Psoriatic arthritis: What can help?

There's a lack of research on exercise therapy specifically for people with psoriatic arthritis. But studies on other inflammatory joint diseases such as rheumatoid arthritis have shown that physical activity has a number of beneficial effects.

Exercise keeps the joints flexible and strengthens the muscles and bones. That helps in everyday situations – like climbing the stairs – and improves your overall fitness. Exercise can also reduce fatigue. It strengthens the cardiovascular (heart and blood vessel) system as well. That is especially important in psoriatic arthritis because the disease increases the risk of developing cardiovascular disease.

The recommended types of exercise include

• strength training,
• endurance sports like swimming, cycling, brisk walking and dancing,
• tai chi, and
• yoga.

Pain and exhaustion can make it more difficult to do exercise, especially at first when your body isn't used to it yet. So it's important to not overdo it and make sure that the exercise you do is suitable for your symptoms and stage of disease. During an acute flare-up or if you have severe pain, it's better to take a break and talk to a doctor.

The most suitable form of exercise will depend on the severity of the psoriatic arthritis and your own preferences. Any inflammation of your tendons or tendon sheaths will also play a role in the decision. Some experts advise against activities like jogging or tennis, which both involve putting a lot of stress on the joints. If you aren't sure about what kind of sports would be suitable for you, you can talk to a doctor or physical therapist about it.

As well as doing exercise on your own and having individual physical therapy sessions, people with inflammatory joint disease can also participate in group "functional fitness training." In Germany, statutory health insurers cover the costs of these group functional training classes for up to 24 months. Functional fitness training involves doing simple exercises or water exercises under the instruction of a physical therapist. These courses are specially tailored to the needs of people with arthritis. Plus, many people find it easier to do sports in groups.

German statutory health insurers will only cover the costs if they have officially recognized that the organizer fulfills the required criteria. And the classes have to be prescribed by a doctor as well. Doctors can prescribe functional fitness training using a special form to ensure that it doesn’t negatively affect their budget.

Statutory health insurers will also cover the costs of rehabilitation exercise classes known as "Rehasport" if they are prescribed by a doctor. The aim of these classes is to improve your endurance, strength, coordination and mobility. They are offered for groups and usually include 50 sessions spaced out over an 18-month period.

You can find out more about sports activities for people with inflammatory joint disease by contacting support groups, for instance.

Quitting smoking has a lot of health benefits. Smoking reduces your life expectancy and causes many lung diseases and types of cancer. It also makes you more prone to infections and cardiovascular (heart and blood vessel) diseases. This risk is already higher for people with psoriatic arthritis anyway. Some of the medications used to treat psoriasis increase the risk of infections as well.

Quitting smoking isn't easy and often doesn't work the first time you try it. But many people succeed in quitting after several attempts. There are also many ways to get help, such as telephone hotlines and courses for quitting smoking.

People who are very overweight are advised to lose weight. There are two main reasons for this. Losing weight will reduce the load placed on your joints. Also, being very overweight can increase the amount of inflammation in your body and weaken the effect of the psoriasis medication. Studies suggest that medications are more effective after losing weight. Even weighing 5% less can already reduce the strain on your joints.

It's usually possible to lose weight by changing your diet. This can also be hard to do, and it means having to change your habits. But there are various sources of support.

Drinking too much alcohol is thought to have a negative effect on joint inflammation too. This is because large amounts of alcohol can make the body release more enzymes that activate certain inflammatory proteins. There are currently no good-quality studies looking into the effects of drinking less alcohol in people who have psoriatic arthritis. But there are still many good reasons for drinking alcohol only in moderation. And there are a lot of tips that can help you to drink less.

Doctors don't recommend any special diets for people with psoriatic arthritis. Dietary supplements such as vitamin D or omega-3 fatty acids have not been proven to help in people who have psoriatic arthritis.

As well as the exercise therapy mentioned above, physical therapists also offer various types of "passive" treatments, including approaches using heating or cooling and other treatments based on physical stimuli. But these types of treatments are only considered as additional therapies for the relief of acute symptoms. They are not alternatives to "active" treatments like exercise therapy.

Various types of daily living aids can help people with advanced arthritis and joint damage to manage better in everyday life. Examples include dressing aids and specially designed cutlery. Occupational therapy involves learning to cope with the limitations caused by the disease in everyday life and making use of special aids in order to lead an independent life for as long as possible.

Treatment with medication plays an important role in psoriatic arthritis. Two types of medications can be used:

• Medications that relieve symptoms like pain
• Medications that have an effect on the cause of the disease and reduce inflammation in the joints (disease-modifying drugs, or DMDs). These medications can both relieve the symptoms and prevent damage to the joints.

The medications that are considered for treatment will depend on things like how severe the joint inflammation is, whether (and how badly) the skin is affected and how doctors think the disease will continue to develop.

Anti-inflammatory painkillers like diclofenac, ibuprofen or naproxen can relieve pain, but don't prevent possible joint damage. These medications belong to a group of medications known as non-steroidal anti-inflammatory drugs (NSAIDs).

NSAIDs sometimes cause gastrointestinal (stomach and bowel) problems. When taken over a long period of time, they can also increase the risk of cardiovascular disease. In order to reduce side effects as much as possible, it's important to use them correctly and take them only when you need to.

Gels or creams with diclofenac or ibuprofen in them have fewer side effects. They can be used as an alternative to pain-relief tablets. Acetaminophen (paracetamol) is hardly effective at all in the treatment of arthritis.

Steroids (corticosteroids) can be injected into individual joints in order to relieve acute pain. This option is considered for the treatment of particularly persistent joint inflammations or while waiting for other treatments to start working.

Doctors generally advise against taking steroids in tablet form (oral steroids) for psoriatic arthritis. If used at all, they should only be used very sparingly. That means taking them at a low dose and not for longer periods of time, because otherwise they could have serious side effects. What's more, stopping treatment with steroid tablets can lead to a psoriasis flare-up.

Disease-modifying anti-rheumatic drugs (DMARDs) can reduce inflammation in the joints. They are used continuously over longer periods of time, even when you don't have any acute symptoms. There are two groups of DMARDs:

• Conventional disease-modifying drugs (such as methotrexate (MTX) and leflunomide)
• Biologics (medications that are produced using biotechnology)

They include the drugs abatacept, adalimumab, certolizumab pegol, etanercept, infliximab, ixekizumab, golimumab, secukinumab and ustekinumab. They are considered as a treatment option if conventional DMARDs aren't effective enough.

There are two other disease-modifying drugs called apremilast and tofacitinib. They can also be used if treatment with conventional disease-modifying drugs isn't effective enough.

In mild psoriatic arthritis that only affects the knees, elbows or wrists, treatment with NSAID painkillers is sometimes all that is needed. If this isn't effective enough or if there is reason to believe that the disease will develop into a more serious case, treatment with disease-modifying drugs is recommended.

Psoriatic arthritis is more likely to become severe if

• five or more joints are affected,
• x-ray images show that the affected joints are already visibly damaged,
• the inflammation is severe (this is determined based on inflammatory markers in the blood), or
• tendons and connective tissue are inflamed too, not just joints (for instance, if a whole finger or an Achilles tendon is inflamed).

Some medications help to reduce both the visible skin problems and the inflammation in joints. Examples include apremilast, methotrexate and most biologics. Because of this double-action effect, they are often the treatment of choice for psoriatic arthritis.

The treatments used for psoriatic arthritis will depend on various factors, including

• the severity of the inflammation in the joints and the type of symptoms,
• whether you only have inflamed joints or the psoriasis affects your skin too,
• which joints are affected, and
• what the various pros and cons of the treatment mean to you.

When considering which treatment strategy to follow, it can be helpful to seek advice from both a dermatologist (skin specialist) and a rheumatologist.