Psoriatic Arthritis: Monitoring for Disease Progression

Lana Dykes: Getting back to my second question, can we touch on the progression from psoriasis to psoriatic arthritis, and the progressive nature of psoriatic arthritis, in general?

Christopher Parker, DO: Yes. Let me take this from a couple different angles. Again, I try to put myself in the patient’s shoes. I feel like I’m more empathic and understanding and I can understand their priorities better if I feel like I have this same condition.

If the patient comes in to me and reports that things are worse, I say, “OK, what do you mean by worse?” They might say joint stiffness; they may have more prolonged stiffness. “Oh, what does that do to you?” “Well, I have to get up a lot earlier to take a shower and loosen up. I get my medicines going. I’m up really early and then, boy, I really crash at night because I have to be up so early.”

And then, of course, they are always going to report pain. I really want to try to understand not only how much pain they are having, but I make them tell me whether we are talking about something that’s nuisance level or something more bothersome. Or if it’s more than that, and it’s really painful and impairing—impairing functions of daily living or other aspects that they want me to know about. This helps me understand how much we have to work on this. If I dive in and they’re telling me about nuisance-level stuff, then I go, “OK, we may not have to make modifications at all if it’s nuisance level.”

The other thing about progression, which I alluded to earlier but want to make sure I go back to, is the idea of damage. I think it would be false to say that every patient with psoriatic arthritis or musculoskeletal symptoms associated with psoriasis gets permanent damage. But because I know that some patients with psoriatic arthritis will get damage or could get damage, I want to home in on that. I wouldn’t say I always comfortably know what amount of pain equals damage, so I always have to examine their joints. I don’t just look to see how tender they are, or swollen, but I really try to understand their function. How do they move? I also rely on imaging along the way to help me understand if I’m getting damage. And naturally, if they are, even if they’re having good symptom control, I’m not going to be happy, and I’m going to want to augment therapy to address that.

The one thing that I’ve learned in the more than 20 years of being a rheumatologist is, it’s always fascinating to me to see that some patients have a nickel’s worth of psoriasis and it makes them crazy. Not on their face, but just somewhere on their body. “Oh, this is terrible.” And then I see other people for whom I would think their condition looks bad. However, they say, “Oh, this is not bad. I’ve had a lot worse,” and they don’t want me to plus-up their therapy at all for skin purposes, even if I want to. So, regarding the skin part of the disease, I really let my patients do the assessment and consider their happiness. If they’re pretty happy with what they’ve got, I’m good with that. If they’re not happy, I’m stepping it up. That is how I put that on the scale, or continuum, of disease activity.

Transcript edited for clarity