What treatment options are available for back pain associated with psoriasis?

Treatment Options for Back Pain Associated with Psoriasis

For patients with back pain associated with psoriasis, TNF inhibitors are the most effective treatment option when the pain is due to axial psoriatic arthritis that has failed conventional therapies. 1

Diagnosis of Axial Psoriatic Arthritis

Back pain in patients with psoriasis should be evaluated for possible axial involvement of psoriatic arthritis (PsA). Diagnosis of axial disease should be based on the presence of at least two of the following criteria:

• Inflammatory back pain characteristics:

  • Onset age <45 years
  • Symptoms >3 months
  • Morning stiffness >30 minutes
  • Insidious onset
  • Improvement with exercise
  • Alternating buttock pain 1

• Limitation of motion of cervical, thoracic, or lumbar spine in sagittal and frontal planes 1

• Radiological criteria:

  • Plain x-ray showing unilateral sacroiliitis grade 2 or more
  • Syndesmophytes
  • MRI changes in sacroiliac joints (bone marrow edema, erosions, joint space narrowing) 1, 2

Treatment Algorithm for Back Pain in Psoriatic Arthritis

First-Line Therapy

• NSAIDs for control of joint symptoms but not skin symptoms 1
• Physical therapy and exercise program 1
• Education about the condition 1

Second-Line Therapy

• Intra-articular glucocorticoid injections for persistent inflammation 1
• Sacroiliac joint injections for axial symptoms 1

Third-Line Therapy (For Moderate to Severe Disease)

• TNF inhibitors (etanercept, infliximab, adalimumab) for patients who fail to respond to NSAIDs and other conventional therapies 1
• Disease activity in the spine can be measured using the BASDAI score, where active disease is defined as a score >4 1
• A treatment response is defined as a BASDAI score <3 or a reduction by 2 points 1

Important Considerations

• Traditional oral DMARDs (methotrexate, leflunomide, sulfasalazine) have not been shown to be effective for axial manifestations of PsA and are not considered adequate for PsA axial disease 1, 2

• Systemic corticosteroids are not typically recommended in the treatment of psoriasis and should only be used in discrete circumstances, not for chronic use, due to potential post-steroid psoriasis flare 1

• Approximately 25-70% of patients with PsA exhibit signs of inflammatory axial involvement (axial PsA) 2, 3

• Axial disease may be asymptomatic in 20-25% of patients with PsA, so imaging may be necessary even in the absence of back pain 4

Treatment Selection Based on Disease Severity

For patients with axial PsA, treatment selection should be based on disease severity:

• Mild disease: NSAIDs and non-pharmacological approaches 1

• Moderate disease: Consider sacroiliac injections, systemic agents for skin involvement 1

• Severe disease: TNF inhibitors such as etanercept (Enbrel) or adalimumab (Humira) are recommended 1, 5, 6

Special Considerations

• If a patient has both axial disease and moderate-to-severe skin involvement, TNF inhibitors may be particularly beneficial as they address both conditions 1, 5, 6

• The presence of dactylitis, enthesitis (including plantar fasciitis), and DIP joint involvement are common in PsA but uncommon in other forms of back pain 1, 7

• Early therapeutic intervention is important for preventing permanent joint and spine damage and loss of functionality 3

• Patients should be monitored for response after 6 weeks of treatment 1