Chronic Pain in Psoriatic Arthritis

Psoriatic arthritis (PsA) is an inflammatory arthritis that causes joint swelling, pain, and stiffness. It’s linked to psoriasis, a skin condition causing inflamed, scaly patches on the skin. PsA affects about 20% of people with psoriasis, but you can also develop PsA without having psoriasis.

PsA is an autoimmune condition, which is when the body’s immune system mistakenly attacks healthy cells. The exact cause of PsA is unknown but may include a mix of genetic and environmental factors.

Pain is a hallmark symptom of PsA. While people with PsA often experience pain and tenderness in the joints, tendons, and muscles, they can also have pain resulting from acute swelling, stiffness, and reduced range of motion. PsA can sometimes involve painful skin and nail changes. Bodywide fatigue can also contribute to feelings of general pain and discomfort.

“Up to a third of patients with psoriatic arthritis have chronic pain,” Alexis Ogdie, MD, associate professor of medicine (rheumatology) at the Hospital of the University of Pennsylvania, tells Health. Chronic pain is classified as having three or more months of pain in several body regions, she says.

Dr. Ogdie talks with Health about how her understanding and treatment of chronic pain in PsA have evolved since her early days as a rheumatologist—and how she approaches the condition with her patients.

Alexis Ogdie, MD: I’ve seen the importance of addressing comorbidities—conditions that occur at the same time as the psoriatic arthritis. So, I always make sure to cover those in an initial appointment. With psoriatic arthritis, I discuss the role of obesity, diabetes, and depression or anxiety in PsA. I also try to assess if they have chronic pain syndrome, and if that’s occurring with or without the presence of an inflammatory disease.

I also want to know how often they exercise, how well they sleep, and what things are most limiting or problematic for them. Finally, I want to know about their health goals: How do they want to feel in six months to a year?

Dr. Ogdie: People with a lot of joint swelling tend to have an all-over pain that comes and goes, and typically, the pain improves with treatment of the psoriatic arthritis. But it can be difficult to separate the pain symptoms from other symptoms to determine the best course of treatment. For example, switching therapies to treat pain may not be the right call if the person isn’t having increased inflammation.

So, it’s a complex part of caring for the disease, especially for people who have had multiple unsuccessful therapies.

Dr. Ogdie: We give our patients a survey based on the fibromyalgia [a condition causing bodywide pain and fatigue] criteria that asks about the amount of pain they have in the different body regions. Then, we add that up for a total pain score.

But there are additional symptoms to consider. We take into account fatigue, cognitive problems or trouble thinking, sleep issues, pain in the abdomen, headaches, depression, jaw and facial pain, and tender points. These aren’t necessarily part of the score, but having that constellation of symptoms over a period of time is consistent with chronic pain and can give us a clue of pain levels.

Dr. Ogdie: Regular aerobic exercise is one of the best medicines for chronic pain and fatigue. It can also help with pain down the road. Exercise helps maintain the muscles around the joints, which can help stabilize the joints and prevent additional inflammation and pain.

Sleep is so important for how we cope with life, and that includes coping with pain. Less sleep can often lead to more pain. And if someone has higher pain, they may not get much sleep because their pain keeps them up at night. So, I’ve learned treatment needs to involve helping the patient get better sleep.

Dr. Ogdie: Understanding chronic pain took a long time to learn as a young rheumatologist—it was frustrating for me. I think many physicians see chronic pain as frustrating because there aren’t a lot of visible solutions, and patients are usually fed up and frustrated by it, too. But I’ve learned that teaching patients more about their pain and giving them self-management tools is helpful for both parties involved.

I also try to let the patient know what our medical team can do and where our limitations are, so the patient knows where they need to do the work to complete their care.