Ask a nurse: How can I manage my psoriasis when I have psoriatic arthritis?

Dealing with pain and fatigue can be tough at the best of times, but if you have psoriatic arthritis, you might also have to deal with another frustrating problem: psoriasis.

Psoriasis is a skin condition that causes raised patches of skin with scales. Itchiness can be one of the most persistent and frustrating symptoms of psoriasis. But we know that it can have a real impact on people’s mental and emotional wellbeing too.

Although there is no one-off cure for psoriasis, the good news is there are treatments available to keep it under control.

For instance, you might try prescription creams and ointments that you apply to the skin. Creams tend to be lighter and more easily absorbed than ointments, which are typically greasy, thick and more moisturising than creams.  

There are also tablets and injections, such as methotrexate, adalimumab or secukinumab, which can be used to treat both psoriatic arthritis and psoriasis.  

Here Lucy Moorhead, Nurse Consultant in Inflammatory Skin Disease, explains more about psoriasis, as well as her tips for applying treatments to the skin.  

What is psoriasis?

One in four people who have psoriasis have psoriatic arthritis. "We still treat the two conditions as separate,” says Lucy. “But there is a link between the two of them.”

Psoriasis and psoriatic arthritis are both autoimmune conditions where the immune system, which is the body’s natural self-defence system, attacks the skin (psoriasis) or the joints (psoriatic arthritis), and often both.

“When the skin is affected, there is an overproduction of skin cells,” explains Lucy. Normally skin cells are produced and replaced approximately every month, but if you have psoriasis, this process happens in just a few days. As the cells build up, this creates scaly patches (called plaques) that can appear on any part of the body.

“The scalp, buttocks, elbows and knees are common areas where you’ll find psoriasis,” says Lucy. “It can also affect the groin, in the armpits, and under the breast. And in those areas, psoriasis might look quite different to elsewhere on the body. It might look very red and shiny and while elsewhere on the body scales may be present that give it a silvery colour.”

If you have darker skin, it can look and feel a lot different too. “With darker skin types... you may not see redness, you may see hyperpigmentation instead.”

Getting support for your psoriasis

If your psoriasis is bothering you and isn't under control, it’s worth asking for a referral to a skin doctor (dermatologist). They’ll be able to offer you advice. Plus, they may be able to prescribe treatments such as:

• steroid creams
• vitamin D derivatives such as calcipotriol
• coal tar preparations
• light therapy.

If you have psoriatic arthritis, your rheumatologist may also prescribe treatments, which may help your psoriasis. These include medicines such as:

• methotrexate
• ciclosporin
• biologic DMARDS.

Advice for managing your psoriasis

Here Lucy provides her advice on looking after your skin if you have psoriasis:

Keeping your skin clean

Before applying any creams, it’s important to make sure that your skin is clean. But Lucy says that “cleanliness is rarely a problem with the patients I see. It's almost over cleanliness.”

For that reason, Lucy suggests:

• taking one shower or bath a day, not longer than 15 minutes in tepid water
• using a soap substitute such as aqueous cream
• trying to pat dry with a nice soft towel, rather than vigorously rubbing. 

What is an emollient and how should I apply them?

One of the first psoriasis treatments you may receive is an emollient.

“An emollient is basically a simple moisturiser,” explains Lucy. You can buy an emollient from your pharmacy without a prescription. But, if your psoriasis is severe, it’s worth talking to your healthcare team, as you may need a stronger treatment.

“Emollients work by softening scales, decreasing the dryness and cracking of plaques, and by applying them you can also decrease symptoms of soreness and itching as well.”

So, what’s the best way to apply your emollient? Lucy suggests that the secret is to “stroke in the direction of hair growth.”

“Typically, people want to rub it in but that can block the hair follicles if you're using greasier emollients.”

What are steroids creams and how are they applied?

Steroid creams and ointments reduce the inflammation caused when your immune system attacks the skin. This slows down the production of your skin cells and reduces the itch.

“Topical steroids come in four different strengths: there's mild, moderate, strong and very strong,” Lucy says. These should only be used when recommended by your healthcare team.

“Your healthcare professional will tell you which steroid to put where on your body but typically you want to reserve the stronger steroids for the parts of your body where the skin is thicker, so for instance, your trunk, arms and your legs. Whereas in areas of your body where your skin is thinner, so your face or groin, you might want to use a milder strength steroid.”

“It can be a good idea to use an emollient first before applying a steroid cream,” says Lucy. “It’s like a primer or the undercoat. It helps get your skin in the best condition possible to have your active treatments applied.”

Treating scalp psoriasis

Think you have psoriasis on your scalp? It usually looks like psoriasis elsewhere, but you might find that psoriasis on your scalp can look like dandruff.

Scalp psoriasis can come up around your hairline or behind the ears. So, if you have psoriatic arthritis, as well as a dry, itchy, flaky scalp, it could be psoriasis.

Lucy says that one of the most usual problems people face with scalp psoriasis is that they're “often prescribed only one product at a time when they need a combination of products.”

Treating scalp psoriasis often involves daily hair washing so, if this isn’t practical for your hair, Lucy says it’s worth being upfront with your healthcare team to “find a treatment regime that works for you.”

“If you only want to wash your hair once a week or your scalp is very dry, then you don't have to use a scalp preparation. You might benefit from using an ointment instead. Remember there are lots of different products out there.”

Treating nail psoriasis

Psoriasis may not just affect the skin; it can also affect your nails too – and this is particularly common if you have psoriatic arthritis.

“If you have psoriasis along with visible signs that your nails are affected too, that can be a strong predictor that you either has psoriatic arthritis or is likely to develop it in the in the future,” Lucy explains.

Signs to look out for include:

• discoloration or thickening of the nail
• ‘pitting’ (small dents in the surface of the nail)
• fragile nails that split or crumble easily
• nails that lift off or detach from the nail bed (‘onycholysis’).

So, if you have problems with your nails and pain, swelling or stiffness in your joints, then it is worth talking to a healthcare professional about whether you could have, or be at risk of, psoriatic arthritis.

Lucy says she would also "be wary of gel nails, as although people may use them to disguise nail changes, they can be harmful to the nail bed."

Making it a habit

When you’re juggling work, chores and your day-to-day hobbies, it can be difficult to make time for your skin treatment. But there are small steps you can take to make it a daily habit.

“We know it can be really difficult to put creams and ointments on regularly,” Lucy says. “So, if you're not able to do it, don't beat yourself up about it. The best thing to do is to sit down and work out a regime that works best with you.”

“If you don't like the moisturiser you're using - say it's too greasy or you don't like the smell - then it’s worth [trying] an alternative. Because there are loads of different ones out there. If you like it, you're more likely to apply it.”

Get support

Living with the pain and fatigue of psoriatic arthritis can be tough at the best of times – but if you have psoriasis as well, it can bring its own unique set of challenges. If you’re struggling, Lucy says not to bottle up how you’re feeling.

Talk to a friend, family member or your healthcare team. It might also be helpful to chat to other people with psoriasis, for example, you could reach out to the Psoriasis Association for support and advice.

“Psoriasis can have a huge impact on people's life,” she says. “A parliamentary report in 2020 found that 98% of people with a skin condition say that it affects their mental health. So, understand that you're not alone and talk to somebody because there is lots of support out there.”

We’re here to help 

If you need advice or support, you can also:

• Call our free helpline on 0800 5200 520  
• Chat to our Arthritis Virtual Assistant 
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