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Severe PsA: Arthritis Mutilans

Medically Reviewed by Michael W. Smith, MD on July 12, 2021

Arthritis mutilans is the most severe and painful form of psoriatic arthritis (PsA). It's thought to affect about 5% of people with PsA. Some reports suggest that as many as 16% of people with PsA may have it.

Arthritis mutilans can affect your hands, wrists, knees, and feet. It attacks and destroys the joints that connect your tendons and ligaments to the bones in your fingers and toes. The fingers become shorter due to bones breaking down. The medical term for this is osteolysis. Overtime, it leads to permanent deformity and disability of the affected area.

Causes and Risk Factors for Arthritis Mutilans

Arthritis mutilans is rare. To understand what leads to it, you'll have to understand PsA.

PsA is a chronic, autoimmune condition that happens when your immune system attacks healthy tissue and cells. It triggers your joints to become inflamed.

Experts aren't sure what triggers the immune response, but they think genes or things in the environment like viruses or bacteria may play a role.

People with psoriasis, a skin condition that causes red, itchy, and inflamed skin, are at higher risk of developing PsA. About 40% of people with PsA have a family member with psoriasis or arthritis.

Arthritis mutilans tends to happen in people who've had PsA for a long time. Bone loss at the joints makes the bones shorter. The skin over the area then creates what looks like "telescopic fingers" or "pencil-in-cup," where you can pull the fingers in and out like a telescope. The joint deformities are also called "opera glass hands." This is more common in men than in women and happens more often in people who develop arthritis mutilans at a younger age.

Symptoms to Watch For

PsA symptoms include:

  • Stiffness in your hands or feet
  • Painful joints with redness, heat, and swelling in the surrounding tissue
  • "Sausage-like" appearance of your fingers or toes

Symptoms of the more severe arthritis mutilans include:

  • Severe pain and inflammation in the joints of your hands and feet
  • Bone loss around the joints in your hands, wrists, or feet
  • Shortening or telescoping of the fingers and toes
  • Deformities in your hands and feet
  • Trouble with your range of motion in the affected area
  • Fusing of the bone (ankylosis)
  • Partial dislocation (subluxation)
  • Nail changes such as pitting, lesions, or dents
  • Back pain
  • Neck pain
  • Fatigue
  • Rash
  • Foot pain

People most often develop arthritis mutilans between the ages of 30 to 50. Often it happens in people who have had psoriasis for over 10 years.

If you notice symptoms of arthritis mutilans, see a doctor as soon as possible as the deformities can be permanent. People who get treatment early tend to have better results.

How Is Arthritis Mutilans Diagnosed?

There's no specific test to diagnose PsA. Your doctor will make a diagnosis based on observations, your symptoms, and a process of elimination. The symptoms of PsA can be similar to other joint conditions like rheumatoid arthritis, gout, and reactive arthritis.

If your doctor has diagnosed you with PsA, they will monitor you to determine if it becomes arthritis mutilans. If you notice your symptoms have changed, you should talk to your doctor.

They might do a blood test and perform imaging tests like MRI and X-ray to check for bone and joint deformities.

Treatment Options

Arthritis mutilans can cause permanent damage to your joints and limit your range of motion. It's important to spot it as early as possible so you can begin treatment.

The goals of treatment for arthritis mutilans include:

  • Slowing down bone loss
  • Keeping your joints from deteriorating
  • Easing inflammation in the joints
  • Reducing the risk of developing other conditions like heart disease, depression, and obesity
  • Improving your quality of life
  • Preserving your range of motion

Together, you and your rheumatologist will come up with a treatment plan that's right for you.

This can include:

Nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs help with inflammation and pain. You'll probably need to take NSAIDs for several weeks before you'll see their full effects.

Glucocorticosteroid injections. These are steroids you'll get through injections. They can help with inflammation in your joints and pain. Steroid injections usually have fewer side effects than steroids you take by mouth.

Biologics. Your doctor may prescribe these medications if you're having a hard time with your daily routine. Biologics reduce inflammation and suppress your immune system. They usually begin to work within 2 weeks, but it can take up to 3 months for you to notice an improvement. Biologics include medications such as abatacept, secukinumab, and ustekinumab.

Disease-modifying antirheumatic drugs (DMARDs). These drugs, also known as "nonbiologics," include cyclosporine, leflunomide, methotrexate, sulfasalazine, and others. Your doctor may recommend methotrexate if you have several swollen joints. You can get this medication in pills or injections. If you have side effects while you're on methotrexate, your doctor may have you try a different nonbiologic drug instead.

Let your doctor know if you're having side effects or if your treatments aren't working. You may need to switch to another medication. They will also suggest lifestyle changes, including weight loss if you need it. Weight loss can help your treatments work better.

Surgery. If your PsA is severe enough, your doctor may recommend surgery to replace damaged bones with parts made from plastic or metal. The surgery can give you back function in your limbs and reduce pain, but it can't stop inflammation. If you have surgery, you'll need to see your doctor regularly to monitor the new joints. You may still need prescription medications for pain and inflammation.

Show Sources

SOURCES:

National Psoriasis Foundation: "Why Treat Psoriatic Arthritis?" "About Psoriatic Arthritis."

Journal of Rheumatology: "Psoriatic Arthritis Mutilans: Clinical and Radiographic Criteria. A Systematic Review," "Acute Presentation of Arthritis Mutilans."

MedlinePlus: "Psoriatic Arthritis."

Medscape: "Psoriatic Arthritis."

UpToDate: "Patient education: Psoriatic arthritis (Beyond the Basics)."

NYU Langone Health: "Surgery for Psoriatic Arthritis."

Mayo Clinic: "Psoriatic Arthritis."

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