Having posted an indepth page of information on lymphedema and rheumatoid arthritis, I thought it might be helpful to also include a page on psoriatic arthritis, which has also been demonstrated to be involved in lymphedema.
To understand the possible relationship between arthritis, or any inflammatory disease and lymphedema, I want to share something Tom Kincheloe, a lymphedema therapist and a member of our online support group Advocates for Lymphedema shared:
Any of these conditions: bacteria, viruses, trauma, surgery, radiation, frostbite, burns, immune reactions, dead cells and cellular debris, shock, irritation of sensory nerve fibers (as in neurogenic inflammation), irregular shear stress, etc., can generate an acute inflammation response. In rheumatoid arthritis,(or Psoriatic Arthritis) it is chronic inflammation caused by “degranulation of the mast cells” that protect the sensitive nerve fibers resulting in chronic irritation and inflammation, which then leads to edema then lymphedema (if the inflammation is not controlled). As I explained to the student nurses during my inservice a few days ago, edema is a symptom and lymphedema is a disease. Edema (swelling) will commonly occur with any type of injury or disease where any tissue is damaged (internally and/or externally) and is part of the normal initial inflammatory healing response. It's when it goes unresolved that the edema can develope into lymphedema because continuous inflammation and infection may destroy the tiny lymphatic vessels resulting in permanent damage to the lymphatic system. So to answer your question: ANY inflammation response due to any of the above causes can lead to lymphedema, including RA and/or poriatic arthritis..”
His reference book for this information was the Lymphedema textbook for Physicians and Therapists (Foldi and Foldi, eds.)
Psoriatic arthritis is an inflammatory condition that affects the joints of children and adults with psoriasis. Psoriasis is a skin condition that causes patches of thick, red skin to form on certain areas of your body. Not everyone with psoriasis develops psoriatic arthritis, but everyone with psoriatic arthritis has psoriasis.
Most people develop the skin signs of psoriasis first and are later diagnosed with psoriatic arthritis. Joint pain in people with psoriatic arthritis can range from mild to severe. Many experience changing signs and symptoms as the disease continues.
Many definitions of psoriatic arthritis exist, which makes it hard to estimate how many people have the disease. About 10 percent to 15 percent of people with psoriasis eventually develop psoriatic arthritis. While no cure for psoriatic arthritis exists, doctors work to control your signs and symptoms and prevent damage to your joints.
Signs and symptoms
Psoriatic arthritis may affect one joint or many. Signs and symptoms of psoriatic arthritis include:
Pain in affected joints
Joints that are warm to the touch
Patterns of joint pain in psoriatic arthritis
Doctors have identified five patterns in which psoriatic arthritis typically occurs. Most people move from one pattern of psoriatic arthritis to another throughout their lives. Treatment usually varies based on the pattern of joint involvement you experience. Patterns of psoriatic arthritis include:
Pain in joints on one side of your body. The mildest form of psoriatic arthritis, called asymmetric psoriatic arthritis, usually affects joints on only one side of your body or different joints on each side — including those in your hip, knee, ankle or wrist. One to three joints are generally involved, and they're often tender and red. When asymmetric arthritis occurs in your hands and feet, swelling and inflammation in the tendons can cause your fingers and toes to resemble small sausages (dactylitis).
Pain in joints on both sides of your body. Symmetric psoriatic arthritis usually affects four or more of the same joints on both sides of your body. More women than men have symmetric psoriatic arthritis, and psoriasis associated with this condition tends to be severe.
Pain in your finger joints. Distal interphalangeal (DIP) joint predominant psoriatic arthritis is rare and occurs mostly in men. DIP affects the small joints closest to the nails (distal joints) in the fingers and toes. Pain in your spine. This form of psoriatic arthritis, called spondylitis, can cause inflammation in your spine as well as stiffness and inflammation in your neck, lower back or sacroiliac joints. Inflammation can also occur where ligaments and tendons attach to your spine. As the disease progresses, movement tends to become increasingly painful and difficult.
Destructive arthritis. A small percentage of people with psoriatic arthritis have arthritis mutilans — a severe, painful and disabling form of the disease. Over time, arthritis mutilans destroys the small bones in the hands, especially the fingers, leading to permanent deformity and disability.
Psoriasis is a skin condition marked by a rapid buildup of rough, dry, dead skin cells that form thick scales. Arthritis causes pain and stiffness in your joints. Both are autoimmune problems — disorders that occur when your body's immune system, which normally fights harmful organisms such as viruses and bacteria, begins to attack healthy cells and tissue. The abnormal immune response causes inflammation in your joints as well as the overproduction of skin cells.
It's not entirely clear why the immune system turns on itself, but it seems likely that both genetic and environmental factors play a role. Many people with psoriatic arthritis have a close relative, such as a parent or sibling, with the disease, and researchers have discovered certain gene mutations that appear to be associated with psoriatic arthritis.
Having a genetic mutation doesn't necessarily mean you'll develop psoriatic arthritis, but it does mean you have a greater tendency to do so than other people do. Physical trauma or something in the environment — such as a viral or bacterial infection — may eventually trigger psoriatic arthritis in people who have an inherited tendency.
Having psoriasis is the single greatest risk factor for psoriatic arthritis. In particular, people who experience psoriasis lesions on their nails are more likely to develop psoriatic arthritis.
Other risk factors include:
Your family history. Many people with psoriatic arthritis have a close relative with the disease. Your age. Although anyone can develop psoriatic arthritis, it occurs most often in adults between the ages of 30 and 50.
Your sex. In general, psoriatic arthritis affects men and women equally, but DIP and spondylitis are more likely to affect men, whereas symmetric arthritis occurs more often in women.
When to seek medical advice
If you have persistent discomfort and swelling in multiple joints, see your doctor. He or she can work with you to develop a pain management and treatment plan.
Screening and diagnosis
No single test can confirm a diagnosis of psoriatic arthritis. Your doctor will assess your signs and symptoms and work to rule out other causes of joint pain, such as osteoarthritis and rheumatoid arthritis. Tests that help to distinguish psoriatic arthritis from other conditions include:
X-rays. These can help pinpoint changes in the joints that occur in psoriatic arthritis but not in other arthritic conditions.
Joint fluid test. In this test, your doctor removes a small sample of fluid from one of your joints — often the knee — for analysis in a laboratory. Uric acid crystals in your joint fluid may indicate that you have gout, rather than psoriatic arthritis.
Sed rate. This blood test checks your erythrocyte sedimentation rate (ESR), commonly known as the sed rate, by measuring how far from the top of a glass tube your red blood cells fall in a given time. Generally, the blood cells fall farther — that is, the sed rate increases — when inflammation is present. But because many conditions can cause inflammation in the body, including many forms of arthritis and other rheumatic diseases, an elevated sed rate alone can't confirm the presence of psoriatic arthritis.
Rheumatoid factor (RF). RF is an antibody — a protein made by the immune system — that's often present in the blood of people with rheumatoid arthritis, but not in the blood of people with psoriatic arthritis. For that reason, this test can help your doctor distinguish between the two conditions.
Most people are diagnosed with psoriasis before they begin experiencing the pain of psoriatic arthritis. In a minority of cases, people experience the joint pain of psoriatic arthritis before they have signs and symptoms of psoriasis. In these cases, if you have joint pain that suggests psoriatic arthritis, your doctor will conduct a careful examination of your skin to look for any signs and symptoms of psoriasis.
Psoriatic arthritis can be debilitating and painful, making it difficult to go about your daily routine. Despite medications, psoriatic arthritis can cause erosion in your joints.
Doctors have difficulty determining who will experience the most destructive forms of this disease and who won't. In general, people diagnosed with psoriatic arthritis at a younger age, women and those with sudden-onset joint pain are more likely to develop severe psoriatic arthritis.
No cure exists for psoriatic arthritis. Your doctor works to control inflammation in your affected joints in order to prevent joint pain and disability. This is usually accomplished with medications and, rarely, surgery.
Medications commonly used to treat psoriatic arthritis include
Nonsteroidal anti-inflammatory drugs (NSAIDs). Drugs such as aspirin and ibuprofen (Advil, Motrin, others) may help control pain, swelling and morning stiffness. Prescription NSAIDs provide higher potencies than do over-the-counter drugs. But all NSAIDs can irritate your stomach and intestine, and long-term use can lead to ulcers and gastrointestinal bleeding.
Other potential side effects include damage to your kidneys, fluid retention and heart failure. In addition, NSAIDs may worsen skin problems. Still, these medications may be a good option for people with minor joint pain and stiffness.
Corticosteroids. If you have mild psoriatic arthritis, your doctor might recommend corticosteroids to control infrequent joint pain flares. Corticosteroids can be taken orally, or they can be injected directly into aching joints. Corticosteroid injections provide almost immediate relief and improve range of motion — sometimes for months. But because injected steroids can cause damage, their use is usually limited.
Disease-modifying antirheumatic drugs (DMARDs). Rather than just reducing pain and inflammation, this class of drugs helps limit the amount of joint damage that occurs in psoriatic arthritis. But because DMARDs act slowly, you may not notice the effects for weeks or even months. For that reason, your doctor may prescribe a pain reliever, such as aspirin, in addition to a DMARD. Examples of DMARDs include sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil) and methotrexate.
Immunosuppressant medications. These medications act to suppress the immune system, which normally protects the body from harmful organisms, but which attacks healthy tissue in people with psoriatic arthritis. Commonly used immunosuppressants include azathioprine (Imuran), cyclosporine (Sandimmune, Neoral) and leflunomide (Arava).
Immunosuppressants can have potentially dangerous side effects and usually are used in only the most severe cases of psoriatic arthritis. Because they suppress the immune system, all such drugs can lead to anemia and an increased risk of serious infection. And many of them can cause liver and kidney problems.
TNF-alpha inhibitors. Your doctor may recommend tumor necrosis factor-alpha (TNF-alpha) inhibitors if you have severe psoriatic arthritis. These drugs block a protein that causes inflammation in some types of arthritis. Drugs in this category include etanercept (Enbrel), adalimumab (Humira) and infliximab (Remicade). TNF-alpha inhibitors can help manage signs and symptoms of psoriasis, as well. However, these drugs carry a risk of side effects, including serious infections.
Although surgery is rarely performed for psoriatic arthritis, your doctor may recommend some form of joint operation when other treatments fail to relieve your symptoms. Surgeons use various procedures to ease pain and restore mobility. Because these operations pose some risks, be sure you thoroughly discuss your options with your doctor.
Some of the most encouraging news about psoriatic arthritis is that you can do a great deal on your own to help manage the condition:
Maintain a healthy weight. Maintaining a healthy weight places less strain on your joints, leading to reduced pain and increased energy and mobility. The best way to increase nutrients while limiting calories is to eat more plant-based foods — fruits, vegetables and whole grains.
Exercise regularly. Exercise is essential for everyone — and that includes people with arthritis. In fact, exercise alone can help relieve many of the symptoms of arthritic conditions, including pain and fatigue. You're the best judge of how much you can do, but an appropriate activity level should make you feel the same or better afterward, not worse. Introduce new activities gradually and heed warning signs. If you experience new pain later in the day or fatigue the following day, you've probably done too much.
Use cold and hot packs. Because cold has a numbing effect, it can dull the sensation of pain. Before using an ice pack, apply a thin layer of mineral oil over the painful joint. Place a damp towel over the mineral oil and then put the ice pack on the towel. You can apply cold several times a day for 20 or 30 minutes. Some people prefer to briefly massage the painful area with an ice cube. If you try this method, keep the ice moving to avoid frostbite. You can also use heat to relax tense muscles and relieve pain. Try an electric heating pad on the low setting — be sure to place a towel between your skin and the heating pad. Using a heat lamp, an inexpensive gel-filled pack found in most pharmacies, or taking a warm bath or shower also may help.
Use proper body mechanics. Changing the way you carry out everyday tasks can make a tremendous difference in how you feel. For example, you can avoid straining your finger joints by using a specially-designed opener to twist the lids from jars, by lifting heavy pans or other objects with both hands and by pushing open doors with your whole body instead of just your fingers. Ask your doctor about other ways you can protect your joints.
Pace yourself. Battling pain and inflammation can leave you feeling exhausted. In addition, some arthritis medications can cause fatigue. The key isn't to stop being active entirely, but to rest before you become too tired. Divide exercise or work activities into short segments. And find time to relax several times throughout the day.
Psoriatic arthritis can be discouraging because skin and joint problems frequently don't flare and go into remission at the same time. If you're struggling to cope, consider trying to:
Learn as much as you can about psoriatic arthritis. Find out how the disease progresses, your prognosis and your treatment options, including the newest information on diet and exercise. The more you learn, the more active you can be in your own care.
Learn to manage stress. The chemicals your body releases when you're under stress can help you deal with demanding situations. But there's a downside. Those same chemicals can suppress your immune system and aggravate both psoriasis and arthritis. Trying to cope with worsening symptoms may make you feel even more stressed, setting up a destructive cycle. Although it's not possible to eliminate stress from your life, you can learn to manage it.
Maintain a strong support system. The support of friends and family can make a tremendous difference when you're facing the physical and psychological challenges of psoriatic arthritis. Just having someone to talk to can give you strength. For some people, support groups can offer the same benefits — this may be especially important if you're worried about burdening your loved ones. Talk to your doctor or contact your local Arthritis Foundation chapter.
Br J Dermatol. 2000 Dec
Böhm M, Riemann B, Luger TA, Bonsmann G. Departments of Dermatology and Nuclear Medicine, University of Münster, Von Esmarch-Str. 56, D-48149 Münster, Germany. email@example.com
Keywords: lymphedema, psoriasis, psoriatic arthritis
Lymphedema is an unusual extra-articular feature of rheumatoid arthritis and has rarely been described in psoriatic arthritis. We report a 41-year-old man with psoriasis and psoriatic arthritis who developed bilateral lymphoedema of the upper extremities. Lymphoscintigraphy showed absent lymphatic drainage in the right arm and a subnormal increase in lymphatic flow under manual exertion in both arms. Colour Doppler ultrasound studies did not reveal venous or arterial abnormalities. Conservative management and therapy with cyclosporin (for worsening arthritis) resulted in partial resolution of the lymphoedema and improvement of flow parameters on the right side upon repeat lymphoscintigraphy.
Clin Exp Rheumatol. 2001 May-Jun
Cantini F, Salvarani C, Olivieri I, Macchioni L, Niccoli L, Padula A, Falcone C, Boiardi L, Bozza A, Barozzi L, Pavlica P. Unità Reumatologica, II Divisione di Medicina, Ospedale di Prato, Piazza Ospedale 1, 59100 Prato, Italy.firstname.lastname@example.org
OBJECTIVE: To evaluate the frequency and the clinical characteristics of distal extremity swelling with pitting edema in patients with psoriatic arthritis (PsA).
METHODS: This was a case-control study of consecutive outpatients with PsA (old and new diagnosis) observed over a 3-month period in three secondary referral centers in Italy. As controls we used the two consecutive rheumatic outpatients, excluding those with spondylarthropathies, observed after a PsA patient. The demographic and clinical features were assessed by clinical examination and review of the medical records.
RESULTS: A total of 183 patients with PsA and 366 controls were evaluated. Distal extremity swelling with pitting edema was recorded in 39/183 (21%) PsA patients and in 18/366 (4.9%) controls (p < 0.0001). In 8/39 (20%) patients this feature presented as a first, isolated manifestation of PsA, and in 8 others it was associated with other features of PsA at diagnosis. The upper and lower extremities were affected, predominantly asymmetrically, in 40% and 60% of the cases respectively. In patients with pitting edema compared to those without this feature, the frequency of Achilles enthesitis and plantar fasciitis, calculated together, was higher (p < 0.05) and the duration of arthritis was significantly lower (p = 0.02). In 7 patients the clinical evidence of a predominant involvement of tenosynovial structures was confirmed by MRI.
CONCLUSION: Upper or lower distal extremity swelling with pitting edema due to tenosynovitis, usually unilateral, is a common feature in PsA patients and may represent the first, isolated manifestation of the disease.
J Rheumatol. 1999 Aug
Salvarani C, Cantini F, Olivieri I, Niccoli L, Senesi C, Macchioni L, Boiardi L, Padula A. Servizio di Reumatologia, Arcispedale S. Maria Nuova, Reggio Emilia, Italy. email@example.com Distal extremity swelling with pitting edema due to altered lymphatic drainage has been reported in some patients with psoriatic arthritis (PsA). The edema usually affected the upper limbs in an asymmetric pattern and was resistant to therapy. We describe 2 additional cases. The distal swelling and pitting edema responded promptly and completely to corticosteroids in the first patient but persisted in the second. Lymphoscintigraphy and magnetic resonance imaging (MRI) revealed a predominant tenosynovitis in the hand without lymphedema in the first patient, and impaired lymphatic drainage without tenosynovial sheath involvement in the second. We conclude that 2 different mechanisms, characterized by a different response to therapy, may be associated with the same clinical picture of distal swelling with pitting edema in patients with psoriatic arthritis. Lymphoscintigraphy and MRI are useful in defining the structures involved and in predicting the prognosis.
Semin Arthritis Rheum. 1993 Apr
Mulherin DM, FitzGerald O, Bresnihan B. Department of Rheumatology, University College Dublin, St Vincent's Hospital, Ireland.
Upper limb lymphedema occurs rarely in rheumatoid arthritis (RA) but has been reported only once in psoriatic arthritis (PsA). The pathogenesis is unknown. This study describes four patients (three women) with upper limb lymphedema, chronic symmetrical polyarthritis, and psoriasis. Three were seronegative, diagnosed PsA; one was seropositive. Age ranged from 39 to 64 years, duration of psoriasis was 6 to 42 years, and duration of arthritis was 6 to 12 years. Onset of lymphedema was unrelated to the extent or severity of arthritis, and no other cause for this condition was identified. Radiological appearances ranged from mildly abnormal to advanced joint destruction, but carpal disease was prominent in all patients. Lymphoscintigraphy was abnormal in three subjects. Lymphedema became bilateral in two and was associated with radiological progression of arthritis. Disease-modifying therapy produced improvement of lymphedema in two patients and correction of the lymphoscintigraphic abnormality in one. This study describes upper limb lymphedema in patients with PsA and suggests that local synovitis may play a role in its pathogenesis.
Two cases of distal extremity swelling with pitting oedema in psoriatic arthritis: the different pathological mechanisms.
Efficacy of Etanercept in Lymphedema Associated with Psoriatic Arthritis