Psoriatic Arthritis

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Psoriatic Arthritis

Psoriasis is a common skin disorder that consists of silvery scales on bright red plaques on the skin. Television commercials for treatment used to refer to this disease as “the heartbreak of psoriasis”, and indeed it a very difficult skin disease to control. In some cases however there is systemic involvement, and the skin lesions become the least of the problems. This occurs in psoriatic arthritis.

Some 15-20% of people who have widespread psoriasis have coexisting arthritis. The arthritis can be quite disabling, and mimic a severe type such as rheumatoid arthritis. The involvement is usually symmetrical, and involves distant joints in the body, although it may not be as crippling. There are forms of psoriatic arthritis where joint themselves may be gradually worn away and destroyed.

Psoriasis generally preceeds the development of the arthritis by months to years. As a rule, the more severe skin disease cases generally are associated with arthritis than are milder ones. It is more of a detective search when there is limited psoriasis involvement (one patch, for example, maybe even hidden in the scalp) or when the arthritis suddenly appears after the skin involvement has been in remission. Nail pitting, a residue of previous psoriasis, may be the only clue in the search.

Laboratory studies generally show an increase in the erythrocyte sedimentation rate. Anemia may occur when the involvement is quite severe and wide spread. X-Rays are helpful in judging severity- those that show bone loss and erosion of both bones and joints generally represent much more active disease.

Treatment is very difficult in the disease, and is usually symptomatic. Anti-inflammatory medicines are used with fair results. Corticosteroids may have to be used when the disease flares, and prolonged use of them may cause unwanted side effects. Certain medicines originally diagnosed as anti-cancer agents, such as methotrexate, do show benefit. One of the difficult associations both in treatment and in underwriting is an increased incidence of alcoholism, both in response to pain relief and the frustration of managing the disease itself.

While psoriasis limited to the skin rarely if ever carries an underwriting consequence, cases of psoriatic arthritis may be rated, depending on their severity. The similarity of the type and activity of the arthritis to rheumatoid or ankylosing spondylitis (which involves the sacro-iliac area) is key. The disease is usually broken up into mild, moderate and severe. Those cases that are mild and symptomatic and do not show marked changes in bone structure and minimal systemic involvement are usually taken standard. The severe type is the most problemsome- when disability is marked, reliance on corticosteroids and pain medication is high, and when other body organs are involved, the rating may be significant. Underwriters also watch for the coexistence of alcoholism, which is a poor prognostic sign. Thankfully most cases can be taken standard or with a small rating overall.

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