Can psoriasis affect the spine?

Psoriatic Arthritis Can Affect the Spine

Yes, psoriasis can affect the spine in the form of psoriatic spondylitis, which occurs in approximately 5% of patients with psoriatic arthritis as an exclusive manifestation, and in 20-50% of patients with both spine and peripheral joint involvement. 1

Axial Involvement in Psoriatic Arthritis

Psoriatic arthritis (PsA) is an inflammatory seronegative spondyloarthropathy that can manifest with various patterns of joint involvement. When it affects the spine, it's known as axial PsA or psoriatic spondylitis.

Characteristics of Axial PsA:

• Presentation: Can present as sacroiliitis (often asymmetric and sometimes asymptomatic) or spondylitis affecting any level of the spine in a "skip" fashion 1

• Comparison to Ankylosing Spondylitis:

  • Less symptomatic than ankylosing spondylitis
  • More likely to have asymmetric disease
  • Generally less severe disease
  • Presence of psoriatic plaques or nail changes (absent in ankylosing spondylitis)
  • Less likely to progress to ankylosis (total loss of joint space) 1

• Detection: May require imaging studies including radiographs, MRI, or CT to identify, especially in asymptomatic cases 1

Clinical Manifestations and Diagnosis

Axial PsA may present with:

• Morning stiffness lasting more than 30 minutes 2
• Inflammatory back pain that improves with activity and worsens with rest
• Limited spinal mobility
• Cervical spine involvement with pain and reduced mobility 3

Diagnosis requires:

• Clinical assessment for inflammatory back pain
• Imaging studies to detect joint damage and inflammation
• Presence of psoriatic skin or nail lesions (in most cases)
• Exclusion of other causes of spondyloarthritis 4

Importance of Early Detection

Early detection of axial involvement in PsA is crucial because:

• Up to 50% of untreated PsA patients may develop permanent joint damage 2
• Early intervention may prevent structural damage and disability 2
• Regular screening for PsA manifestations, including axial involvement, is recommended for all psoriasis patients 2

Management Considerations

Treatment of axial PsA should target:

• Reduction of inflammation
• Prevention of structural damage
• Improvement of function and quality of life 1

The management approach should consider:

• Disease severity (mild, moderate, or severe) 1
• Presence of other manifestations (peripheral arthritis, skin disease, enthesitis, dactylitis) 1
• Comorbidities (cardiovascular disease, metabolic syndrome) 1

Key Takeaways

1. Spine involvement in psoriatic arthritis is real and clinically significant
2. It can occur exclusively (5% of cases) or alongside peripheral joint involvement (20-50% of cases)
3. It may be asymptomatic and detected only through imaging
4. It differs from ankylosing spondylitis in being often asymmetric and generally less severe
5. Early detection and treatment are essential to prevent permanent joint damage

For patients with psoriasis experiencing back pain with inflammatory characteristics, evaluation for axial PsA should be considered, particularly if they have other features of PsA such as peripheral arthritis, dactylitis, enthesitis, or nail changes.