Difficulties in Diagnosing and Treating Psoriatic Arthritis

The diagnosis and treatment of Psoriatic Arthritis (PsA) can pose a uniquely puzzling picture and may initially present as seronegative rheumatoid arthritis before more definitive signs and symptoms appear. In the following article, Katherine Poehlmann, PhD, provides a comprehensive overview of the prevalence of PsA, variations in disease presentation, potential causes, methods used for diagnosis, and available forms of treatment, including antibiotic protocols (AP).


Difficulties in Diagnosing and Treating Psoriatic Arthritis

Katherine Poehlmann, PhD

Psoriatic Arthritis (PsA) is a type of inflammatory arthritis in association with psoriasis, a chronic skin disease that got its name from the Greek word meaning, “itch.” The skin becomes inflamed and red eruptions appear that begin to itch excessively. The skin at the joints may crack.

PsA is considered to be an autoimmune disease that can afflict any age group, gender, or ethnicity. Because PsA presents with a wide variety of other symptoms (e.g., gut dysbiosis), accurate diagnosis may be missed or delayed, and statistics on prevalence are hard to obtain. According to the Mayo Clinic, most patients tend to develop psoriasis first before being diagnosed with PsA, but the joint problems may already exist before the first skin lesions appear. We do know that PsA usually begins with skin psoriasis in 84% of cases, but only one-third of people with psoriasis end up getting PsA. 55% of those living with PsA will develop five or more deformed joints in 10 years from the onset of the disease.

Symptoms and Diagnosis

The deformed joints of PsA sufferers often lead to misdiagnosis, such as rheumatoid arthritis (RA). Since PsA usually begins with skin psoriasis, the patient may choose to see a dermatologist first. This specialist should be able to determine whether the rash is truly psoriasis and not eczema, atopic dermatitis, acne, scabies, rosacea, allergic reaction (e.g., histamine), insect bites, hives, heat rash, or other skin condition.

Dry, flaky skin could indicate dehydration, which may be mistaken for psoriasis. Be sure to consume adequate water and fluids to nourish cells. A form of psoriasis called pustular psoriasis can become severe if the body suffers fluid and electrolyte imbalances.

Ideally, diagnosis and treatment should be coordinated with a rheumatologist for optimal patient care. Liver dysfunction (failure to neutralize and eliminate toxins efficiently) can manifest as skin rashes or lesions. Therefore, additional consultations with a hepatologist (liver specialist) and a gastroenterologist (for gut dysbiosis) are advised to discover the root causes of psoriasis symptoms.

There are many types of psoriasis, the most common form being plaque psoriasis, where the immune system causes too many skin cells to be generated in some areas of the body, accumulating to form red, flaky patches. Scratching while trying to relieve itchy patches can lead to recurring bacterial skin infections.

PsA triggers can be dietary (poor nutrition), environmental (e.g., contact with chemicals or allergens), viruses, polymicrobial infections, physical trauma (including injury, vaccination, oral ulcers), certain prescription drugs, and stress, which is the most common trigger.

Some PsA patients may develop ankylosing spondylitis (AS), one of several arthritis-based conditions that cause painful swelling and inflammation in the joints and vertebrae of the spine. About 70 % of patients with AS have subclinical gut inflammation, indicating that AS and irritable bowel disease (IBD) may share a common origin (gut microbiome dysbiosis). Other research finds one possible cause of AS to be Klebsiella pneumoniae, a persistent pathogen in the gut microbiome that produces toxins diffusing to nearby tissues and structures. Among many other contenders are various strains of mycoplasma, chlamydia, staphylococcus, streptococcus, and Lyme disease. Genetics also plays a role. Genetic marker HLA-B27 is present in 90%–95% of AS patients and strongly associated with over 100 inflammatory diseases including PsA, IBD, reactive arthritis (aka Reiter’s syndrome), RA, sacroiliitis, and Crohn’s disease.

Non-joint symptoms of PsA are generalized fatigue, hearing loss, eye inflammation (uveitis or conjunctivitis), psoriasis, and inflammation of tendons and ligaments (especially in the feet). Nail changes (on fingers or toes) can be an early warning sign of PsA, possibly indicating a sulphur deficiency. Changes include pitting, ridges, crumbling, white or red spots, or lifting of the nail. When these changes cause pain and an inability to do routine tasks like buttoning clothes or grasping small objects, a rheumatologist should be consulted.

Unfortunately, there is no definitive single test for PsA. Diagnosis is made using a detailed medical history (especially psoriasis conditions), thorough physical exam, and blood tests (including tests for RA). Expensive MRIs and x-rays may not lead to treatments. It is worth noting that the rheumatoid factor, normally an indicator of RA, is not usually found in PsA patients.

It is beyond the scope of this article to explore the highly complex inter-relationships between the immune system and the microbes inhabiting the gut microbiome that lead to specific inflammatory diseases. Recent research shows how some immunological conditions associated with changes in the skin microbiota are influenced by consuming specific probiotics and prebiotics designed to alter intestinal microbiota. An inflammatory disease state may result from the combined pathogenicity of the sum of microbes, both bacterial and viral, that an individual accumulates over the course of a lifetime.

Treatment Options

Non-steroidal anti-inflammatory drugs (NSAIDs) and traditional disease modifying antirheumatic drugs (DMARDs) commonly used as initial therapy for PsA have been found to be marginally effective, sometimes harmful. Methotrexate (MTX) is sometimes given as a first line DMARD, but this drug has serious negative side effects on the liver, lungs, and kidneys. Rheumatologists usually prescribe injectable medications called “biologics” for PsA. Examples are Enbrel, Remicade, and Humira. These very expensive drugs calm down the immune system’s response to the overreaction of T-cells to proteins interleukin 17-A, tumor necrosis factor-alpha (TNFα), and interleukins 12 and 23. Biologics are designed to target a specific part of the immune system, whereas MTX is metabolized by the entire body. Screening for latent tuberculosis should be done prior to commencing a TNFα inhibitor and other biologics.

Since biologics are among PsA drugs also prescribed for RA, a patient diagnosed with PsA should consider Dr. Brown’s protocol combining antibiotics with anti-inflammatory compounds as a probe. A Jarisch-Herxheimer reaction is to be expected if bacterial infection is present. A superior alternative to MTX is the antibiotic Bactrim DS. Antihistamines plus high dosage vitamin C should protect against another part of the inflammation cascade.

Non-prescription methods such as massage, acupuncture, acupressure, hot and cold packs, spa therapy, and stress management techniques can be helpful to relieve painful joint symptoms and improve one’s quality of life. Over-the-counter (OTC) topical creams containing capsaicin, salicylates, or counterirritants like eucalyptus, camphor, or wintergreen oil produce sensations that temporarily block nerve endings that transmit pain signals to the brain. Phototherapy can be an effective treatment for psoriasis. Essential oils like lavender, tea tree, rose, and chamomile can bring relief to inflamed skin, reduce stress, and support the healing process.

Some herbal supplements available in both topical and oral forms can alleviate painful symptoms of RA and PsA. Some of these are aloe vera, Methylsulfonylmethane (MSM), vitamin A, apple cider vinegar, arnica, vitamin D, ginger, Manuka honey, and turmeric. An anti-inflammatory diet is highly recommended by the National Psoriasis Foundation.

Before taking any OTC supplements, be aware of potential interaction with your other medications and treatments. Seek advice from your doctor, who is ideally a natural medicine-trained orthomolecular practitioner.