Spondyloarthritis is a group of diseases characterized by inflammation in the

spine (“spondylitis”) and joints (“arthritis”).

Types of spondyloarthritis include:
 Ankylosing spondylitis
 Axial spondyloarthritis
 Enteropathic spondyloarthritis
 Peripheral spondyloarthritis
 Psoriatic arthritis
 Reactive arthritis
Ankylosing spondylitis is a variant of spondyloarthritis that affects young adults.
In ankylosing spondylitis, inflammation in the spine and sacroiliac joints causes
chronic pain and stiffness in the back. Spondyloarthritis patients predominantly
have disease in peripheral joints and frequently have inflammation at the
attachment sites of tendons and ligaments to bones. Inflammation of whole fingers
and toes is common, giving rise to a characteristic sausage-like appearance.
Psoriatic arthritis is another variant of spondyloarthritis. In psoriatic arthritis,
psoriasis of the skin is paired with musculoskeletal features of spondyloarthritis,
typically affecting peripheral joints. Eye inflammation (uveitis) is common in
patients with ankylosing spondylitis or psoriatic arthritis.
Causes and Risk Factors
It is thought that spondyloarthritis develops through to the interaction of genetic
and environmental factors. Many patients with spondyloarthritis are positive for
HLA-B27, a gene variant that controls immune responses. However, no single
gene determines whether a person will develop spondyloarthritis. Many other
genetic variants have been identified that increase disease risk. Reactive arthritis is
a type of spondyloarthritis that develops after a urinary tract infection, or an
episode of infectious diarrhea caused by certain types of bacteria. It has been
hypothesized that bacteria also play a role in ankylosing spondylitis and other
variants of spondyloarthritis, typically without causing overt infection. Patients
with inflammatory bowel (Crohn’s disease or ulcerative colitis) disease may
develop spondyloarthritis suggesting that certain disease mechanisms are shared.
Currently, we do not understand enough about the causes of spondyloarthritis to be
able to prevent the disease.
Symptoms
Symptoms of spondyloarthritis vary between patients but may include:
 Longstanding low back pain
 Back stiffness
 Back pain and stiffness are typically worse at night and improve with
exercise
 Fatigue
 Painful swelling of joints
 Sausage-like appearance of fingers or toes
 Heel pain
 Skin and nail changes of psoriasis
 Episodes of eye inflammation (uveitis)
Many patients with spondyloarthritis have a first degree relative with
spondyloarthritis or spondyloarthritis-related disease (ankylosing spondylitis,
psoriatic arthritis, psoriasis, Crohn’s disease, ulcerative colitis, uveitis).
Diagnosis
Your doctor typically will begin by going through your medical history and
conducting a thorough physical exam. Tests and procedures that may be used for
diagnosing spondyloarthritis include:
 Blood tests, to determine your HLA-B27 status and measure markers of
inflammation.
 Imaging studies, to look for evidence of inflammation and rule out other
potential causes of the patient’s symptoms. The specific type of imaging
study (X-ray, ultrasound, MRI) will vary depending on the patient’s
symptoms.
Treatment
The treatment for spondyloarthritis depends on the type of spondyloarthritis and
severity of the illness. Treatment options include the following medications:
 Non-steroidal anti-inflammatory drugs (NSAIDs)
 Disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate or
sulfasalazine may be used in patients with peripheral arthritis. These
medications are not effective for the treatment of spinal inflammation.
 Biologics are second-line drugs used for patients with inflammation in the
spine (ankylosing spondylitis). TNF inhibitors, IL-17A inhibitors and other
biologics are also used to treat peripheral spondyloarthritis. Drug
development efforts in this field are ongoing.
 Physical therapy - is an important part of long-term management of spinal
disease.

7 Diseases That Can Mimic Psoriatic Arthritis — and Delay Your

Diagnosis
PUBLISHED 12/10/19 BY LINDA RODGERS
This chronic inflammatory arthritis can have many different symptoms,
which is why it’s so easy to misdiagnose — and miss, say
rheumatologists.
Like many types of inflammatory arthritis, psoriatic arthritis (PsA) is an
autoimmune disease that affects your joints, causing pain, stiffness, and swelling
(as well as long-term damage). Men and women tend to develop PsA in equal
numbers, and the first symptoms usually appear when people are between the ages
of 30 and 50.
People commonly associate psoriatic arthritis with psoriasis, an autoimmune
disease that affects the skin, causing flares of red, silvery plaques, although you
don’t necessarily need to have psoriasis to develop PsA.
“Up to 20 to even 30 percent of patients who have psoriasis will go on to develop
psoriatic arthritis,” says Rebecca Haberman, MD, clinical instructor of
rheumatology at the department of medicine, NYU Langone Health in New York
City. “But it’s really only recently that psoriatic arthritis has come to the forefront
of both rheumatology and dermatology. Dermatologists don’t always know all of
the signs or the symptoms of psoriatic arthritis to know when to refer people to a
rheumatologist.”
That helps to explain why some people with psoriasis aren’t readily diagnosed with
psoriatic arthritis, says Dr. Haberman. In fact, a 2015 study published in
the Journal of the American Academy of Dermatology found that about 15 percent
of patients with psoriasis had undiagnosed PsA.
Misdiagnosing Psoriatic Arthritis: Why It’s Common
People with PsA may not have psoriasis or may not *realize* they have
psoriasis
In about 70 percent of PsA cases, psoriasis symptoms come first. In about another
15 percent, psoriasis and PsA symptoms strike at the same time and in another 15
percent, the arthritis-like symptoms come first.
When patients don’t have obvious psoriasis symptoms, it can lead doctors to not
suspect PsA, says Daytona Beach, Florida, rheumatologist and CreakyJoints
medical advisor Vinicius Domingues, MD. “Patients have zero skin
manifestations, but they have an inflammatory pattern of pain, and then just
because they don’t have psoriasis, doctors don’t diagnose them with psoriatic
arthritis.”
Or you may have psoriasis, but not realize or think about it much. “It’s not always
easy to diagnose the psoriasis or see the psoriasis,” Dr. Haberman notes. “Patients
think, ‘Oh, I’ve had this one little area behind my ear that sometimes itches,’ but
otherwise they never notice it. Or they could have a little fleck in their scalp, which
they just think is dandruff.”
PsA has many different symptoms
Even taking skin manifestations out of the equation, “psoriatic arthritis is a very
complex, heterogeneous disease. It can present in many different ways,” Dr.
Haberman explains.
You can have different symptoms — from swollen joints to pain in your heels to
fatigue — those doctors don’t realize are signs of PsA. Some PsA patients have
traditional joint pain while others might complain more of enthesitis, or
inflammation where ligaments and tendons connect to bones, such as at the heel or
bottom of the foot. Read more about the different “domains” of PsA.
Blood tests can be confusing
PsA patients often test positive for blood markers of inflammation, such as C-
reactive protein (CRP) or erythrocyte sedimentation rate (ESR). But psoriatic
arthritis is considered a “seronegative” arthritis, which means that it doesn’t have
telltale antibodies the way rheumatoid arthritis (RA) does with rheumatoid factor
and anti-CCP. This can cause confusion between PsA and seronegative rheumatoid
arthritis, in which RA patients don’t have these antibodies either. Seronegative RA
occurs in 20 to 30 percent of RA cases. Read more here about seronegative RA vs.
seropositive RA.
The Importance of Early Diagnosis
Given all these factors, it’s no wonder that a 2018 study conducted by our parent
non-profit organization, the Global Healthy Living Foundation, found that 96
percent of people who were ultimately diagnosed with psoriatic arthritis received at
least one misdiagnosis first. For about 30 percent of PsA patients, it took more than
five years to get diagnosed.
These diagnosis delays could lead to irreversible joint damage, which is why it’s
key to identify the problem early — and start treating it.
Here is a list of the most common health issues that can have symptoms that are
similar to psoriatic arthritis. If you suspect you have any of them, share your
concerns with your doctor or dermatologist and ask if further testing is right for
you.
Osteoarthritis
In the GHLF study, 22 percent of people with PsA said they were misdiagnosed
with osteoarthritis. While some signs of osteoarthritis can be similar to those of
PsA — swollen joints, pain, and stiffness — people tend to develop osteoarthritis
at older ages than they do PsA. However, previous injury to a joint may increase
your risk of developing OA earlier.
Osteoarthritis is caused by mechanical wear and tear on cartilage and bones. The
condition often appears gradually. Psoriatic arthritis, on the other hand, is an
autoimmune disorder that is caused by an out-of-control immune system attacking
the tissues around the joints.
The way specific joint symptoms manifest is usually different between OA and
PsA. Take stiffness, for example: “Patients with PsA have a lot of stiffness. It
usually happens in the mornings, and the stiffness will get better as the day
progresses and as they start to use their body, like their hands or their back,” says
Dr. Haberman.
Patients with osteoarthritis may also feel stiff, but that stiffness tends to go away
within 30 minutes, says Dr. Haberman. In contract to PsA, osteoarthritis pain tends
to get worse when you use your joints. For instance, if you have osteoarthritis in
your knees, they’ll hurt as you go up and down the stairs.
Another difference is whether or when you get swelling in your joints. Tender,
achy joints are common for patients with osteoarthritis — but generally they tend
to swell only when you overuse them. In PsA, you may wake up with swollen
joints without having exerted yourself at all. “What I tell people is, ‘Listen, if you
have knee pain after walking 10 miles, you just overdid it. However, if you wake
up with your joints red, warm, and swollen, then we have a problem,’” Dr.
Domingues says.
Blood tests and X-rays can help distinguish inflammatory arthritic arthritis like
PsA from OA, as can joint fluid analysis. Osteoarthritis is typically treated with
non-steroidal anti-inflammatory medications (NSAIDs) along with lifestyle
changes, while PsA usually requires disease-modifying medication to address the
root underlying inflammation.
Rheumatoid arthritis
Rheumatoid arthritis and psoriatic arthritis are both autoimmune disorders that
cause inflammation in the joints and throughout the body. Rheumatoid arthritis,
like PsA, causes the synovial tissues that line the joints to thicken, causing pain,
tenderness, and swelling.
But while the symptoms can be similar, there can be distinct differences.
“Rheumatoid arthritis is often symmetric, which means if you have it on one joint
on one side, you often have it on the other side. Psoriatic arthritis is usually
asymmetric,” Dr. Haberman explains.
“Psoriatic arthritis often involves the most distal joints,” she continues. “For
example, on your hands, PsA affects the joints that are closest to the fingernails,
whereas rheumatoid arthritis affects in the hands often affects the more proximal
joints — the middle joints in your hands and the knuckle joints.”
When these joints get damaged, it can show up in X-rays or on MRIs, which can
provide more clues so a rheumatologist can distinguish between these two types of
inflammatory arthritis, says Dr. Domingues. “Rheumatoid arthritis typically
doesn’t affect the distal interphalangeal joint, but that’s very common in psoriatic
arthritis.”
Blood tests can often distinguish between RA and PsA as well. While both types of
arthritis can cause inflammatory markers in your blood, patients with PsA typically
don’t have the two antibodies that up to 80 percent of patients with RA have:
rheumatoid factor (RF) and cyclic citrullinated peptide (CCP), according to a
review study in RD Open.
If you are misdiagnosed with RA when what you really have is PsA, it’s good to
know that some of the same drugs are used to treat both conditions, such as
methotrexate and a few of the biologics, such as those in the TNF inhibitor class.
The problem is that some RA-specific drugs may not be as effective against
psoriasis plaques, and there are other types of biologic medications, such as IL-17
inhibitors and IL-23 inhibitors, that growing evidence shows are better suited to
targeting psoriasis-related skin issues in addition to joint pain.
Gout
The prevalence of gout has been documented for thousands of years — even the
ancient Egyptians made reference to it. This painful form of arthritis occurs when
you have too much uric acid in your body, which then crystallizes in and around
the joints. The result: You wake up one morning with a red, swollen, painful finger
big toe, though gout can affect other joints as well.
Like gout patients, people with psoriatic arthritis can also develop symptoms fairly
quickly. And PsA patients can also have just one swollen finger or toe (called
dactylitis).
“We often call them ‘sausage digits,’” says Dr. Haberman. “If that’s the only sign,
a provider might say, ‘Oh, you just have one swollen joint. It’s your big toe. It’s
probably gout.’”
Another source of confusion is that gout and PsA can co-exist. Patients who have
psoriatic arthritis and psoriasis also tend to have higher rates of gout, too,
according to Harvard research published in the journal Annals of Rheumatic
Diseases.
A typical gout flare usually involves one or two joints and will go away on its own
in about two weeks even if you don’t treat it, notes Dr. Haberman. That’s not the
case in psoriatic arthritis patients — dactylitis can take months to resolve.
Another key difference between PsA and gout: “When you have gout, the joint is
much hotter, much more swollen, and a lot more tender,” Dr. Haberman explains.
“So even putting a sheet over it makes it hurt intensely, which is not really the
classic characteristics of dactylitis.”
To diagnose gout, doctors can analyze the fluid they’ve extracted with a needle
from an affected toe or finger to see if it contains crystals of uric acid. They can
also measure the amount of uric acid in your blood, although people with PsA and
psoriasis can also have high uric acid levels.
Treating gout usually requires taking a uric acid-lowering medication to prevent
future flares and joint damage, along with lifestyle changes such as weight loss or
perhaps following a low-purine diet.
Axial spondyloarthritis
Back pain is one of the key features of axial spondyloarthritis (axSpA) — a type of
chronic inflammatory arthritis — since inflammation affects the vertebrate in your
spine and the area where your spine meets the pelvis, called the sacroiliac joints.
But back pain can also occur in psoriatic arthritis.
So what’s the difference between axSpA and PsA? They are both considered types
of spondyloarthritis, which is a “family” of types of arthritis that have certain
symptoms and genetic markers in common.
The genetic marker HLA-B27 is very common in people with axSpA; in some
populations, as many as 90 percent of patients with axSpA have it (though HLA-
B27 is less common among African Americans and other groups). About 20
percent of people with PsA are positive for HLA-B27.
Both PsA and axSpA can affect the spine as well as peripheral joints, like the
knees and hips. PsA and axSpA patients can have enthesitis and dactylitis.
In “typical” cases, patients with axSpA present with lower back pain as their
dominant symptom and patients with PsA present with peripheral joint pain as
their dominant symptom, but for some people, the distinctions are not that black
and white.
For example, according to a study in the journal Nature Reviews Rheumatology,
isolated spondylitis, or back inflammation, occurs in 5 percent of PsA patients,
while psoriasis also occurs in about 10 percent of patients with axSpA. And many
people with axSpA go on to have peripheral joint pain.
If this all sounds confusing, that’s because it is. In fact, experts are still debating
whether psoriatic arthritis with axial (spine) symptoms and axSpA are “are
separate entities with overlapping characteristics, or whether they represent
different clinical presentations of the same disease,” according to this article
in Rheumatology Advisor.
While research does seem to indicate that there are distinct differences in axSpA
patients who have psoriasis and PsA patients who have lower back pain, it’s easy
to see how diagnosing one from the other could be tricky depending on which sets
of symptoms patients are complaining about.
There is overlap between treatment for both conditions, such as anti-TNF biologics
and IL-17 inhibitor biologics. But treatment can differ in many cases. For example,
conventional disease-modifying drugs like methotrexate can treat peripheral joint
inflammation — and are commonly used in psoriatic arthritis — but they cannot
treat axial symptoms.
That’s why “it is important for rheumatologists to make the right diagnosis and
follow and treat patients accordingly,” University of Toronto rheumatologist Dafna
Gladman, MD, told Rheumatology Advisor.
To make the right diagnosis, doctors look for the most salient clinical features of
PsA, including skin psoriasis, as well as use X-rays and even MRIs to look for
evidence of the types of damage and inflammation, says Dr. Haberman.
Reactive arthritis
Reactive arthritis is also a type of spondyloarthritis. It is triggered by a bacterial
infection from such bacteria as Campylobacter, Chlamydia, Salmonella, Shigella,
or Yersinia, which are typically either sexually transmitted or digested from
food. These germs are very common, and most people who are exposed to them
will not develop reactive arthritis. But for a small group, who likely are genetically
predisposed, becoming infected with these bacteria causes the immune system to
react in a way that also causes joint pain and other symptoms.
Reactive arthritis can look similar to psoriatic arthritis in that both conditions can
cause asymmetric joint pain, especially in the lower limbs, back pain, enthesitis,
and dactylitis. But the defining factor for reactive arthritis is symptoms or a history
of infection. Reactive arthritis also tends to cause eye inflammation (eyes will look
red, watery, and irritated) and inflammation in the urinary tract (which can make
going to the bathroom painful).
Doctors won’t necessarily rule out reactive arthritis if there’s no sign of triggering
bacteria (the infection could clear while other symptoms persist), but involvement
of the eye or urethra tend to point to reactive arthritis.
Arthritis related to inflammatory bowel disease
Arthritis can also be a co-occurring disease in inflammatory bowel diseases like
Crohn’s disease and ulcerative colitis. This kind of arthritis, also a type of
spondyloarthritis, is called enteropathic arthritis. The pattern of symptoms can be
very similar to that of PsA, including asymmetric joint pain and lower back pain.
Psoriasis can also co-occur in people with inflammatory bowel disease, which
makes separating PsA from IBD-related arthritis even more confusing.
But usually people with IBD-related arthritis do not have the nail changes
characteristic of PsA. The “distal” joints of the fingers — the ones closest to the
fingernails — also tend to not be affected in IBD-related arthritis.
Plantar fasciitis
Plantar fasciitis — inflammation of a band of tissue that runs across the bottom of
your foot, causing heel pain — is technically considered a symptom of psoriatic
arthritis.
In most cases of plantar fasciitis, the inflammation occurs because of repetitive
stretching or stress on the area, such as physical activities that put a lot of stress on
your heel, being obese, or having a job that keeps you on your feet for most of the
day. But in PsA, plantar fasciitis is also happening because of dysfunction with
inflammation related to your immune system. This causes enthesitis, or
inflammation where ligaments (in this case, the plantar fascia) attach to bone.
In one study of PsA patients from Dr. Gladman at the University of Toronto, 35
percent had enthesitis, and the plantar fascia was among the three most common
sites.
The problem is that many people who experience heel pain seek treatment at a
podiatrist or other health care provider who don’t think to suspect PsA (or another
kind of spondyloarthritis, such as axSpA) as a potential root cause. That’s what
happened to this PsA patient, whose PsA went undiagnosed because it was
mistaken for plantar fasciitis.
If you’re being treated for plantar fasciitis and the condition isn’t getting better or
keeps re-occurring, consider the other symptoms and domains of psoriatic
arthritis (such as history of psoriasis, joint pain, fatigue) and ask your doctor
whether further testing, including blood tests and X-rays, is warranted.
Getting to the Bottom of a Psoriatic Arthritis Diagnosis (Or Something Else)
Getting a proper PsA diagnosis depends on so many things, including seeing a
savvy provider who spends the time to take a comprehensive medical history. 
“The history is really definitive,” explains Dr. Domingues.
That means a doctor will probably ask you if you have or ever had psoriasis. This
is the time to mention any itchy, flaky spots, even if you’ve always thought you
just had dry skin. The provider should also ask about any first-degree family
members — a sibling or parent — who might have had psoriasis, because you can
be diagnosed with PsA with a family history of the condition, Dr. Haberman
explains.
The doctor will also examine your nails and toenails because they can be affected
by psoriasis, even though it’s not obvious. Some signs include nails that are pitted
or have ridges, are discolored or look they’re crumbling and separating from the
nail bed.
Then the doctor will ask you about your joint pain (how much stiffness, where you
have pain) as well as do a thorough physical examination. Blood tests can reveal
inflammatory markers (and distinguish between the different types of arthritis) and
X-rays and other imaging tests can show joint damage and inflammation in the
joint. If you are having any aches and pains and you think or know you have
psoriasis, don’t write off your symptoms. Instead, ask your provider to refer you to
a rheumatologist, which is the best type of provider to determine if you have PsA
or another condition. “We’re more than happy to see patients, and we’d like to see
them early,” says Dr. Haberman. “Even if we say, ‘This isn’t psoriatic arthritis
yet,’ it also gives us a chance to educate patients on what they should look out for
in the future, because psoriatic arthritis can develop years after a psoriasis
diagnosis.” Check out PainSpot, our pain locator tool. Answer a few simple
questions about what hurts and discover possible conditions that could be causing
it. Start your PainSpot quiz.
Keep Reading
ACR 2019: 9 New Things to Know About Psoriatic Arthritis
Psoriatic Arthritis Risk Factors and Causes You Need to Know About
What Psoriatic Arthritis Does to Your Feet, and 6 Ways to Keep Them Healthy