Psoriatic arthritis (PA), also known as arthropathic psoriasis, is an inflammatory joint disease associated with psoriasis. Psoriasis, also known as psoriasis, is statistically complicated by arthritis in about 2.6-7% of cases and has similar symptoms to rheumatoid arthritis with different pathologies. The cause of this disease is not fully understood. The occurrence of this disease is related to the complex interaction between genetics, immunity, environment and infection.
1.Pathology
Synovial tissue biopsy shows mild hyperplasia and hypertrophy of synovial cells early in the lesion, with a small amount of fibrin-like material exuding. There was mild edema and fibrous tissue hyperplasia under the synovial cells, and the small blood vessels were obviously hyperplastic and congested, with a small amount of lymphocyte and plasma cell infiltration. In the late stage of the lesion, the synovial fibrous tissue increased significantly, and the residual small vessels thickened and narrowed.
2.Clinical manifestations
PA usually starts insidiously. Pain is often milder than rheumatoid arthritis, and occasionally it has an acute gout-like onset. The age of onset is mostly between 30 and 40 years old, and less frequently occurs in children under 13 years old.
There are five clinical types through the performance of the joints.
(1) Few fingers (toes) type: the most common, accounting for about 70%. It is a single or several finger joints involved, asymmetrical, with joint swelling and tenosynovitis, giving the fingers (toes) a gut-expanding shape.
(2) Rheumatoid arthritis-like type: 15% of cases are symmetric, multiple arthritis with claw-shaped hands. Patients may exhibit clinical features similar to rheumatoid arthritis presenting with morning stiffness, symmetric involvement, proximal phalangeal spindle swelling, and late ulnar deviation. Occasionally, there are rheumatoid nodules or positive rheumatoid factor.
(3) Asymmetric distal interphalangeal joint type: accounting for 5%, mainly involving the distal interphalangeal joint. It shows redness, swelling and deformity, often starting from the toe and later involving other joints. The pain is lighter than rheumatoid arthritis and is often associated with nail dystrophy, which is more common in men.
(4) Destructive arthritis type: 5% of the cases are severe joint destruction. Mostly invades multiple joints of the hands and feet and sacroiliac joints. It is characterized by progressive pars plana erosion, resulting in osteolysis, with or without bony joint stiffness, resembling neuropathic arthropathy, and is painless. This type of skin psoriasis is often widespread and severe and is either pustular or erythrodermic.
(5) Ankylosing spondylitis type: 5% of cases present as simple spondylitis or spondylitis overlapping with peripheral arthritis. The spinal lesions are non-marginal ligamentous bones, especially in the thoracic and lumbar spine, with narrowing and sclerosis of the synovial joint space, erosion of the intervertebral disc junction and bony hyperplasia at the anterior edge of the vertebral body, mainly in the lower cervical spine. Peripheral arthritis involves the distal phalangeal (toe) joints and presents as bilateral symmetric or unilateral asymmetric erosive arthritis. Inflammation can occur in the synovial membrane as well as along the tendon attachment points into the skeletal region. The sacroiliac joint may be involved in some patients. The clinical features of this type are stiffness of the spine, which occurs after the venous state and in the morning and lasts more than 30 minutes.
80% of patients have damage to the finger or toe nails, and damage to the small joints of the hands and feet this is more common. Chronic psoriatic damage to the claw nails causes vascular changes that eventually affect the joints beneath them. The degree of bone changes has been found to be closely related to the severity of nail changes, and both often occur in the same finger (toe). Common nail changes include punctate depressions, transverse breaks, longitudinal ridges, discoloration, hyperkeratosis under the nail, and nail stripping.
Skin lesions occur on the scalp and extremities, especially at the elbows and knees, and are scattered or generalized. The lesions are papules and plaques, round or irregular in shape, and are covered with abundant silvery-white phosphoric flakes, which are removed to reveal a shiny film. These three features have diagnostic significance.
In psoriatic arthritis, other systemic damage may be associated. The common ones are: acute anterior uveitis, conjunctivitis, sclerositis, dry keratitis; inflammatory bowel disease and gastrointestinal amyloidosis; spinal inflammatory heart disease, characterized by aortic valve closure insufficiency, persistent conduction block, and cardiac hypertrophy of unknown origin. There may also be fever, wasting, anemia and other systemic symptoms.
3.Treatment
(1) General treatment Patients should take proper rest, reduce labor intensity, and avoid overexertion and joint injury. Sufficient activities and exercises should be carried out for all joints every day to maintain and improve joint function.
(2) Non-hormonal anti-inflammatory drugs These drugs have strong anti-inflammatory effects and are effective in eliminating inflammatory pain. At present, enteric aspirin, anti-inflammatory pain (indomethacin), inflammatory pain Xikang, aminomethacin, ketone based ibuprofen, fenbid, etc. are commonly used. Recently, there are reports that anti-inflammatory pain has aggravated psoriasis lesions, so the use of this drug is still controversial.
(3) Anti-tumor therapy Although these drugs have certain efficacy, they have toxic reactions and are prone to relapse after discontinuation. Therefore, they are not the direction of treatment for psoriasis, and the indications should be strictly selected when applying them. Before and during medication, liver and kidney function and white blood cell count should be checked regularly.
(4) Physiotherapy, body therapy and related TCM treatments have corresponding effects on the disease.
(5) Intra-articular long-acting corticosteroid injection therapy has certain efficacy, but repeated injections are likely to cause infection.
(6) Surgical treatment: Arthroplasty can be used to restore joint function in some patients who have developed joint deformity and functional impairment. At present, hip and knee repair surgery has been successful.