Is cold plunge therapy effective for treating psoriatic arthritis?

Cold Plunge Therapy for Psoriatic Arthritis

Cold plunge therapy is not recommended for treating psoriatic arthritis as it is not included in any evidence-based treatment guidelines and could potentially exacerbate symptoms in inflammatory joint conditions.

Evidence-Based Treatment Approaches for Psoriatic Arthritis

Pharmacological Treatments

The treatment of psoriatic arthritis follows a structured approach based on disease severity:

1. Mild Disease:

   • NSAIDs are the mainstay of initial therapy, with good clinical response in 75-85% of patients 1
   • Intra-articular glucocorticoid injections for persistently inflamed joints 2

2. Moderate to Severe Disease:

   • Disease-modifying antirheumatic drugs (DMARDs) including:
     • Sulfasalazine (Level A evidence)
     • Leflunomide (Level A evidence)
     • Methotrexate (Level B evidence)
     • Cyclosporine (Level B evidence) 2

3. Severe or Refractory Disease:

   • TNF inhibitors (etanercept, infliximab, adalimumab) for patients who fail to respond to at least one DMARD therapy (Level A evidence) 2
   • Newer biologics targeting IL-17, IL-12/23, and IL-23 pathways 3
   • Small molecule inhibitors including JAK and TYK2 inhibitors 3

Non-Pharmacological Approaches

The 2018 American College of Rheumatology/National Psoriasis Foundation guidelines recommend several non-pharmacological interventions with varying levels of evidence 2:

1. Exercise - Conditional recommendation (low-quality evidence)

   • Low-impact exercise (e.g., swimming, tai chi, yoga) is preferred over high-impact exercise

2. Physical and Occupational Therapy - Conditional recommendation (very low to low-quality evidence)

3. Weight Loss for overweight/obese patients - Conditional recommendation (low-quality evidence)

4. Massage Therapy - Conditional recommendation (very low-quality evidence)

5. Acupuncture - Conditional recommendation (very low-quality evidence)

6. Smoking Cessation - Strong recommendation (moderate-quality evidence)

Cold Plunge Therapy and Psoriatic Arthritis

Cold plunge therapy (immersion in cold water) is notably absent from all current treatment guidelines for psoriatic arthritis. While cold therapy in the form of localized application (ice packs) may temporarily reduce pain and inflammation in some inflammatory conditions, whole-body cold exposure through cold plunging presents several concerns:

1. Potential for Symptom Exacerbation: Cold exposure can trigger flares in some inflammatory conditions and may worsen joint stiffness

2. Lack of Evidence: No clinical trials or guideline recommendations support cold plunge therapy for psoriatic arthritis

3. Skin Considerations: Patients with psoriatic arthritis often have concurrent psoriasis, and cold exposure could potentially worsen skin symptoms

Treatment Algorithm for Psoriatic Arthritis

1. Assess Disease Severity and Domains:

   • Peripheral arthritis
   • Skin and nail involvement
   • Axial disease
   • Enthesitis
   • Dactylitis

2. Initial Treatment:

   • For mild disease: NSAIDs and targeted intra-articular injections
   • For skin involvement: Consider appropriate topical therapies

3. Escalation for Inadequate Response:

   • Add conventional DMARDs (methotrexate often first-line)
   • Consider combination therapy for partial response

4. Biologic Therapy for moderate-severe disease or inadequate response to conventional therapy:

   • TNF inhibitors
   • IL-17 inhibitors
   • IL-12/23 or IL-23 inhibitors

5. Incorporate Recommended Non-Pharmacological Approaches:

   • Low-impact exercise
   • Physical/occupational therapy
   • Weight management if applicable

Conclusion

When managing psoriatic arthritis, clinicians should follow evidence-based guidelines that emphasize pharmacological treatments (NSAIDs, DMARDs, biologics) and recommended non-pharmacological approaches (exercise, physical therapy). Cold plunge therapy is not supported by current evidence and could potentially worsen symptoms in patients with inflammatory arthritis.