Staying positive in the face of adversity
He had an active, outdoor life. Football was his passion and he was a lighting fast mid-fielder. Now he is limited by pain and exhaustion, and waking up can be the hardest part of the day. Psoriatic arthritis -a condition that causes inflammation of the joints, making them stiff and swollen- hit Dhanushka* at a very early age. Now in his 20’s, he is limited in certain movements.
Dhanushka has had to put his higher studies on hold for treatment, but he realises the need to stay positive amidst it all. “I want the disease to be gone, but I have to wake up each day confronting the fact that it’s still with me. I can’t let the depression take over,” he tells us.
Dr. Harindu Wijesinghe
“Psoriatic arthritis is not uncommon in Sri Lanka,” says Consultant Rheumatologist, Dr. Harindu Wijesinghe. About one in 50 people in Sri Lanka has Psoriasis -the skin disease associated with thickened, reddened skin which causes irritation and noticeable flaky, silver-white ‘scales’. In turn, about one or two out of 10 people with psoriasis will develop psoriatic arthritis.
“The exact cause of it is still very much a mystery to the medical world, but it has much to do with genetics, the immune system and environmental factors,” says Dr. Wijesinghe. “Certain people may have a genetic make-up susceptible to the disease, given the trigger is pulled in the form of a certain pathogen.”
The disease comes about when the soft tissue of the joints of the body is attacked by the body’s own autoimmune system. “The autoimmune system usually helps prevent infections, but there can be abnormalities in the system where it can start ‘turning its weapons on its own people’ by attacking the body’s joints,” Dr. Wijesinghe says. The most affected joints are the knees, ankles, joints in the buttock area, neck and lower back, while the hands and nails can get discoloured.
Common symptoms are:
- pain, swelling and stiffness in one or more joints (referred to as ‘angry joints’)
- pain and stiffness in the buttocks, lower back or neck (also known as spondylitis)
- pain in tendons, such as at the back of the heel or sole of the foot (tendons are the strong cords attaching muscle to bone)
- changes in nails, such as thickening, colour change or separation from the skin.
- pain and redness in the eyes (also known as iritis)
nearly morning stiffness, making it difficult to move joints for up to an hour after you wake up.
Dr. Wijesinghe says that a patient with psoriasis should see a rheumatologist without delay if they start getting unusual aches and pains. “”It is imperative that patients with psoriasis refer a rheumatologist immediately once such symptoms occur, because there is a danger in not diagnosing it earlier. These pains need not be confused with wear and tear as that kind of pain occurs only while you work. Pain and stiffness due to psoriatic arthritis is different in the sense that it occurs at a certain time of the day, every day.”
The doctors may be able to work on the damaged joints, but it can never come back to the original state if left unattended for too long, he adds. Psoriatic arthritis is diagnosed based on one’s symptoms and what the rheumatologist finds out upon examination. There is no specific test for psoriatic arthritis, however blood tests for inflammation, such as the erythrocyte sedimentation rate (ESR) test help in the diagnosis.
Dr. Wijesinghe believes that it is a disease that can be largely controlled with the right treatment. “With the right treatment, most people can lead full and active lives.” However there are people who find that their symptoms worsen at times (known as ‘flare’) and then settle down for a period of time. A few others may develop a more severe, destructive form which can cause deformity to the joints in the hands and feet. “This deformity is hard to reverse and that is why early diagnosis is important,” he stresses.
Currently there is no cure for psoriatic arthritis. But treatment (a team effort between the dermatologist, rheumatologist and sometimes a physiotherapist) has improved dramatically, with new medicines.
There are generally three types of drugs that can be used to treat the disease:
- Non-steroidal anti-inflammatory drugs (NSAIDs) block the inflammation that occurs in the lining of your joints. Effective in reducing the pain bringing relief within a few hours, they however need to be taken at regular intervals. Some may not find it of help, in which case a different NSAID is tried.
- Disease Modifying Anti-Rheumatic Drugs (DMARDs) help by attacking the causes of the inflammation in the lining of the joints. They can act quite differently from anti-inflammatory drugs, in that it may be several weeks before they have an effect. Therefore it is important to continue with the tablets. Prednisolone is one such drug, but it cannot be taken in high doses as it can aggravate the skin rash. Drugs such as Methotrexate and Leflunomide, are other options says Dr. Wijesinghe. DMARDs can be injected directly into the joints and this is an extremely safe procedure that is even done on pregnant mothers, he says, debunking the myths around such injections.
- Biological agents, are used if the either of the above do not help. They are extremely effective, but extremely expensive with one injection costing up to Rs. 200,000. Infliximad is the drug used in Sri Lanka, while there are other varieties overseas. These are more effective since they target a specific place of action, much like a ‘smart bomb’. Side-effects can include increased immuno-susceptibility.
“Psoriasis in general, as well as psoriatic arthritis is hard to treat. It can become chronic and people may lose faith,” says Dr. Wijesinghe. “In such situations people turn towards other forms of treatment, but western medicine can fully control the disease.”
“The skin rash has a huge stigma associated with it and people are afraid to interact with such patients out of fear of catching it. But psoriasis and psoriatic arthritis are not contagious diseases,” he points out. “Breaking that barrier will not only allow the patient to feel like everyone else, but it will also improve the treatment.”
As there is currently no cure for psoriatic arthritis, patients tend to feel scared, frustrated, sad and sometimes angry. “Being aware of these emotions and over-ruling it with a positive attitude is imperative,” says Dr. Wijesinghe.
“You may have to live with the disease for a prolonged period of time, but treatment options have come a long way towards helping in controlling the effects of psoriatic arthritis.”
Combining your medical treatment with simple, but significant lifestyle changes can help with the emotional and physical challenges of living with psoriatic arthritis and improve your outlook from day to day.
Dhanushka may not be back on the football field any time soon, but he hopes that his university studies will resume and life will return to normal. With the right treatment, he will someday be handling the ball again; being positive is the biggest leap in that direction.
*name has been changed
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