Psoriasis and Psoriatic Arthritis: What You See and What You Don’t
by Laurie Wertich
It’s the simple, everyday tasks that can prove particularly frustrating for Jaime Moy, a Detroit, Michigan–area mom who lives with psoriasis and psoriatic arthritis.
“It’s very difficult when you’re the type of person who is used to doing everything you can to help other people and you’re put in a position where you have to ask for help,” says Jaime, who learned she had the autoimmune diseases about 10 years ago. “It’s not an easy thing to do—I still struggle with that now.”
Though she tries to stay as active as possible—she enjoys kickboxing and walking with friends—swollen joints sometimes prevent her from doing these activities and interfere with her ability to take care of her family the way she’d like.
“I feel like I don’t want to put too much burden on my family. I don’t want to have to ask my husband to drive me up to the store or carry a load of laundry downstairs,” she says. “It’s in my nature to be independent.” Although, she adds, “those times when I really can’t do those things, my husband and son are very supportive.”
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What Are Psoriasis and Psoriatic Arthritis?
According to the National Psoriasis Foundation, psoriasis is a non-contagious, chronic autoimmune disease that causes red, raised, scaly patches to appear on the skin. It occurs when the immune system sends out faulty signals that speed up the growth cycle of skin cells, causing layers of skin to accumulate.
Psoriasis is the most common autoimmune disease in the United States, affecting as many as 7.5 million Americans. It’s been linked to other serious health conditions as well, including cardiovascular disease, diabetes, and depression.
About 30 percent of people with psoriasis develop psoriatic arthritis (PsA), which, like psoriasis, can range from mild to severe. Most people first develop the skin symptoms of psoriasis and later develop symptoms of PsA—though in some cases arthritis symptoms can appear in advance of the scaly skin patches characteristic of psoriasis.
Psoriatic arthritis can develop at any age, but it most commonly appears between the ages of 30 and 50. Genes, the immune system, and environmental factors are all believed to play a role in the onset of the disease, according to the National Psoriasis Foundation.
There is no blood test to determine whether someone with psoriasis will develop PsA, says Elaine Husni, MD, MPH, member of the National Psoriasis Foundation’s Medical Board and a rheumatologist at the Cleveland Clinic. “We don’t have very solid clues,” she adds. Dr. Husni recommends that patients diagnosed with psoriasis have regular follow-ups with a dermatologist to discuss changes in their health.
Dr. Husni says that psoriasis patients will want to be especially aware of symptoms of PsA, such as sausage-like swelling along the length of their fingers or toes (called dactylitis) and joint and back pain that lasts for more than six weeks. Achilles tendonitis or “tennis elbow” also may signal PsA in those who already have psoriasis, she adds.
If these symptoms develop, it is important to talk with both a dermatologist and a rheumatologist, says Arthur Mandelin II, MD, PhD, assistant professor of medicine in the Department of Medicine, Division of Rheumatology, at Northwestern University Feinberg School of Medicine in Chicago. Including both specialists early on as symptoms develop can help ensure that patients receive optimal care, Dr. Mandelin says, because the physicians can compare notes and work hand-in-hand on treatment options.
Physical Symptoms Take an Emotional Toll
For Jaime Moy and other women who have psoriasis and PsA, managing these diseases means coping with fluctuating physical and emotional issues related to the condition. The swollen, painful joints characteristic of PsA and the itchy, uncomfortable skin that marks psoriasis are often paired with inner turmoil for women facing these diagnoses, especially as they confront others’ lack of knowledge of these diseases.
“Unfortunately, psoriasis is not well understood by the public in general,” says Dr. Mandelin. This lack of awareness, especially concerning the outward appearance of the disease, can lead to hurt and embarrassment for patients who experience others’ reactions to their appearance. “People don’t understand that it’s not contagious,” Dr. Mandelin says.
The lack of understanding about the disease among the general public leads women, in particular, to struggle emotionally in the face of a psoriasis diagnosis, according to the National Psoriasis Foundation. One reason is because women can feel heightened pressure to conceal the psoriasis patches that appear on their skin.
“I believe that women are more cosmetically sensitive to psoriasis,” says Dr. Husni. “They tend to worry more about the appearance of their lesions.” And, she says, the visible symptoms of PsA can cause similar distress: “Psoriatic arthritis affects things beyond the joints—swollen fingers and toes, sausage-like swelling, a lot more nail changes.”
Jaime Moy, who serves as a National Psoriasis Foundation community ambassador, agrees that women are affected differently than men by the symptoms of psoriasis. “In general, there’s more pressure on women to look a certain way in society, and I think that plays a big role for many women when psoriasis shows.” It can be especially tough, she says, in situations like swimming in public, where skin is on display, causing many patients to question whether the activity is worth the emotional toll: “It’s not easy. You do stop and think, Do I want to subject myself to the stares, the criticism, the don’t-come-near-me-you’re-contagious reactions? Or is it just easier to not go to the pool, not go out in public, not wear short-sleeved shirts?”
Psoriasis, PSA, and Pregnancy
For women of childbearing age, psoriasis and psoriatic arthritis raise unique considerations.
Pregnancy can be a tough time for women with these diseases, says Chris Jones-Wollerton, a mother who lives with psoriasis and PsA who is also a certified birth doula, a certified postpartum doula, and a board-certified lactation consultant.
“Imagine if you’re covered with psoriasis during childbirth; not only are you dealing with the fetal monitoring belt but you’re hampered in terms of movement and positions,” Jones-Wollerton says.
PsA brings its own challenges to pregnancy: “If a mom has psoriatic arthritis and is having trouble just getting around in general because of discomfort in the spine or in hands or feet, she is going to find pregnancy very difficult,” she says.
Beyond the physical reality of managing the limitations that psoriasis and PsA might cause during pregnancy and childbirth, Jones- Wollerton says that some women struggle with even the idea of motherhood in the face of the diagnosis.
“When I first became a member of the National Psoriasis Foundation, one woman I was in touch with said she planned to never have children because she was so uncomfortable with her body and was worried about going off her medication—she felt [that remaining on her medication] just really outweighed the benefits of having children,” Jones- Wollerton says.
For women who do want to have children, she says, one major consideration is the role of treatment during pregnancy. “There will always be the big questions about medication during pregnancy—it’s a hard decision,” she says. “You want to make the choices that are safest for your baby, but you also need to manage your disease.”
Dr. Mandelin says that while some medications are known to be too dangerous to use during pregnancy (Trexall® [methotrexate], for example, is often prescribed for psoriasis but can potentially cause birth defects), other treatments are safe and can provide symptom relief both when a woman is expecting and during breastfeeding. He notes that because research findings are limited, however, “the safety data for pregnant women with psoriasis and psoriatic arthritis are not perfect. It all becomes shades of gray and degrees of risk—it is a very individualized choice.”
Dr. Mandelin advises women who are considering treatment and discussing options during pregnancy with their care team to take into account their disease burden. Questions to guide a conversation with a physician might include: “What would be the consequences if we did nothing? If we removed medication?”
Ultimately, Dr. Mandelin says, treatment options should be an ongoing discussion throughout pregnancy.
While there is no clear reason why this happens, some women find that the autoimmune disease goes into remission during pregnancy. Others experience worsened symptoms. The fluctuating and highly individual nature of the disease makes it especially important keep in touch with not only an OB/GYN but also a dermatologist and a rheumatologist throughout pregnancy and postpartum, Dr. Mandelin says.
“Just a Small Part of My Life”
Living with psoriasis and PsA means finding ways to best manage the diseases, patients say, recognizing potential triggers and coping with symptoms as they arise and change.
“For a long time, both of the diseases were really well controlled. It wasn’t until about three years ago that I had a big flare,” says Jaime Moy, who has tried Trexall as well as the biologics Humira® (adalimumab) and Enbrel® (etanercept). Jaime says she is doing better now and has learned to recognize at least one thing that she believes will bring on a flare: “For me, stress is a big trigger.”
To help keep her stress level as low as possible, Jaime attends twice-weekly kickboxing classes. “It’s great to get out stress,” she says, adding that “there are days when I go in and I can’t punch anything. My joints hurt too much.” On those days she does shadow boxing, which entails punching air rather than bags or her mitt-wearing instructor.
For Jaime staying active has been essential in maintaining her emotional and physical wellness. “If I don’t stay active, my arthritis is worse—a lot worse,” she says. “I do it to release stress, for the company of friends; I do it to feel better. I am going to hurt whether I’m sitting on the couch or I’m out on a walk. I might as well get some fresh air and sunshine. When I get back home, I might have to get out the ice and put it on my knees, but sometimes you don’t know the next chance you will get to do this.”
Beyond her commitment to staying active, Jaime strives to keep the diagnosis in perspective and focus on the big picture. “It’s just a small part of my life, and it’s not the only part of my life,” she says. “There’s so much more to me than just psoriasis and psoriatic arthritis.”
Jones-Wollerton, who has three children, says her psoriasis and psoriatic arthritis can be disabling at times, but she too is committed to living a full, happy life despite the diagnosis. “I am trying to live my life as best as I can. I am not going to let psoriasis or psoriatic arthritis dictate what I’m going to do as a woman, as a mother,” she says. “I’ve had to adapt my parenting style, and it can be difficult at times, but I wouldn’t change a thing. There are so many things out of our control that we can’t change about our disease, but we can control how we view ourselves and the type of support we can get.”