Psoriatic Arthritis vs. Ankylosing Spondylitis: Signs, Treatment – Verywell Health

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Psoriatic Arthritis vs. Ankylosing Spondylitis: Signs, Treatment – Verywell Health

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Marissa Sansone, MD, is a board-certified doctor of internal medicine and a current fellow in rheumatology at Yale University. She actively teaches rheumatology to medical residents and students, and peer-reviews abstracts in the journal Rheumatology.
Both psoriatic arthritis (PSA) and ankylosing spondylitis (AS) are types of spondyloarthritis, inflammatory diseases that affect the hands, feet, back, pelvis, neck, and larger joints. Spondyloarthritic conditions can also affect the skin, eyes, and other organs. The most common form of spondyloarthritis is AS.

Both PsA and AS cause joint pain, swelling, and stiffness. PsA primarily affects the hands and feet, and large joints, including the knees and ankles. In AS, symptoms mainly affect the back and sacroiliac joints, the area where the spine connects to the pelvis, although other joints can be affected.
If left untreated, both PsA and AS can cause permanent damage to joints. An early and correct diagnosis is vital for both these conditions so your doctor can start you on a treatment plan to ease pain and prevent long-term problems.
PsA and AS are often confused with other types of inflammatory arthritis, and sometimes they are mistaken for each other. This article will discuss the similarities and differences of PsA and AS, including symptoms, causes, and treatments.
Chinnapong / Getty Images
PsA and AS can share similar symptoms and features. Spondyloarthritic conditions are considered axial, which means they mainly affect the spine. They can also be peripheral, meaning they mainly affect other joints, including the hands, feet, and knees.

PsA is often considered peripheral and AS is considered axial, but axial and peripheral features can overlap in different types of spondyloarthritis.
Joint pain, tenderness, and swelling

Joint stiffness in the morning and after prolonged inactivity
Reduced range of motion in affected joints
Low back pain and stiffness
Enthesitis (inflammation of entheses, where connective tissue attaches to bone)

Dactylitis (severe swelling of finger and toe joints)
Skin rash
Nail changes
Eye inflammation
Chronic fatigue
Anemia (lack of healthy red blood cells)
Back pain

Stiffness of the low back and hips, especially in the morning and after prolonged inactivity
Gastrointestinal troubles (relating to the stomach and intestines)
Breathing troubles
Neck pain
Skin rash
Eye inflammation
Enthesitis
Chronic fatigue
Hip and buttocks pain
Shoulder pain
Joint fusion and spinal ligament calcification
PsA affects 60 to 250 per 100,000 American adults. It affects one in three people with the autoimmune skin condition psoriasis. Psoriasis causes skin cells to grow quickly, leading skin cells to pile up in scaly, silvery patches, called skin plaques.

PsA can affect various joints, including the arms, legs, spine, hands, and feet. It is categorized into five major types.
The five types are:

The symptoms of PsA may come on gradually and mildly for some people. For others, they may be sudden and severe. Not all people with PsA will experience the same symptoms.

The most common symptoms of PsA are:

According to the Johns Hopkins Arthritis Center, the prevalence of AS in the United States is around 200 to 500 of every 100,000 people. The earliest signs and symptoms of AS might include pain and stiffness in the lower back and hips, especially in the morning and after being inactive for a long period.
Additional symptoms of AS include:

While PsA and AS have many similar symptoms, there are specific symptoms that set them apart.
Symptoms that set these conditions apart include:

Both PsA and AS come with long waiting periods for diagnosis, up to 10 years in some cases. This is because they can be mistaken for other conditions, including fibromyalgia, rheumatoid arthritis, and osteoarthritis. They can also be mistaken for each other.
PsA and AS are both autoimmune diseases, conditions in which the immune system malfunctions and attacks healthy tissues. Much like other autoimmune diseases, PsA and AS have no specific known causes, although genetics is believed to be involved. 
In particular, many people with spondyloarthritis conditions have a gene called HLA-B27, which puts them at higher risk for their conditions. However, not everyone with this gene will develop PsA, AS, or another spondyloarthritis condition.
One 2021 report in the journal Frontiers in Immunology reports that 75%–90% of people with AS test positive for HLA-B27, and 20%–50% of people with PsA have this gene marker.
Researchers think PsA develops from a combination of genetic and environmental factors. They suspect immune system problems, infections, obesity, smoking, chronic stress, and physical trauma all play a part in determining who might develop the condition.
The people who have the highest risk for PsA are those with psoriasis, but it is very possible to have PsA without psoriasis or to have psoriasis and not develop PsA.
Having a family history of PsA or psoriasis increases your risk for PsA. A child whose parent has PsA or psoriasis has a greater risk for PsA.

According to the Cleveland Clinic, research on PsA has found increased levels of tumor necrosis factor (TNF) in the joints and affected skin of people with PsA. These higher levels are responsible for overwhelming the immune system and causing it to produce the inflammation responsible for PsA.

Known risk factors for PsA include:

PsA affects males and females in equal numbers. It most frequently occurs in adults ages 35 to 55, but it can affect anyone regardless of age, including children.
Much like PsA, AS can run in families, and the HLA-B27 gene can be inherited. Having the HLA-B27 gene increases your risk for AS to about 50%.
Still, having this gene isn't enough to cause the disease to develop. Other factors—environmental (including infection, trauma, and chronic stress, etc.) and even sporadic events—in association with the gene contribute to disease development.

AS has a strong genetic component, as shown in family and twin studies. The sibling risk for AS is 9.2% compared to 0.1% in the general population. The most direct evidence on family history is the rates of AS in HLA-B27-positive identical twins­ at around 60% risk and 27% for HLA-B27-positive fraternal twins.

Risk factors for AS are:

The correct diagnosis for PsA or AS is essential. It is best done by a rheumatologist, a doctor who has additional training and experience in diagnosing and treating diseases of the joints, bones, and muscles. There is no single test that can confirm either condition, so doctors will focus on ruling out other conditions.

One of the first steps in looking for a diagnosis starts with your doctor asking about family and medical history and symptoms. A physical exam will also look for joint pain patterns and pain areas, nail and skin symptoms, and eye inflammation.

Lab work, including blood work and joint fluid samples, can help in diagnosing PsA or AS. Blood work looks for inflammation and helps to rule out other types of inflammatory conditions like rheumatoid arthritis. Testing joint fluid can help rule out gout, which causes uric acid crystal buildup in the joint fluid.
If your doctor suspects PsA or AS, they will request X-rays to check for joint damage. Magnetic resonance imaging (MRI) and ultrasound can find inflammation and bone changes. Sometimes, skin biopsies are done to determine if psoriasis is involved.

If your doctor suspects AS, you will likely be tested for HLA-B27. Because HLA-B27 is seen less frequently in people with PsA, the test is done to predict whether PsA might affect your spine.

No cure exists for either PsA or AS, but both conditions are treatable and manageable. Treatment is aimed at managing symptoms, protecting the joints, slowing down disease progression, and improving quality of life. Your rheumatologist will work with you to determine the best plan of action that meets your health needs. 

Treatments for PsA and AS tend to overlap, but certain medications might be better for treating one condition over the other.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil (ibuprofen) and Motrin (naproxen) are used for mild cases of PsA.
If a person experiences a more moderate disease, their doctor will also prescribe disease-modifying antirheumatic drugs (DMARDs) or biologics. These suppress their overactive immune system and reduce inflammation to help manage pain and other symptoms. 
DMARDs commonly prescribed to treatment PsA include Trexall (methotrexate), Arava (leflunomide), and Azulfidine (sulfasalazine). Common biologic drug therapies used in treating PsA are TNF inhibitors, interleukin (IL) inhibitors, and T-cell inhibitors.

Newer treatments for PsA are Janus kinase (JAK) inhibitors, medicines that work to tamp down the immune system and prevent inflammation that leads to joint damage, and Otzela (apremilast), which controls inflammation by blocking an enzyme called phosphodiesterase type 4 (PDE4).

People with PsA who have skin symptoms also benefit from topical treatments, including corticosteroid creams and anti-inflammatory medications, as well as phototherapy (treatment by exposure to ultraviolet, or UV, light) to reduce and manage the effects of itching and skin pain.

Surgery for managing PsA is rare, but it can be used if joints are severely damaged to improve mobility and relieve discomfort.

NSAIDs are considered first-line therapy for treating AS. But if these medicines don’t help manage inflammation and other AS symptoms, your doctor will prescribe biologic drug therapies.
Different types of biologics are used to treat AS, including TNF inhibitors and IL-17 inhibitors. Cosentyx (secukinumab) and Taltz (ixekizumab) are the two most prescribed biologics for AS, but many others have been used to help manage symptoms in people with AS.
Much like PsA, surgery for AS is only done in the most severe cases. When it is done, it is usually done to straighten the spine.
People who live with PsA or AS can benefit from making healthy lifestyle choices.  
Lifestyle changes might include:
Autoimmune diseases and spondyloarthritis generally cannot be prevented. If you have a family history of PsA, AS, autoimmune diseases, or spondyloarthritis conditions, ask your doctor to help you identify risk factors for developing these conditions.

While researchers know that people with psoriasis might have a higher risk for PsA and some people have genetic markers that increase their risk for PsA and AS, no specific treatment can prevent these conditions. There is no way to identify people who may go on to develop these conditions. 

Some risk factors and triggers for PsA and AS can be prevented—such as smoking, diet, and exposure to chronic stress. But even with managing these, you can still end up with PsA, AS, and other similar diseases.

If you are concerned about your risk for PsA or AS, reach out to your healthcare provider to discuss this risk and be evaluated for these conditions. Early diagnosis can help reduce the risk for joint damage.

PsA and AS are two common types of spondyloarthritis, inflammatory conditions that affect the back, pelvis, neck, and larger joints. These conditions share many characteristics, including symptoms and genetic causes.
They can also be challenging to diagnose, and neither disease can be cured. Fortunately, there are many treatment options to ease pain and other symptoms and improve your quality of life. Prevention of PsA and AS is not always possible, although managing some risk factors can reduce your risk.

Both PsA and AS can worsen as you age but they are not disabling or life-threatening for most people. However, symptoms, such as joint pain, back pain, and fatigue can interfere with your quality of life.

Talk to your healthcare provider about how you can manage symptoms of PsA or AS so that you can continue to be active and enjoy life.
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