Basic pharmacotherapy and flare management
Since the disease is chronic, all medical interventions are pathogenetic and symptomatic in nature. Nonsteroidal anti-inflammatory drugs (NSAIDs) traditionally serve as first-line medications to suppress active joint inflammation. In pediatric practice, diclofenac or indometacin are most commonly prescribed. The recommended daily dosage of these drugs is 2–3 mg/kg of the child's body weight.
Systemic use of glucocorticoids (GCs) is kept to a strict minimum to avoid severe side effects. The main method of hormonal agent use remains local therapy—intra-articular injections. For these purposes, special depot formulations of drugs are used, such as methylprednisolone or betamethasone.
However, in cases of acute, severe conditions, a physician may prescribe systemic pulse therapy. For this purpose, methylprednisolone is used at a dosage of 5 to 15 mg/kg per day. The course of pulse therapy is usually short, lasting exactly 3 days, and the calculated daily dose must be divided into two administrations.
Disease-modifying antirheumatic drugs (DMARDs)
The management strategy for patients with psoriatic arthritis is based on the step-down/step-up therapy principle. Systemic treatment begins with the prescription of disease-modifying antirheumatic drugs, which allow for control of the immune response activity.
Main drugs and their administration regimens:
- Methotrexate: is one of the main drugs in the treatment regimen. It is prescribed orally or intramuscularly at a rate of 10–15 mg/m² of body surface area per week.
- Sulfasalazine: the daily dosage is 30 mg/kg, and this volume must be divided into two doses.
- Leflunomide: therapy with this agent begins with a high loading dose (100 mg per day for the first three days). After that, the patient is switched to a maintenance dose of 20 mg per day. For children weighing less than 40 kg, the maintenance dose is adjusted and reduced to 10–20 mg per day.
- Cyclosporine: is prescribed at a rate of 3 mg/kg of body weight.
Genetically engineered biological therapy (GEBT)
If baseline therapy proves insufficiently effective, the patient is moved to the next step: genetically engineered biological therapy. This group includes powerful modern drugs that are tumor necrosis factor alpha (TNF-α) inhibitors, such as infliximab, adalimumab, and etanercept.
Transitioning a child to GEBT requires strict medical indications. These include:
- Treatment resistance: established when there is a lack of clinical effect from the use of at least two different DMARDs.
- Persistence of stable activity: clinical manifestations do not subside despite adequate DMARD dosages.
- Presence of specific severe manifestations: development of isolated psoriatic spondyloarthritis, acute dactylitis, as well as pronounced tendon involvement (enthesitis and tenosynovitis).
Non-pharmacological management, prevention, and prognosis
Pharmacological treatment must be accompanied by appropriate non-pharmacological management. In joint involvement, bed rest is not indicated for children—on the contrary, an active lifestyle is recommended. The basis of rehabilitation is daily exercise therapy (physical therapy), which is critical for maintaining joint range of motion. Concurrently with the treatment of joint syndrome, local therapy for skin manifestations of psoriasis is performed (dermatological monitoring is required).
Specific preventive measures for psoriatic arthritis have not yet been developed. Secondary prevention boils down to minimizing trigger factors that can provoke a flare. Patients should avoid hypothermia, excessive solar radiation (prolonged sun exposure), heavy physical exertion, and psycho-emotional stress.
In childhood, the prognosis is generally considered favorable, although the disease course is highly variable. Sustained clinical remission is successfully achieved in 20–50% of patients. Approximately 25% of children experience chronicity of the process with the development of chronic polyarthritis. A severe course, accompanied by the loss of joint function and subsequent disability, is observed in approximately 10% of cases.
To remember the main triggers of psoriatic arthritis flares, use the acronym SPINA: Stress, Percooled (hypothermia), Insolation (excessive), Naгрузка (load — the A is just for euphony).
Class and exam questions
Can glucocorticoids be used systemically as a long-term course?
No, systemic glucocorticoid use in psoriatic arthritis is strictly limited. Preference is given to intra-articular injections of depot formulations. Systemic drugs (e.g., methylprednisolone) are used only as a short 3-day course of pulse therapy to relieve acute conditions.
In what case does a physician prescribe biological therapy (TNF-α inhibitors)?
The transition to biological therapy is carried out in the absence of an effect from two different DMARDs, with persistently high disease activity, and in severe lesions such as acute dactylitis or psoriatic spondyloarthritis.
Should a child's movement be restricted during the illness?
On the contrary, patients are encouraged to maintain an active lifestyle. Daily physical therapy exercises are a mandatory condition for preserving the function of affected joints and preventing disability.
What else to study on this topic
- Mechanism of action and side effects of TNF-α inhibitors
- Methodology for administering glucocorticoid pulse therapy in pediatrics
- Specifics of local dermatological therapy in psoriatic arthritis
- Criteria for assessing resistance to disease-modifying antirheumatic drugs
- Features of the course and diagnosis of isolated psoriatic spondyloarthritis
Master the entire topic in the Pediatrics course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Treatment of Psoriatic Arthritis" and 3,738 more subject pages
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 71 video lessons on the subject
Other topics of «Chapter 9. Rheumatic Diseases»
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.