter syndrome and ankylosing spondylitis, it is classified as a seronegative spondyloarthropathy.
I. Signs and symptoms and diagnosis
Nail or skin psoriasis can occur before or after arthritis. Patients with seronegative inflammatory polyarthritis should be examined for undetected or mild psoriasis as well as nail depressions, and should be asked about a family history of psoriasis.
The distal interphalangeal (toe) joints are most likely to be involved. Asymmetrical involvement of large and small joints (including sacroiliac joints and spine) is common, without rheumatoid nodules, and the exacerbation or remission of joint and skin symptoms may be consistent. Arthritis and extensive destruction and dislocation of large and small joints.
Auxiliary examination
There is no specific test for this disease. Increased blood sedimentation, mild anemia, and elevated γ and α2 globulin are non-specific changes. About 10% to 20% of patients have mildly increased uric acid in the blood. Rheumatoid factor is negative. Lupus cells, antinuclear antibodies and autoantibodies are all negative. Synovial fluid examination is also nonspecific, with a leukocyte count of 2 to 15×109/L, predominantly neutrophils, and occasionally up to 100×109/L in massive exudate. synovial fluid viscosity is reduced.
The disease is similar to rheumatoid arthritis and often involves the distal interphalangeal (toe) joints, sacroiliac joints and the spine. The common X-ray manifestations are loss of cartilage; erosion of the joint surface; narrowing of the joint space; disfiguring arthritis showing marked osteolysis and ankylosis, which may appear as a “pencil sign”; isolated marginal or non-marginal ligamentous bone redundancy; choroidal osteochondritis; osteoporosis and cystic changes of bone tissue.
Differential diagnosis
1, rheumatoid arthritis is a wandering polyarthritis, mostly in the small joints of the extremities, symmetrical involvement. Late metacarpophalangeal joints are oblique to the ulnar side. Rheumatoid nodules are visible on the skin. Positive rheumatoid factor.
2. Typical cases of Reite syndrome have non-specific uveitis, conjunctivitis, arthritis (especially in the weight-bearing joints of the lower extremities) and skin lesions. Patients with this syndrome may have an oyster shell-like psoriatic rash and joint symptoms very similar to psoriatic arthritis. A period of follow-up is required to confirm the diagnosis of these atypical cases.
Ankylosing spondylitis occurs in men under 30 years of age. Early symptoms include low back pain, lumbosacral discomfort, intermittent or alternating sciatica, and stiffness in the lower extremities and lumbar region. In the late stage, the spine and lower limbs become stiff and bowed. x-ray shows a bamboo-like deformity of the spine.
4, gout gout-induced acute arthritis starts rapidly, mostly at night, relieved during the day, after months to years of repeated attacks, forming chronic gout, producing joint deformity and stiffness. According to clinical symptoms, hyperuricemia, gout stone discharge, synovial fluid detection of uric acid crystals; colchicine, allopurinol treatment is effective and helps to identify.
Fourth, treatment measures
Although there are many treatment methods for this disease, most of them can only achieve the recent clinical effect, but cannot stop the recurrence.
1, general treatment patients should rest properly, reduce the intensity of labor, avoid overexertion and joint injury. All joints should have sufficient daily activity and exercise to maintain and improve joint function.
2.Non-hormonal anti-inflammatory drugs have a strong anti-inflammatory effect and are effective in eliminating inflammatory pain. At present, commonly used enteric aspirin, anti-inflammatory pain (indomethacin), inflammatory pain Xikang, aminomethacin, ketone based ibuprofen, fenbid, etc.. Recently, there are reports that anti-inflammatory pain has aggravated psoriasis skin lesions, so the use of this drug is still controversial.
3.Anti-tumor therapy This kind of drugs have certain efficacy but have toxic reactions and are easy to relapse after stopping. Therefore, they are not the direction of treatment for psoriasis, and the indications should be strictly selected when applying them. Liver and kidney functions and white blood cell counts should be checked regularly before and during the use of medication. Drugs effective in psoriatic arthritis are.
(1) Methotrexate (MTX): MTX mainly acts on the DNA synthesis phase (S phase) of the cell cycle, and all psoriatic epidermal cells are inhibited after 36 hours of administration.
There are different opinions on the method of administration. There is a single dose of oral, intramuscular or intravenous injection, the weekly dosage is 25-50mg; there is also a daily oral 2.5mg for 5d, rest 2d, then 5d, rest 7d. Weinstein provides the principle of epidermal cell kinetics, proposed oral 2.5-7.5mg every 12hl, in 6h for a total of 3 times, and then given weekly in the same way.
(2) Propionamide (rozoxane, ICRF159): This drug mainly acts in the late prophase of mitosis (G2) and the early stage of mitotic segregation (M). Atherton et al. reported that this drug can rapidly suppress the associated arthritis. The main side effect is neutropenia, which can occur rapidly, sometimes severely, and may even cause.
Dosage: The initial dose is 125mg 3 times daily, 2d per week. 4-8 weeks later, depending on the white blood cell count, the dose is increased appropriately to 125mg or 250mg 3 times daily, 2d per week, alternately. For psoriatic arthritis can also be given 3 d weekly.
(3) Lymphocyte inhibitor cyclosporine A, which can inhibit T lymphocytes, mainly TH cells, resulting in reduced expression of HLA-DR antigen.
Dose and method: Generally 5-12mg/kg daily, administered orally. Usually requires a plasma concentration of not less than 100ng/ml, and is most effective above 200ng/ml, but higher than 400ng/ml is likely to cause nephrotoxic reactions, and more than 600ng/ml is required for neurological toxicity. This drug should not be used in combination with ketoconazole or levulinic acid (melphalan) to produce serious side effects due to high plasma concentrations in rabbits.
(4) Heavy metal agents: Comparative studies have shown that heavy metal agents have a high remission effect on psoriatic arthritis, between to psoriatic lesions are not effective.
Sodium arsenite (socliumarsenite), also known as sodium caguti, is commonly used. 100mg daily, intramuscular injection, 10-20d a course of treatment.
(5) Anti-syndromic drugs: chloroquine (chloroquiniphosphas), the efficacy of which on psoriasis is variable. Some people report better effect on photosensitivity and psoriatic arthritis; others report that psoriatic and erythroderma can be induced during the treatment, and it is rarely used at present.
(6) Corticosteroids: At present, such drugs are generally not advocated for the treatment of PA. sometimes they are only used for patients whose condition is severe and other drug treatments are ineffective.
4.Chinese medicine Chinese medicine believes that psoriatic arthritis is mostly caused by wind-damp paralysis and liver-kidney deficiency.
(1) Feng-damp paralysis and obstruction: joint swelling and pain is the main cause, and the disease duration is relatively short.
Treatment: dispel dampness and clear heat, detoxify and clear the ligaments.
Formulation: Duluxiaosheng Tang plus reduction. Medicines used: Gentiana macrophylla, Fenfeng, Mulberry branch, Doklamia, Wailingxian, Baixiang Pi, Tu Fu Ling, Angelica, Radix Paeoniae Alba, Chrysanthemum, Niubizi.
The symptoms of the upper extremities mainly add turmeric, sea wind vine; the symptoms of the lower extremities mainly add Fang Wei.
(2) Liver and kidney deficiency: joint deformation and restricted movement are the main causes, with a long duration of illness.
Treatment: Jian Bu Hu Qian Wan. Medicinal use: Shu Di, Cornu Cervi Pantotrichum, Angelica Sinensis, Dampi, Eucommia Ulmoides, Sequoia, Papaya, Dog’s Backbone, Tortoise Board, Tiger Bone, Ocimum sanctum, Tu Fu Ling, g significata, Stretching tendons, etc.
(3) Chinese patent medicines.
①Legongteng tablets: It is ethyl acetate extract, containing leigongteng methicin, which has strong anti-inflammatory and immunosuppressive effects. Take 2 tablets each time, 3 times a day. It can also be used to take Lei Gong Vine Polysaccharide Tablets 1~1.5mg/kg per day, divided into 3 times.
②Kunming bergamot tablets: each tablet contains 0.5mg of ethanolic paste powder of Kunming bergamot (2g of raw herbs), 3-6 tablets each time, 3 times a day. The amount should not exceed 18 tablets at a time.
5.Topical medicine mainly targets psoriasis skin lesions. Commonly used drugs are: 5% sulfur, 5%-10% salicylic acid, 2%-10% coal tar, 0.1%-1% anthralin, 1:10,000-1:20,000 mustard gas, 0.05% ammonia mustard, 10%-15% ciclopirox, 2%-5% repellent bean paste, 0.025%-0.1% vitamin A acid, etc., formulated as ointment, solution or tincture.