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Diseases and Conditions

Guide to living with psoriatic arthritis: Part 1

September 26, 2017
Psoriatic arthritis is an autoimmune disease that not only affects skin, but also joints

In an earlier post I presented a guide to living with rheumatoid arthritis (RA).  That’s all good if you have RA, but what if your rheumatologist diagnosed you with psoriatic arthritis?  What’s psoriatic arthritis and how is it similar or dissimilar to RA?  This week I’ll present to you Part 1 of a Guide to living with psoriatic arthritis.  I’m going to present this as a three-part series.  Part 1 will cover the basics: what is psoriatic arthritis, the cause, risks, symptoms, diagnosis, and treatment.  In Part 2 I’ll cover prognosis, what to expect, diet and exercise.  In Part 3, I’ll be covering the financial side of psoriatic arthritis: How to get access to medications and how to navigate the complicated world of health insurance.

What is psoriatic arthritis?

Psoriatic arthritis (PsA) is a type of autoimmune inflammatory arthritis that afflicts people who suffer from psoriasis (PsO).  It’s estimated that about 26% of people who suffer from psoriasis will get psoriatic arthritis at one point during their lifetime.  Typically, people develop psoriasis first and then get the arthritis.  In some cases, people develop arthritis first and then get psoriasis but this is a lot less common.   Psoriatic arthritis is one of the more common causes of autoimmune arthritis affecting about 2 to 3% of the population.[1]

What is psoriasis and what are the different types of psoriasis?

Psoriasis is an autoimmune disease that affects the skin.  It typically involves the elbows, knees, and scalp, but you can find it in many other areas.  It typically causes itchiness, burning as well as a stinging sensation.  Psoriasis affects about 2% of African-Americans and affects about 3.6% of Caucasians.  Usually people develop it between the ages of 15 and 35, but it can also happen in very young children and older adults as well.

There are many different types of psoriasis and they are all associated with psoriatic arthritis.

  • Plaque psoriasis
  • Guttate psoriasis
  • Inverse psoriasis
  • Pustular psoriasis
  • Erythrodermic psoriasis (life-threatening type of psoriasis)

Please follow this link to learn more about psoriasis.[2]

What causes psoriatic arthritis?

Like most diseases in rheumatology, we’re not sure.  We do know that there’s a strong genetic and environmental part to psoriatic arthritis.  Here are some genetic associations.

  • HLA-Cw6 is associated with severe early onset skin psoriasis
  • HLA-B38 and HLA-B39 are associated with psoriatic arthritis
  • HLA-B27 is associated with psoriatic arthritis that affects the spine.

Although genes do play a part in psoriatic arthritis, most people who have psoriatic arthritis have no genetic risk factors.

The Koebner Phenomenon

Have you ever heard of the Koebner phenomenon?  This phenomenon describes a new skin lesion in an area where healthy skin was injured.  For example, let’s imagine that you have psoriasis.  A mosquito comes along and bites you, it itches, so you scratch.  Then, about 10 days later, you notice that you’ve developed psoriasis in the area you scratched.  That’s the Koebner phenomenon.[3]

Now try to imagine the Koebner phenomenon involving joints.  It’s thought that about 25% of people who get psoriatic arthritis develop the condition after trauma to a joint.  We call this the deep Koebner phenomenon.[4]

Ultimately, we still don’t know exactly why people develop psoriatic arthritis.  Our best guess like most autoimmune diseases, is that certain people are born with a predisposition to develop both psoriasis and psoriatic arthritis.  Then, something in the environment triggers the disease to “come online”.

Does everyone with psoriasis get psoriatic arthritis?

No.  A recent Japanese study tried to find certain risk factors that predispose patients with psoriasis to develop psoriatic arthritis.  First, they found that about 17% of people with psoriasis also had psoriatic arthritis.   Second, they found that people who had psoriasis involving their nails had a higher chance of having psoriatic arthritis: 29% (PsO) versus 62% (PsA).  Interestingly, they also found that people who had high uric acid levels also had a higher risk of having psoriatic arthritis 9% (PsO) versus 22% (PsA).[5]

As a side note, when uric acid levels are high, this increases the risk of gout.

How does psoriasis affect the nails?

Nail psoriasis is very common.  It ranges from about 50% to 87% of people who have psoriasis.  Now, nail psoriasis can present in many ways depending on the anatomic site of the psoriasis inside the nail.  First, a bit of anatomy.

Nail anatomy

 

The nail consists of the nail fold, the nail matrix, and the nail bed.  The nail fold is where the blood vessels supplying the nail come from.  They can be compromised in many diseases such as scleroderma.  The nail matrix is responsible for formation of the nail plate and the nail bed is responsible for attaching the nail plate firmly in place.

Anatomy of the nail

 

When psoriasis affects the nail matrix.  It can cause pitting, crumbling, white spots and red spots in the lunula.  When psoriasis affects the nail bed, it can cause splinter hemorrhages and splitting of the nail from the nail bed (onychyolysis).[6]  Please click the following link to learn more about nail psoriasis + pics.

Please note that none of the features of nail psoriasis are exclusive to psoriasis.  Other diseases can cause these, including:

  • Reactive arthritis
  • Alopecia areata
  • Chemical dermatitis
  • Pemphigus vulgaris.
  • Incontinentia pigmenti

How is psoriatic arthritis different from rheumatoid arthritis?

Although both psoriatic arthritis and rheumatoid arthritis are both autoimmune diseases that affect joints, they are both distinct diseases.  It isn’t simply because you have psoriasis and inflammation in your joints, that you have psoriatic arthritis. Many people with psoriasis have rheumatoid arthritis.  Psoriatic arthritis and rheumatoid arthritis have their own pathophysiology, epidemiology, and symptoms.  Although they do share many treatment options, they also have some medications tailor-made for them.

Here some of the main clinical differences between psoriatic arthritis and rheumatoid arthritis.

  Psoriatic arthritis Rheumatoid arthritis
Joint distribution Asymmetrical Symmetrical
Joint involvement DIP, dactylitis MCP, PIPs, wrists, and MTPs
Involvement of the spine Common Rare, involves the cervical spine
Labs* RF and CCP antibody negative RF and/or CCP antibody positive

* RF = rheumatoid factor, CCP = Cyclic citrullinated peptide antibodies

As you’ll see later on, it’s a lot more complicated that.  Many people presenting with psoriatic arthritis present almost exactly like rheumatoid arthritis.  Here were a few other features that favor a diagnosis of psoriatic arthritis.

  • Presence of nail pits
  • When there is inflammation of the distal interphalangeal joints (Tip of your finger) without any evidence of osteoarthritis
  • “Sausage digits” = dactylitis. This happens when the tendons that supply of the fingers and toes get inflamed.
  • Any inflammation of tendons and ligaments, such as Achilles tendinitis and plantar fasciitis.
  • When there is a family history of psoriasis or psoriatic arthritis, particularly in a first-degree relative. That mom, dad, kids and siblings.
  • The spine is involved.

What are the symptoms of psoriatic arthritis?

If you’re experiencing joint pain and you have a history of psoriasis, particularly psoriasis that involves your nails, you need to think about psoriatic arthritis.  So what do I mean by joint pain?  When it comes to joint pain, what I really mean is, autoimmune or more specifically, inflammatory joint pain.

Psoriatic arthritis can affect almost any joint: knuckles, wrists, toes, knees, shoulders, elbows, hips, and the spine.  Mechanical joint pain is very different from inflammatory joint pain.  Let me explain.

Peripheral inflammatory joint pain

Peripheral joints include all joints except those involving the spine.  When there is inflammation in a peripheral joint, typically people experience pain, swelling, and stiffness, particularly in the morning that lasts at least an hour.  Sometimes they do see some redness and the joints may feel hot at times.  Often times, people also feel a lot more tired than usual, and they can even run low-grade fevers.

Axial inflammatory joint pain

Axial joints are those that involve the spine.  Inflammation involving the back causes symptoms that are very different from your usual mechanical back pain.  Here are some of the following key characteristics:

  • Back pain present for more than three months.
  • Pain improves with exercise.
  • Pain improves with anti-inflammatory medications like naproxen or ibuprofen.
  • Rest usually worsens the pain.
  • Back pain that wakes you up during the second half of the night.
  • Pain and prolonged stiffness in the morning, typically lasting more than an hour.
  • Alternating deep buttock pain.

Enthesitis

Enthesitis means inflammation of connective tissue that attaches to bones.  These include tendons, ligaments, and bursae.  Most cases of enthesitis are caused by injury or overuse.  Think of a marathon runner with Achilles tendinitis or a tennis player with tennis elbow.  In psoriatic arthritis, the immune system attacks these connection points.  So you can have someone who leads a fairly sedentary life with Achilles tendinitis on both feet, runner’s knee, and plantar fasciitis happening all at once, for no good reason.  Not a pleasant experience.

Uveitis

Uveitis is a general term that we use to describe a group of inflammatory diseases that cause inflammation in many parts of the eye: uvea, lens, retina, optic nerve, and the vitreous.  Depending on where the inflammation is happening, your ophthalmologist may describe it as anterior uveitis, intermediate uveitis, posterior uveitis, or panuveitis.

Uveitis is associated with many diseases including psoriasis and psoriatic arthritis.  Sometimes uveitis is the first manifestation of psoriatic arthritis.  This is why I’ve included this topic here, even though technically it isn’t arthritis.  It’s important to know and keep in the back of your mind.[7]

Patterns of disease

Just like rheumatoid arthritis, psoriatic arthritis, can manifest in many ways.  For those of you who want to get really technical, I’ve included a table describing the most common ways psoriatic arthritis presents.

Subtype Percentage Typical joints
Asymmetric oligoarticular* disease 15-20% DIP joints and PIP joints of the hands and feet.  MCP joints, MTP joints, knees, hips, and ankles.#
Predominant DIP involvement 2-5% DIP joints
Arthritis mutilans$ 5% DIP and PIP joints
Polyarthritis! “rheumatoid–like” 50-60% MCP joints, PIP joints, and wrists.
Axial involvement only (spine) 2-5% Sacroiliac joints, vertebral
Enthesitis predominant Tendons and ligaments[8]

* oligoarticular = 2 – 4 joints

# DIP = distal interphalangeal joints, PIP = proximal interphalangeal joints, MCP = metacarpophalangeal joints, MTP = metatarsophalangeal joints

$ Mutilans = severely deformed

! Polyarthritis = 5 or more joints involved

How is psoriatic arthritis diagnosed?

We currently use the CASPAR criteria to make the diagnosis of psoriatic arthritis.  You need three points to get the diagnosis because having 3 or more points has a 99% specificity and 92% sensitivity for the diagnosis of psoriatic arthritis.  Obviously, there are exceptions as the CASPAR criteria are predominantly used for research purposes.

As you can see, you don’t need to have psoriasis to get a diagnosis of psoriatic arthritis.  I know this sounds counterintuitive.

CASPAR classification criteria

  • Evidence of psoriasis (current, past, family)
    • 2 points if current
    • 1 point if history of psoriasis or family history
  • Psoriatic nail dystrophy = 1 point
  • Negative rheumatoid factor = 1 point
  • Dactylitis = 1 point
  • X-ray changes = 1 point

HLA-B*27 antigen

Unlike rheumatoid arthritis, we do not have blood tests to help with the diagnosis of psoriatic arthritis.  At times, your rheumatologist may order something called a HLA-B*27 test.

HLA-B*27 is a genetic test. The majority of people who have a positive HLA-B*27 are perfectly healthy. HOWEVER, having a positive HLA-B*27 can put you at increased risk of developing what we call spondyloarthritis-associated diseases. This is a family of autoimmune diseases. They include:

  • Ankylosing spondylitis, now called axial spondylitis
  • Peripheral spondyloarthritis
  • Reactive arthritis
  • Psoriasis
  • Psoriatic arthritis
  • Uveitis
  • Crohn’s disease
  • Ulcerative colitis

Not every person with psoriatic arthritis will test positive for HLA-B*27, however, those that do, have a higher risk of having axial involvement.[9]  This is important to know, because it may affect the medication your rheumatologist recommends.

Is there a cure for psoriatic arthritis?

The simple answer to this question is no.  Psoriatic arthritis is a chronic, lifelong disease.  Although there is no cure for psoriatic arthritis, there are many medications that can help halt or slow down progression: disease modifying anti-rheumatic drugs (DMARD).

Cardiovascular disease and psoriatic arthritis

In recent years, scientists have found an association between cardiovascular disease and many autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis, psoriasis, Crohn’s disease, ulcerative colitis, and psoriatic arthritis.  Basically, people who suffer from psoriatic arthritis have a higher risk of developing cardiovascular disease.[10][11]  [12] Unfortunately, they also tend to have more traditional cardiovascular risk factors like high blood pressure, high cholesterol, and diabetes.  [13]On the upside, effective treatment of psoriatic arthritis can decrease this risk.[14]

How is psoriatic arthritis treated?

Like rheumatoid arthritis, psoriatic arthritis is treated with disease modifying anti-rheumatic drugs (DMARDs). These medications are designed to stop or slow down the progression of psoriatic arthritis by targeting the faulty part of the immune system.  Without treatment, psoriatic arthritis, can cause permanent damage to joints, tendons and ligaments leading to functional impairment and a decrease in quality of life.

Which DMARDs are used to treat psoriatic arthritis?

The following are some of the medications that doctors often use to treat psoriatic arthritis.  Your doctor will recommend certain treatments based on the involved joints and organs, as well as severity, allergies, and other medical conditions you may have.

I’ve broken down the different medications into the following broad categories.

Nonsteroidal anti-inflammatory drugs

  • Ibuprofen
  • Meloxicam
  • Naproxen
  • Sulindac
  • Etodolac
  • Diclofenac
  • Indomethacin
  • Celecoxib

Conventional DMARDs

  • Hydroxychloroquine (Plaquenil) – caution as this medication may make psoriasis flare
  • Methotrexate
  • Leflunomide (Arava)
  • Sulfasalazine
  • Azathioprine – rarely used for psoriatic arthritis

Biologics

Tumor necrosis factor – alpha (TNF-alpha) inhibitors

  • Certolizumab pegol (Cimzia)
  • Etanercept (Enbrel)
  • Adalimumab (Humira)
  • Infliximab (Remicade)
  • Golimumab (Simponi)

Interleukin 12 and 23 inhibitors

  • Ustekinumab (Stelara)

Interleukin 17 inhibitors

  • Secukinumab (Cosentyx
  • Brodalumab (Siliq) – not FDA approved for PsA
  • Ixekizumab (Taltz) – not FDA approved for PsA

T cell inhibitors

  • Abatacept

Interleukin 23 inhibitors

  • Guselkumab

Phosphodiesterase 4 inhibitors

  • Apremilast (Otezla)

To read more about treatment for psoriatic arthritis.  Please follow this link.

Biosimilars

Here in the US, we are starting to see biosimilar medications. These are medications that are sort of copied from existing biologic medications.  They are NOT generic medications. The problem with biosimilars is that because of their complexity, it literally is impossible to exactly copy a biologic medication. If you want to learn more about biosimilar medications, please check this article.

Can I stop my medications if I’m feeling better?

No.  Psoriatic arthritis is a life-long disease.  If you’re feeling better, great!  However, it’s probably your medications that are keeping you that way.  If you stop your medications the psoriatic arthritis will likely come back.  Psoriatic arthritis subsides spontaneously in a VERY small subset of people.

If your medication is making you feel sick, talk to your rheumatologist.  They truly have your best interest at mind and they want to find the best treatment for you.

Do not stop your medications without first consulting your rheumatologist.

Next steps

Let’s recap what we’ve learned today.

  • Psoriatic arthritis is an inflammatory arthritis that affects about 26% of people that suffer from psoriasis and affects about 2 to 3% of the population.
  • We know that there is a strong genetic link and environmental component to psoriatic arthritis, but the majority of cases happen spontaneously.
  • People with nail psoriasis have a higher risk of getting psoriatic arthritis.
  • The Koebner phenomenon describes the appearance of a new skin lesion in an area where healthy skin was injured. The same thing can happen in joints.  This is  the deep Koebner phenomenon.
  • Psoriatic arthritis can present in many ways. It can cause peripheral inflammatory arthritis, axial inflammatory arthritis, enthesitis, and uveitis.
  • Doctors use the CASPAR criteria to help make a diagnosis of psoriatic arthritis. You need three points to get the diagnosis because having 3 or more points has a 99% specificity and 92% sensitivity for the diagnosis of psoriatic arthritis.
  • There are no specific tests help make the diagnosis of psoriatic arthritis, however, people that test positive for HLA-B*27 have a higher chance of having psoriatic arthritis in their spine.
  • People with psoriatic arthritis have a higher risk of having cardiovascular disease but treatment can possibly decrease that risk.
  • Psoriatic arthritis is treated with disease modifying anti-rheumatic drugs.

In part 2 of the Guide to living with psoriatic arthritis, I’ll be covering topics such as natural treatments for nail psoriasis and psoriatic arthritis, the FODMAP diet, how to exercise, and strategies on how to reduce stress.   In part 3 of the Guide to living with psoriatic arthritis, I’ll be covering the financial aspect of psoriatic arthritis most notably, health insurance coverage and the prior authorization process for expensive medications.

Stay tuned and please leave your comments below!

Please follow this link to request a rheumatology consultation.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

References

Sick woman main areas of the human body affected by psoriasis: By ann131313 via Shutterstock

Nail anatomy by  Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

[1] Rheumatology secrets, 3rd edition

[2] https://www.psoriasis.org/about-psoriasis

[3] https://www.dermnetnz.org/topics/the-koebner-phenomenon/

[4] Rheumatology secrets, 3rd edition

[5] Tsuruta N, Imaguku S, Narisawa Y.  Hyperuricemia is an independent risk factor for psoriatic arthritis in psoriatic patients. J Dermatol. 2017 Jul 10. doi: 10.1111/1346-8138.13968. [Epub ahead of print]

[6] Manhart R, Rich P. Nail psoriasis. Clin Exp Rheumatol. 2015 Sep-Oct;33(5 Suppl 93):S7-13.

[7] https://nei.nih.gov/health/uveitis/uveitis

[8] Rheumatology Secrets, third edition

[9] Jadon DR, et al. Axial disease in psoriatic arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis. 2017 Apr;76(4):701-707. doi: 10.1136/annrheumdis-2016-209853. Epub 2016 Dec 2.

[10] Ozkan SG, Yzisiz H. Gokbelen YA, Borlu F, Yazisiz V.  Prevalence of metabolic syndrome and degree of cardiovascular disease risk in patients with psoriatic arthritis. Eur J Rheumatol. 2017 Mar;4(1):40-45. doi: 10.5152/eurjrheum.2017.16052. Epub 2017 Mar 1.

[11] Fernandez-Gutierrez B, et al. Cardiovascular disease in immune-mediated inflammatory diseases: A cross-sectional analysis of 6 cohorts. Medicine (Baltimore). 2017 Jun;96(26):e7308. doi: 10.1097/MD.0000000000007308.

[12] Castaneda S, et al. Cardiovascular morbidity and associated risk factors in Spanish patients with chronic inflammatory rheumatic diseases attending rheumatology clinics: Baseline data of the CARMA project. Semin Arthritis Rheum. 2015 Jun;44(6):618-26. doi: 10.1016/j.semarthrit.2014.12.002. Epub 2014 Dec 25.

[13] Jafri K, Bartels CM, Shin D, Gelfand JM, Ogdie A.  Incidence and management of cardiovascular risk factors in psoriatic arthritis and rheumatoid arthritis: a population-based study. Arthritis Care Res (Hoboken). 2017 Jan;69(1):51-57. doi: 10.1002/acr.23094. Epub 2016 Nov 28.

[14] Agca R, Heslinga M, Kneepkens EL, van Dongen C, Nurmohamed MT. The effects of five-year etanercept therapy on cardiovascular risk factors in patients with psoriatic arthritis. J Rheumatol. 2017 Jun 1. pii: jrheum.161418. doi: 10.3899/jrheum.161418. [Epub ahead of print]

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Self-Injection Videos

How to inject methotrexate

September 12, 2017
How to inject methotrexate

Methotrexate is commonly prescribed to treat rheumatoid arthritis, psoriatic arthritis, psoriasis, as well as many other autoimmune diseases. It comes as a pill but in certain situations the medication may be more effective if it’s injected.  That being said, injectable methotrexate comes as a auto-injector pen but due to cost, often times we need to rely on the good old-fashioned method: needle, syringe, and a vial of methotrexate.  First, Dr. Farrell is going to teach us how to inject a vial of methotrexate.  In the second video, she will teach us how to inject with an auto-injector pen.

Preparing for your injection

  • Keep your medication stored in the refrigerator until use
    • Before injecting medication, take the vial out of the refrigerator.
    • Allow it to warm up to room temperature.
  • Pick a place in your house that is clean and has room for your materials (such as the kitchen table).
  • Wash your hands thoroughly with either:
    • Soap & water
    • Hand sanitizer
  • Chose an area to inject – Thigh or Stomach.
    • Chose an area that is intact and clear.
    • It should not have any of the following:
      • Cuts
      • Scrapes
      • Bruises
      • Psoriasis patches
      • If you have extensive psoriasis, inject between patches
      • Moles
      • Scars
    • Please rotate area each time you inject (shown in picture below).

Areas to inject subcutaneous medication

  • Cleanse chosen area
    • Cleanse chosen area with either of the following:
      • Alcohol swab
      • Alcohol and a cotton ball
    • Use the chosen alcohol material to “swipe” area
      • Can either use a circular motion or wipe in “strips”
      • Allow the area to dry

Injecting a methotrexate vial

Drawing the medication

  • If it is your first time using the vial, you will have to remove the plastic cap from the vial
  • Clean the top of the vial with an alcohol swab
  • Open syringe packaging and take syringe out
    • Be careful while doing this – the needle may come apart, so make sure the needle is securely on the syringe before moving on
  • Double check the dosage on your prescription.  Does your doctor want you to inject 0.5 mL? 0.6 mL?
  • Pull plunger to get air into the syringe
    • The amount of air should be half the amount of the dose that you are going to draw up (Example: if you need a dose that is 1 mL of methotrexate, draw up 0.5 mL of air)
  • Press the needle into the vial
    • Should be right into the center of the top of the vial at a 90-degree angle
  • Push the plunger to transfer the air into the vial
  • Flip the vial upside down with the needle still in
  • Pull back on the plunger to draw liquid into the syringe
    • If an air bubble appears into the syringe, push the plunger back up and try pulling out again
    • This may take a few tries before you get only medication into the syringe
  • Once you have withdrawn the dose of the medication that you need, flip the vial and take the needle out

Injecting the medicine

  • Pinch cleansed skin
  • Insert needle into the chosen area at a 45-degree angle
    • You may keep the skin pinched or let go of the skin
  • Push the plunger slowly to inject the medication
  • Once you have injected all of the medication, take the needle out of your skin

After the injection

  • Properly dispose of the entire syringe
    • NEVER recap the needle
    • Sharps Container
      • Can be purchased at your local pharmacy
      • Disposal
        • Hospitals may take full sharps containers, ask first.
        • Pharmacies and Doctors’ offices are not allowed to take used syringes or needles
  • Discard remaining materials in the trash (cap, alcohol swabs, etc.)

Injecting methotrexate with an auto-injector pen

Injecting Otrexup®

  • There will be a number “1” labeled on the auto-injector
    • Twist cap off
  • There will be a number “2” labeled on the auto-injector
    • Press with thumb to flip cap off
  • Place tip of the auto-injector on the skin at a 90-degree angle
  • Press button to release medication
    • Hold for 10 seconds
    • May feel a slight pinch and tingling as the medication goes in

Injecting Rasuvo®

  • There will be a yellow cap at the end that you will pull straight off
  • Place tip of the auto-injector on the skin at a 90-degree angle
  • Press button to release medication
    • Hold for 10 seconds
    • May feel a slight pinch and tingling as the medication goes in

After the injection

  • Properly dispose of the auto-injector.
    • Sharps Container
      • May be provided by the drug company (depending on the medication)
      • Can be purchased at your local pharmacy
      • You may use a coffee can if you are unable to attain a sharps container
      • Disposal
        • Hospitals may take sharps
        • Pharmacies and Doctors’ offices are not allowed to take used syringes or needles
  • Discard remaining materials in the trash (cap, alcohol swabs, etc.)

Credits

Jessica Farrell, PharmD.  Clinical Pharmacist, The Center for Rheumatology/Associate Professor, Albany College of Pharmacy and Health Sciences

With the help of Autumn Koniowka. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences, and Megan Phillips. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences.

A special thanks to Tammy Garren, PhD. Instructional Designer, Center for Innovative Learning, Albany College of Pharmacy and Health Sciences.

Methotrexate vial image: By Li Wa/Shutterstock

Injection site image: By British Columbia Institute of Technology (BCIT). Download this book for free at http://open.bccampus.ca [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

Diseases and Conditions Self-Injection Videos

How to inject Humira, Enbrel, Simponi, and Cimzia

August 28, 2017
Video demonstrations on how to how to inject Humira, Enbrel, Simponi, and Cimzia

Humira®, Enbrel®, Simponi®, and Cimzia® are medications commonly prescribed for rheumatoid arthritis, psoriatic arthritis, psoriasis, and ankylosing spondylitis.  All of these come in self-injectable pens or pre-filled syringes.  You will be asked to inject these yourself or by a love one, in the comfort of your home.  Today, we’re going to go over how to inject these self-injectable medications.

Preparing for your injection

  • Keep your medication stored in the refrigerator until use
    • Before injecting medication, take the autoinjector out of the refrigerator.
    • Allow it to warm up to room temperature.
  • Pick a place in your house that is clean and has room for your materials (such as the kitchen table).
  • Wash your hands thoroughly with either:
    • Soap & water
    • Hand sanitizer
  • Chose an area to inject – Thigh or Stomach.
    • Chose an area that is intact and clear.
    • It should not have any of the following:
      • Cuts
      • Scrapes
      • Bruises
      • Psoriasis patches
      • If you have extensive psoriasis, inject between patches
      • Moles
      • Scars
    •  
    • Please rotate area each time you inject (shown in picture below).
Areas to inject subcutaneous medication

By British Columbia Institute of Technology (BCIT). Download this book for free at http://open.bccampus.ca [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

  • Cleanse chosen area
    • Cleanse chosen area with either of the following:
      • Alcohol swab
      • Alcohol and a cotton ball
    • Use the chosen alcohol material to “swipe” area
      • Can either use a circular motion or wipe in “strips”
      • Allow the area to dry

The injection

  • Take off the white cap, observe the medication in the window to be sure that it is clear (no cloudiness or crystals.)
    • You will see a small air bubble within the window, this is normal and will not cause harm when injecting
  • Press down firmly on the clean area of skin, so that the pen is flush with the skin (90-degree angle).
    • The pen needle will not eject unless pressed firmly to skin

For Cimzia® and other medications that come in prefilled syringes

  • Pinch the skin around the injection site and insert the needle at a 45-degree angle
  • Press in the plunger slowly

You may notice the plunger is hard to press this is due to the size of the medication, be sure to continue to inject slowly to administer all medication

  • Press button to inject the medication.
    • You may feel a slight pinch as the needle enters your skin, and tingling as the medication is administered
    • If you have trouble pressing the button try lifting the pen off your skin, and repressing the pen firmly to the area
  • Hold for 15 seconds.
    • Window will become colored (yellow) but continue to hold dose for at least 15 seconds to ensure that all medication is administered

What to do after the injection

  • Lift the pen up from skin and place the whole pen into the sharps container.
    • If you do not have a sharps container available, contact your pharmacy/doctor’s office about obtaining one
      • In the meantime, you may use an old coffee container with a lid
    • Some hospitals take full Sharps Containers for disposal. Here at the office we do not. Contact your pharmacy for more information about the disposing of your Sharps Container.
  • Discard remaining materials in the trash (cap, alcohol swabs, etc.)

If you have any concerns about your medication (e.g., excessive pain, swelling, redness bruising, bleeding, fever, breathing problems), please contact your rheumatologist.

For more information

Humira® – Abbvie

Enbrel® – Amgen

Simponi® – Janssen

Cimzia® – UCB

Jessica Farrell, PharmD.  Clinical Pharmacist, The Center for Rheumatology/Associate Professor, Albany College of Pharmacy and Health Sciences

With the help of Autumn Koniowka. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences, and Megan Phillips. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences.

A special thanks to Tammy Garren, PhD. Instructional Designer, Center for Innovative Learning, Albany College of Pharmacy and Health Sciences.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

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Tips and Tricks

Simple and easy ways to hydrate your skin

January 23, 2017
Hydrate dry skin

Introduction

Dry, flaky skin got you down? A lack of proper hydration is often the culprit behind dull, lackluster skin. Hydrated skin is essential for maintaining a glowing, radiant complexion. Read on to learn the science-backed methods to restore moisture, bounce, and a healthy glow to your skin.

What is Skin Hydration?

Skin hydration refers to the process of delivering moisture to the skin cells and retaining it in the epidermis (the outermost layer of skin). Hydrated skin has enough water content for the skin to look and feel soft, plump, and supple. Skin that lacks sufficient hydration becomes dry, flaky, and tight. Properly hydrated skin is better able to withstand damage from environmental stresses like pollution, sun exposure, and harsh weather. It also has a more youthful, healthy appearance with fewer visible fine lines and wrinkles. Hydration is essential for proper skin function and homeostasis [1].

When the skin is hydrated, the cells become engorged with water, causing them to plump up. This provides structural stability and resilience to the skin. Hydration also allows skin cells to carry out normal physiological functions like tissue repair, barrier function, and shedding of dead skin cells. Skin that lacks hydration becomes less efficient at protecting against irritants, bacteria, and the early signs of aging. Furthermore, water makes up the base of the skin’s surface layer – without adequate hydration, this surface layer dries out and cracks, which can accelerate aging. Properly hydrating your skin is key to maintaining healthy, youthful skin over time [2].

Why Skin Hydration Matters

Keeping your skin properly hydrated provides many benefits for a youthful, healthy appearance. Hydrated skin is plump and supple, with a dewy, radiant glow. The skin barrier is strong to lock in moisture and keep out irritants when it has enough water content. As we age, skin naturally loses the ability to retain moisture, so it’s especially important for women over 25 to focus on hydration.

The best thing about keeping your skin hydrated is that it can help reduce the look of fine lines and wrinkles. Water makes the skin fuller, smoothing out dryness and crepey texture. By staying hydrated regularly, you can improve the elasticity and firmness of your skin, which can reduce sagging and wrinkles. Proper hydration can also help fight flakiness, tightness, and roughness.

In contrast, the consequences of dehydrated skin are amplified signs of aging. Research shows that insufficient hydration leads to up to 50% more fine lines and wrinkles by age 40. Without adequate moisture, the complexion looks dull, skin feels irritated, and makeup applies unevenly. Long term, extreme dehydration can even cause the skin to crack and become prone to infection.

By making skin hydration a priority with high quality moisturizers, humectant serums, and hydrating skin care routines, women can maintain a youthful complexion with fewer wrinkles and a healthy, radiant glow.

Causes of Dehydrated Skin

There are several factors that can cause the skin to become dehydrated and lacking in moisture. Environmental exposures like sunlight, heat, and cold temperatures can strip moisture from the skin [1]. As we age, the skin’s natural ability to retain moisture decreases leading to increased dryness [2]. Using harsh soaps, over-exfoliating, and excessive hot water can disrupt the skin barrier and deplete natural moisturizing factors [3]. Certain medical conditions like eczema, psoriasis, diabetes, and thyroid disorders can also contribute to dehydrated skin [1].

[1] https://www.medicalnewstoday.com/articles/dehydrated-skin
[2] https://bodewellskin.com/blog/dehydrated-skin/
[3] https://www.theskinsmith.co.uk/what-is-the-cause-of-dehydrated-skin/

Hydrating Ingredients

There are several ingredients that help hydrate skin in different ways:

Humectants

Humectants are ingredients that attract and bind moisture to the skin. They pull water from the dermis and the air into the epidermis. Common humectants include:

  • Glycerin – a natural humectant that draws moisture into the skin (https://www.paulaschoice.com/ingredient-dictionary/ingredient-skin-conditioning-ingredients.html)
  • Hyaluronic acid – attracts and binds up to 1000x its weight in water for plump, hydrated skin

Occlusives

Occlusives create a protective barrier on the skin to prevent moisture loss. They seal hydration into the skin. Examples include:

  • Petrolatum – provides an occlusive layer to lock in moisture
  • Dimethicone – seals hydration and smooths the skin

Emollients

Emollients fill in cracks between skin cells and smooth the skin. They help skin retain moisture. Common emollients:

  • Ceramides – naturally found in skin, supplementing them prevents moisture loss
  • Plant oils like jojoba, almond, and olive oil – nourish skin and provide fatty acids

Using a combination of humectants, occlusives, and emollients is ideal for hydrating different layers of the skin.

Maximizing Absorption

To get the most out of your hydrating skin care products, it’s important to maximize absorption. Here are some research-backed tips:

Apply products to damp skin after cleansing. Damp skin acts like a sponge, quickly absorbing serums, lotions and creams compared to dry skin [1]. Be sure to pat your face dry with a towel instead of rubbing.

Use gentle, circular motions when applying products. Massaging products into the skin in smooth, circular motions can increase penetration compared to simply smoothing products on [2].

Apply products from thinnest to thickest texture. Starting with lightweight serums and ending with richer moisturizers allows each layer to fully absorb before applying the next.

Finish with a protective layer like petroleum jelly. Applying an occlusive layer like petroleum jelly over hydrating products seals in moisture and prevents evaporation from the skin’s surface [3].

Signs of Properly Hydrated Skin

When your skin is properly hydrated, you’ll notice some clear signs. Hydrated skin appears plump, smooth, and dewy rather than tight or flaky. Here are the main signs your skin is getting the moisture it needs:

Plump, smooth skin texture. Hydrated skin will lack wrinkles and feel supple to the touch, rather than dry and rough.

Minimal flaking or tightness. If your skin is properly hydrated, it won’t peel, crack, or feel uncomfortably tight, especially after cleansing.

Healthy, natural glow. With adequate moisture levels, your skin will exhibit a radiant, illuminated sheen rather than looking dull.

According to experts at First Impressions Clinic https://firstimpressionsclinic.ca/2023/03/06/how-to-hydrate-your-skin-this-winter/, properly hydrated skin also does not appear thin or sunken in. The right moisture balance keeps skin looking full and firm.

Lifestyle Tips for Hydrated Skin

In addition to using topical skincare products, there are several daily habits that can help maintain well-hydrated skin:

Drink plenty of water. Getting adequate water intake helps your body stay hydrated from the inside out. Aim for the recommended 8-10 glasses per day.

Eat foods rich in omega-3 fatty acids. Foods like salmon, walnuts, and chia seeds help strengthen the skin barrier and lock in moisture. Omega-3s also help reduce inflammation that can lead to dryness.

Limit hot showers. Extremely hot water can strip the skin of oils. Keep showers warm, not steaming hot, and avoid excessive showering.

Use gentle cleansers. Harsh soaps and cleansers disrupt the skin barrier, causing moisture loss. Opt for gentle, hydrating cleansers without sulfates. Use hypoallergenic products when possible.

Protect skin from sun damage. UV exposure can dehydrate and thin the skin over time. Wear SPF 30+ sunscreen daily.

Adapting these simple lifestyle habits into your daily routine can keep your complexion hydrated, healthy and glowing.

Conclusion

Properly hydrating your skin is key to maintaining a youthful, healthy glow. By understanding what dehydrates skin and how to counteract it with both topical products and lifestyle habits, you can get your complexion looking plump and radiant. Be sure to drink plenty of water, eat omega-3 rich foods, limit hot showers, and apply hydrating serums and occlusive moisturizers. Implement a gentle but thorough skincare routine with ingredients like hyaluronic acid and glycerin to draw moisture into the skin and seal it in. With some discipline and the right products, dry, flaky skin doesn’t stand a chance. Get started today on your journey towards maximizing hydration for smooth, supple skin.

Final Topic Callouts

When your epidermis lacks water and lipids, the many essential functions of the skin become compromised. However, with knowledge of the causes, targeted ingredients, and smart skin care techniques, you can get your skin glowing again. Some key takeaways from our discussion on hydrating your skin:

  • Applying products to damp skin ensures better absorption of hydrating ingredients like glycerin and hyaluronic acid into the deeper layers of the skin.
  • Exfoliating aids hydrating products by removing dead cells that can prevent effective penetration.
  • Occlusive ingredients like petrolatum seal in existing moisture and prevent water loss through the skin’s outer barrier.
  • Limiting hot showers, staying hydrated, and eating omega-3 rich foods can support your topical routine.
  • Look for plumpness and a dewy glow, instead of flakiness and tightness, to assess proper hydration.

With some diligence to your skin care regimen and lifestyle, you can achieve a supple, quenched complexion.