Treatment

Treatment of PsA depends upon the severity of the condition and the features involved. The approach to treat ment utilizes principles of both RA and psoriasis treatment. Given the heterogeneous presentation in PsA, there are specific challenges in determining which medications are most useful for each individual. For example, some medications preferentially impact psoriasis features, but not joint problems and vice versa. In addition, the potency of the medication must match the severity of the disease and the probability of progressive damage. In a large cohort of patients followed by Gladman, predictors of progressive disease included lack of response to nonsteroidal anti-inflammatory drugs (NSAIDs), elevated acute phase reactants, poly-articular disease, erosions on X-ray, and disability (Gladman et al. 1995).

Treatment for PsA, therefore, may range from topical agents (such as vitamin D or corticosteroid cream) or light therapy for mild skin lesions, NSAIDs, intra-articular corticosteroid injections, and physical therapy approaches for mild joint involvement, to traditional disease-modifying anti-rheumatic drugs (DMARDs) and/or biologics for moderate to severe arthritis features. Corticosteroids must be used cautiously in patients with PsA, because withdrawal may trigger a flare of psoriasis. Beyond the scope of this chapter, a full review of topical and light therapy of psoriasis and traditional anti-inflammatory and DMARD therapy of arthritis can be found in a number of recent articles (Lebwohl et al. 2005; Mease 2004; Mease and Antoni 2005; Mease 2004; Mease et al. 2005; Nash and Clegg 2005; Winterfield et al. 2005).

Biologic agents are used increasingly by rheumatol-ogists and dermatologists to treat moderate to severely affected patients who do not respond adequately to traditional DMARDs. These agents, such as the anti-TNF-

medications, have contributed greatly to our ability to improve joint and skin disease, to inhibit progression of structural joint damage, and to improve patients' functional ability and quality of life.

Physical therapy also is an important component of treatment that helps to maintain and/or improve joint mobility, muscle strength and range of motion. Occupational therapists focus on procedures and devices to aid hand and wrist function. Orthopedic procedures, including joint modification or replacement, can help with more severely damaged joints.

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