A 46-Year-Old Man With Spine Pain and a Rash

Herbert S. Diamond, MD, MACP


February 26, 2020

Tumor necrosis factor (TNF) inhibitors are highly effective for skin and joint disease and are recommended as initial treatment for patients with active psoriatic arthritis. No data support the superiority of any one TNF inhibitor over another.[1,4,5,6,7] If initial TNF inhibitor treatment provides an inadequate response, switching to a different TNF inhibitor is recommended.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful for joint pain in psoriatic arthritis, but they do not alter joint progression or benefit skin disease. Methotrexate in higher doses is effective for psoriasis, but neither it nor other disease-modifying antirheumatic drugs (DMARDs), including sulfasalazine and cyclosporine, have been shown to provide long-term benefits in delaying progression in patients with erosive joint disease. DMARDs may be used as initial treatment in patients without severe disease who prefer starting with oral therapy or have a contraindication to TNF inhibitors.

Antimalarials are generally avoided, since they have been associated with a severe, albeit rare, skin reaction. Corticosteroids are used, but tapering of corticosteroids has been associated with flares of skin disease. Local injection of corticosteroids can be useful for the management of individual joints and tendon sheath involvement.

Other, more recently approved biologics are beneficial in patients with an unsatisfactory response to TNF inhibitors. These include several inhibitors of interleukin (IL)-17, which are highly effective for psoriasis; ustekinumab, an IL-12/23 inhibitor; abatacept, a CTLA4-Ig inhibitor, tofacitinib, a JAK inhibitor; and apremilast, a phosphodiesterase-4 inhibitor. Other biologic agents for psoriatic arthritis are in clinical trials.[8]

After the patient in this case began the aforementioned treatment with naproxen and oral methotrexate, there was some improvement in the skin rash but little change in the arthritis, which spread to additional joints. A TNF inhibitor was added to the treatment, and over the next 3 months gradual improvement was observed in the patient’s arthritis, which became almost inactive. Naproxen was discontinued, and the methotrexate dose was decreased back to 15 mg weekly. The patient remains on this treatment regimen, with continued excellent response.


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