Rheumatic Disorders Part III

Rheumatic Disorders Part III:
Spondyloarthropathies
(AS, Reiter’s, PsA)

Maria Carmela L. Domocmat, RN, MSN
Instructor, School of Nursing
Northern Luzon Adventist College

group of interrelated disorders including
Ankylosing sponydilitis (AS)
Reactive arthritis (Reiter’s syndrome)
Psoriatic arthritis (PsA)


distinguished from RA by the ff characteristics:
(-) RF
(-) rheumatoid nodules
asymmetrical inflammatory peripheral arthritis


other characteristics
inflammation occurs where ligament inserts into bone
(enthesis) – rather at synovium
there is overlap between various
tendency toward familial aggregation


Ankylosing Spondylitis
a form of arthritis that primarily affects the spine,
although other joints can become involved.
It causes inflammation of the spinal joints
(vertebrae) that can lead to severe, chronic pain
and discomfort.


In the most advanced cases, this inflammation can
lead to new bone formation on the spine, causing
the spine to fuse in a fixed, immobile position,
sometimes creating a forward-stooped posture
(Kyphosis)


Causes and risk factors
20 and 40, but may begin before age 10.
Risk factors include:
Family history of ankylosing spondylitis
Male gender


hallmark feature
the involvement of the sacroiliac (SI) joints (between
pelvis and the spine) during the progression of the
disease.


S/S
The disease starts with low back pain that
comes and goes.
Pain and stiffness are worse at night, in the
morning, or when not active. may wake patient
from sleep.
pain typically gets better with activity or exercise.


S/S
Fatigue
less common symptoms include:
Eye inflammation or uveitis
Heel pain
Hip pain and stiffness
Joint pain and joint swelling in the shoulders, knees,
and ankles
Loss of appetite
Slight fever
Weight loss


Ankylosing Spondylitis


Complications
Rarely, people may have problems with the
aortic heart valve (aortic insufficiency) and heart
rhythm problems.
Some patients may have pulmonary fibrosis or
restrictive lung disease


Maintain mobility
exercise, engage in ADL
good posture
swimming
sleep posture: emphasize spinal extension (flat
on bed: no pillow, bed boards)
furniture and work station ergonomics


Decrease inflammation, control
pain
NSAIDs
heat therapy – relieve morning pain
sulfasalazine, MTX, TNF alpha-blockers
Corticosteroid therapy
cytotoxic drugs
etabercept, infliximab
If do not respond well to corticosteroids or who are
dependent on high doses of corticosteroids.
Surgery


Education
clothing that fits
promote effective breathing
deep breathing exercise
avoid smoking and respi depressants
(+) dyspnea – pursed-lip breathing; pace activities


Nursing management
Provide education
Exercises can help improve posture and
breathing.
Lying flat on the back at night can help maintain
normal posture.


Promote effective breathing
ongoing assessment of chest-wall expansion
deep-breathing exercises
avoid smoking and respi depressants
for dyspnea – pursed-lip breathing and pacing of
activities


Reactive arthritis
a group of inflammatory conditions that involves
the joints, urethra, and eyes.
A form of peripheral arthritis
Appear shortly after certain infections of GUT or
GIT
sometimes the first manifestation of human
immunodeficiency virus infection.


Causes, incidence, and risk
factors
men before the age of 40.
may follow an infection withChlamydia,
Campylobacter, Salmonella, or Yersinia.
Genes – HLA-B27
most frequently follows genitourinary infection
with Chlamydia trachomatis, but other organisms
have also been implicated.


Triad of symptoms
Nongonococcal urethritis
Conjunctivitis
Arthritis


Symptoms
Urinary symptoms usually appear within days or
weeks of an infection.
Low-grade fever, Conjunctivitis, and arthritis
develop over the next several weeks.
arthritis may be mild or severe, and may affect
only one side of the body or more than one joint.
Cervicitis


Muscle and joint symptoms include:
Achilles tendon pain
Heel pain
Joint pain in the large joints (hip pain, knee pain,
and ankle pain are common)
Low back pain


Eye and skin symptoms include:
Eye discharge
Eye pain - burning
Eye redness
Skin lesions on the palms and soles that may
resemble psoriasis
Small, painless ulcers in the mouth, tongue, and
glans penis
Urinary and genital symptoms may include:


Urinary and genital symptoms may include:
Genital lesions (male)
Incontinence
Penis pain
Skin redness or inflammation
Urethral discharge
Urinary hesitancy
Urinary urgency
Urination - burning or stinging


Dx tests
diagnosis is based on symptoms.
Since the symptoms may occur at different
times, the diagnosis may be delayed.
A physical examination may reveal conjunctivitis
or typical skin lesions.
HLA-B27 antigen
Increased ESR
Joint x-rays
Urinalysis


Treatment
Usually self-limiting: 3-12 mos

Goal - to relieve symptoms and treat any
underlying infection

Pharmacologic mgmt: same with AS
NSAIDS and pain relievers
DMARDs


Treatment
Ocular manifestations:
steroid eye drops or subconjunctival preparations
antibiotics if have an infection.


Treatment
Joint pain:
Intraarticular corticosteroid
PT
Splinting
Managed exercise and activity program
make adjustments if job requires heavy lifting or
strenuous use of the back.


Prevention
Preventing sexually transmitted diseases and
gastrointestinal infection may help prevent this
disease.
Wearing a condom during intercourse can
reduce the risks of sexually transmitted disease.
Wash hands and surface areas thoroughly
before and after preparing food.


Psoriasis
is a common, chronic skin condition that causes
red patches on the body.


Skin cells grow deep in the skin and normally
rise to the surface about once a month. In
persons with psoriasis, this process is too fast
(about 2 weeks instead of 4 weeks) and dead
skin cells build up on the skin's surface.


Psoriasis on the knuckles
This is a picture of a typical case of psoriasis,
with small lesions on the knuckles. Note the
changes in the fingernails.


The following may trigger an attack of psoriasis or make
the condition more difficult to treat:
Bacteria or viral infections, including strep throat and upper
respiratory infections
Dry air or dry skin
Injury to the skin, including cuts, burns, and insect bites
Some medicines, including antimalaria drugs, beta-blockers,
and lithium
Stress
Too little sunlight
Too much sunlight (sunburn)
Too much alcohol


In general, psoriasis may be severe in people
who have a weakened immune system. This
may include persons who have:
AIDS
Autoimmune disorders (such as rheumatoid
arthritis)
Cancer chemotherapy
Up to one-third of people with psoriasis may also
have arthritis, a condition known as psoriatic
arthritis.


Symptoms
Psoriasis can appear suddenly or slowly. In
many cases, psoriasis goes away and then
flares up again repeatedly over time.
People with psoriasis have irritated patches of
skin. The redness is most often seen on the
elbows, knees, and trunk, but it can appear
anywhere on the body. For example, there may
be flaky patches on the scalp.


The skin patches or dots may be:
Itchy
Dry and covered with silver, flaky skin (scales)
Pink-red in color (like the color of salmon)
Raised and thick


Other symptoms may include:
Genital lesions in males
Joint pain or aching (psoriatic arthritis)
Nail changes, including nail thickening, yellow-
brown spots, dents (pits) on the nail surface, and
separation of the nail from the base
Severe dandruff on the scalp


five main types of psoriasis
Psoriasis may affect any or all parts of the skin.
Erythrodermic -- The skin redness is very intense and
covers a large area.
Guttate -- Small, pink-red spots appear on the skin.
Inverse -- Skin redness and irritation occurs in the
armpits, groin, and in between overlapping skin.
Plaque -- Thick, red patches of skin are covered by
flaky, silver-white scales. This is the most common
type of psoriasis.
Pustular -- White blisters are surrounded by red,
irritated skin.


Scalp psoriasis Nail Psoriasis


Plaque Psoriasis Pictures
(Vulgaris/Circular)


Guttate Psoriasis


Pustular Psoriasis


Inverse Psoriasis


Erythrodermic Psoriasis
particularly inflammatory form of psoriasis that
often affects most of the body surface.
least common type of psoriasis
may occur once or more during a lifetime in 1 to 2
percent of people who develop psoriasis


Psoriatic Arthritis


Treatment
The goal of treatment is to control symptoms
and prevent infections.
In general, three treatment options are used for
patients with psoriasis:
Topical medications such as lotions, ointments,
creams, and shampoos
Body-wide (systemic) medications, which are pills or
injections that affect the whole body, not just the skin
Phototherapy, which uses light to treat psoriasis


Treatment
Topical medications
such as lotions, ointments, creams, and shampoos
Topical steroids
Tar preparations
UV Light therapy


Topical meds
Cortisone creams and ointments
Suppress cell division when applied to psoriatic
lesions
More effective when penetrate the skin
How to enhance absorption: apply to skin, wrap with
warm, moist dressings and occlusive outer wrap of
plastic (film, gloves, booties, or similar garments)
Note: when large surface areas are involved – limit
occlusive therapy to 12 hrs/day
Bcoz increased risk of localand systemic S/E


Topical meds
Tar preparations
Creams ,ointments, solutions, lotions, gels, shampoos
that contain coal tar or anthralin
Coal tar – inpatient
messy, cause staining, and have unpleasant odor


Topical meds
Tar preparations
Anthralin (Anthraforte, Drithocreme, Lasan)
A hydrocarbon similar in action to tar
Relieves chronic psoriasis
Can be used alone or in combination with coal tar baths and
UV light
Apply to each lesion for short periods (not exceeeding 2 hrs)


Topical meds
Tar preparations
Anthralin (Anthraforte, Drithocreme, Lasan)
Not used to treat acute, spreading psoriasis – bcoz tend to
induce Koebner’s phenomenon
Koebner’s phenomenon – are psoriasis plaques that form at the
site of a skin injury.
Occurs when trauma to the skin causes a skin lesion. The
amount of trauma required can be very small -- sometimes just
rubbing the skin can cause a lesion to develop.
http://www.psoriasis.org/page.aspx?pid=1660


Topical meds
Prescription medicines containing vitamin D or
vitamin A (retinoids)
Cream, ointment, lotion
For mild to moderate
Calcipotriene (Dovonex)
Tazarotene (Tazorac)


Topical meds
Calcipotriene (Dovonex)
A synthetic form of vitamin D – regulates skin cell
division
Tazarotene (Tazorac)
Vit A derivative
Teratogenic - even when applied topically


Topical meds
Creams to remove the scaling (usually salicylic
acid or lactic acid)
Dandruff shampoos (over-the-counter or
prescription)
Moisturizers


UV light therapy
Or Phototherapy
uses light to treat psoriasis
Note: must wear eye protection during treatment
Types: UVA, UVB
Psoralen and UVA (PUVA)
Common in OPD
Client ingest psoralen – a photosensitizing agent- 2
hrs b4 exposure
2-3 times a week; not on consecutive days


UV light therapy


Observe for generalized redness with edema
and tenderness
Wear dark glasses during treatment and for the
remainder of the day – bcoz of the strong
photosensitizing properties of psoralen
Long term S/E of UVB and PUVA
Premature aging of skin
Actinic keratosis
Increased risk skin Ca


Systemic medications for severe
psoriasis
Immunosuppressants
Retinoids (acitretin)
DMARDs - Cytotoxic agents
Methotrexate or cyclosporine (Folex, Mexate)
C/I – liver damage, bone marrow supression, impaired function
Azathioprine (Imuran)
Cyclosporine (Neoral, Sandimmune)


BRMs (Biologics)
Alefacept (Amevive) – IM weekly x 12 wks
Efalizumab (Raptiva) – subq once/week
Adalimumab (Humira)
Etanercept (Enbrel)
Infliximab (Remicade)
Stelara


Self-care at home
Oatmeal baths
may be soothing and may help to loosen scales.
can use over-the-counter oatmeal bath products.
Or can mix 1 cup of oatmeal into a tub of warm water.
Sunlight may help symptoms go away. Be
careful not to get sunburned.
Relaxation and antistress techniques may be
helpful.


Psoriasis
Maintain skin integrity
Enhance body image
Provide emotional support


Tar - not only look dirty but unpleasant odor;
bed linens, pajamas become stained – further
discouraging social interaction
Encourage contact with other client with similar
problems
Group discussion with family members or SO –
can increase socialization process


Touch - more than any gesture communicates
acceptance of the person and their skin problem
Shake hands during introduction
Place hand on client’s shoulder when explaining
procedure
Do not wear gloves during social interactions


Expectations (prognosis)
Psoriasis is a life-long condition that can be
controlled with treatment.
may go away for a long time and then return.
With appropriate treatment - usually does not
affect general physical health.


Complications
Arthritis
Pain
Severe itching
Secondary skin infections
Side effects from medicines used to treat
psoriasis
Skin cancer from light therapy
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001470/


Psoriatic arthritis is an arthritis that is often
associated with psoriasis of the skin
20-50 years old
Women


Psoriatic arthritis
The cause of is not known
In general, people who have psoriasis have a
higher rate of arthritis than the general
population.


Symptoms
arthritis - may be mild and involve only a few
joints, particularly those at the end of the fingers
or toes.
In some - may be severe and affect many joints,
including the spine.
When spine is affected,
symptoms are stiffness, burning, and pain, most often
in the lower spine and sacrum.


Symptoms
People who also have arthritis usually have the
skin and nail changes of psoriasis. Often, the
skin gets worse at the same time as the arthritis.

Nail pitting in a patient with
psoriatic arthritis.


http://images.emedicinehealth.com/images/4453/4453-13248-30912-31165.jpg


Manage joint pain and inflammation
Same with RA
Control skin lesions
Same with SLE
Slow progression of disease


Treatment
NSAIDS
More severe arthritis - DMARDs, TNF inhibitors

Rest and exercise
Physical therapy may help increase the
movement of specific joints
heat and cold therapy


Expectations (prognosis)
The course of the disease is often mild and
affects only a few joints.
A few people will have severe psoriatic arthritis
in their hands, feet, and spine that causes
deformities.
In those with severe arthritis, treatment can still
be successful in relieving the pain.


Complications
Repeated episodes may occur.


Rheumatic Disorders Part III

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