From the Guidelines
Managing a nasal ulcer in a patient with psoriatic arthritis requires a comprehensive approach that prioritizes the optimization of systemic treatment for psoriatic arthritis, alongside local care of the ulcer. To address the nasal ulcer, it's crucial to first determine if the ulcer is related to the psoriatic disease or has another cause through clinical examination and possibly biopsy. For symptomatic relief, start with saline nasal irrigation 2-3 times daily to cleanse the area. Apply topical treatments such as triamcinolone 0.1% ointment or tacrolimus 0.1% ointment to the ulcer twice daily for 2-4 weeks. For painful ulcers, consider adding lidocaine 2% gel before meals and bedtime. If infection is suspected, obtain cultures and treat with appropriate antibiotics.
Systemic Treatment Optimization
For ulcers related to psoriatic disease activity, optimizing the systemic treatment of psoriatic arthritis is crucial, which may include methotrexate (15-25 mg weekly) as preferred in those with relevant skin involvement, as suggested by 1. Alternatively, TNF inhibitors like adalimumab (40 mg every other week), or IL-17 inhibitors like secukinumab (300 mg monthly) can be considered based on the patient's response and the presence of skin involvement. The choice of systemic therapy should be guided by the EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies, which emphasize reaching the target of remission or low disease activity 1.
Local Care and Prevention
Avoid nasal trauma by discontinuing nose picking and nasal steroid sprays until healing occurs. Humidification of living spaces and petroleum jelly application to the nasal vestibule can prevent dryness. Monitor for healing within 2-4 weeks and consider otolaryngology referral if the ulcer persists or worsens.
Key Considerations
- Regular disease activity assessment is essential to adjust therapy appropriately, aiming for remission or low disease activity 1.
- The balance between efficacy and safety must be considered, taking into account the individual patient's characteristics, contraindications, and risks associated with each therapy 1. By addressing both the local manifestation of the nasal ulcer and the systemic aspects of psoriatic arthritis, it's possible to improve outcomes in terms of morbidity, mortality, and quality of life for patients with this condition.
From the Research
Management of Nasal Ulcer in Psoriatic Arthritis
- There is limited information available on the management of nasal ulcers in patients with psoriatic arthritis.
- The available studies focus on the treatment of psoriatic arthritis and psoriasis, but do not specifically address nasal ulcers 2, 3, 4, 5, 6.
- However, it can be inferred that the management of nasal ulcers in patients with psoriatic arthritis may involve a multidisciplinary approach, including the use of topical agents, systemic therapies, and biological therapies to control the underlying disease process 3, 4.
- The treatment of psoriatic arthritis typically involves the use of non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and biological therapies, such as tumor necrosis factor (TNF) inhibitors 3, 4, 5, 6.
- The choice of treatment for nasal ulcers in patients with psoriatic arthritis would likely depend on the severity of the ulcer and the overall disease activity, as well as the patient's medical history and other factors 2, 3, 4, 5, 6.
Treatment Options
- Topical agents, such as corticosteroids and antibiotics, may be used to treat nasal ulcers in patients with psoriatic arthritis 3.
- Systemic therapies, such as methotrexate and cyclosporine, may be used to control the underlying disease process and reduce inflammation 3, 4, 5.
- Biological therapies, such as TNF inhibitors, may be used to treat patients with moderate to severe psoriatic arthritis and nasal ulcers 3, 4, 6.
- NSAIDs, such as indomethacin and diclofenac, may be used to relieve pain and reduce inflammation in patients with nasal ulcers and psoriatic arthritis 6.