Lifestyle

Psoriatic arthritis (PsA) is a chronic inflammatory disorder that is diagnosed when symptoms of psoriasis are accompanied by inflammation in the joints[i]. Thus, people with PsA have patches of red, silvery, scaly skin as well as pain in the joints, such as in the hand, foot, and the back. The joint pain is often preceded by swelling in the toes and fingers. PsA is a progressive disorder and should be actively monitored and managed in order to reduce inflammation, prevent damage and improve day-to-day function and overall quality of life.

Alcohol is a risk factor for developing PsA. Fortunately, it is a lifestyle factor that can be changed. Alcohol can affect the immune system in several ways. When a person drinks alcohol regularly, it is theorized that their immune system is more ‘ramped up’, or what we call ‘pro-inflammatory’.1 However, this ‘ramped up’ version of the immune system isn’t better or stronger – in fact, it can make people more susceptible to infections.

Alcohol can also inappropriately stimulate immune cells known as B- and T-lymphocytes, leading to production of antibodies to a person’s own body cells.2 These antibodies may start attacking tissues in the body, leading to inflammation and tissue damage. Alcohol also increases the levels of an enzyme that makes tumour necrosis factor (TNF), a molecule that is very pro-inflammatory and is plays an important role in psoriasis and psoriatic arthritis (PsA).3 Skin cells called keratinocytes are also stimulated to grow much more quickly in the presence of alcohol; this overgrowth of keratinocytes is one of the many mechanisms of developing psoriasis, and possibly PsA. Finally, because alcohol has a lot of calories, drinking alcohol regularly can contribute to increasing weight and/or metabolic syndrome – both of which can worsen psoriasis and PsA.

Drinking alcohol is a well-known risk factor for developing psoriasis.4 In PsA, however, research is still ongoing. A 2020 study showed that patients with psoriasis who are moderate drinkers (which this study described as 0.1-3 units of alcohol* per day or 3 beers/day maximum) had an increased risk of developing PsA compared to non-drinkers.5 Another study from 2015 looked at PsA in women and showed that excessive alcohol drinking (>30 grams of alcohol* per day or approximately 2 or more beers/day) can trigger PsA when compared to non-drinkers.6 The same study showed that moderate drinking (which this study described as 0.1-14.9 grams per day, or roughly 1 beer/day) had the lowest risk of triggering PsA. 

Even if you do not drink moderately or more often than that, drinking alcohol can increase your risks of developing psoriasis or PsA. Further research is needed to further clarify the association between alcohol and PsA. Though it is not entirely clear what dose of alcohol increases the risk of developing PsA, patients with psoriasis who drink alcohol may find benefit from reducing their consumption of alcohol. 

Medications that may be used to treat psoriasis or PsA also affect the liver, so these medications may be contraindicated in patients with heavy alcohol use. Reducing your alcohol consumption can improve inflammation, reduce liver damage, and allow the use of more medications to control the disease. 

*one unit of alcohol = ~14 grams of alcohol = one 12 oz beer = a 5 oz glass of wine = a 1.5 oz shot of hard liquor7

References: 

  1. Svanström C, Lonne-Rahm S-B, Nordlind K. Psoriasis and alcohol. Psoriasis Targets Ther. 2019;9:75-79. doi:10.2147/ptt.s164104
  2. Szabo G, Mandrekar P. A recent perspective on alcohol, immunity, and host defense. Alcohol Clin Exp Res. 2009;33(2):220-232. doi:10.1111/j.1530-0277.2008.00842.x
  3. Serwin AB, Sokolowska M, Dylejko E, Chodynicka B. Tumour necrosis factor (TNF-α) alpha converting enzyme and soluble TNF-α receptor type 1 in psoriasis patients in relation to the chronic alcohol consumption. J Eur Acad Dermatology Venereol. 2008;22(6):712-717. doi:10.1111/j.1468-3083.2008.02584.x
  4. Brenaut E, Horreau C, Pouplard C, et al. Alcohol consumption and psoriasis: A systematic literature review. J Eur Acad Dermatology Venereol. 2013;27(SUPPL.3):30-35. doi:10.1111/jdv.12164
  5. Green A, Shaddick G, Charlton R, et al. Modifiable risk factors and the development of psoriatic arthritis in people with psoriasis. Br J Dermatol. 2020;182(3):714-720. doi:10.1111/bjd.18227
  6. Wu S, Cho E, Li WQ, Han J, Qureshi AA. Alcohol intake and risk of incident psoriatic arthritis in women. J Rheumatol. 2015;42(5):835-840. doi:10.3899/jrheum.140808
  7. Health Canada. Low-risk alcohol drinking guidelines – Canada.ca. https://www.canada.ca/en/health-canada/services/substance-use/alcohol/low-risk-alcohol-drinking-guidelines.html. Published 2021. Accessed August 1, 2022.

 

 

Smoking has been associated with an increased risk of both psoriasis and psoriatic arthritis (PsA) in the general population.1-3 One large study found that those who smoked were 27% more likely to develop psoriatic arthritis than non-smokers.4 Paradoxically, studies have not shown an increased risk of psoriatic arthritis in people who have pre-existing psoriasis and smoke.1,4-6

However, other studies have found that people with PsA who smoke tend to have more severe disease and may have poorer responses to treatment compared to non-smokers.3,7,8 Individuals who have smoked for longer and consume more cigarettes per day tend to develop more severe PsA.3 Smoking may cause an increase in inflammatory cytokines, which are involved in causing PsA and are targeted by some of the biologic therapies that are used to treat PsA.9-12

It is recommended that people with PsA quit smoking.10,13 Quitting smoking can have several other benefits, including a reduced risk of cardiovascular disease, which patients with PsA are at a higher risk for developing.13-15 There are many different medications and psychological support programs available to assist with smoking cessation. 

References

  1. Xie W, Huang H, Deng X, Gao D, Zhang Z. Modifiable lifestyle and environmental factors associated with onset of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational studies. J Am Acad Dermatol. 2021;84(3):701-711. doi:10.1016/j.jaad.2020.08.060
  2. Armstrong AW, Harskamp CT, Dhillon JS, et al. Psoriasis and smoking: a systematic review and meta-analysis. Br J Dermatol. 2014;170:304-314. 
  3. Li W, Han J, Qureshi AA. Smoking and risk of incident psoriatic arthritis in US women. Ann Rheum Dis. 2012;71:804-808. 
  4. Nguyen UDT, Zhang Y, Lu N, et al. Smoking paradox in the development of psoriatic arthritis among patients with psoriasis: a population-based study. Ann Rheum Dis. 2018;77(1):119-123. doi:10.1136/annrheumdis-2017-211625
  5. Gazel U, Ayan G, Solmaz D, Akar S, Aydin SZ. The impact of smoking on prevalence of psoriasis and psoriatic arthritis. Rheumatology (Oxford). 2020;59(10):2695-2710. doi:10.1093/rheumatology/keaa179
  6. Eder L, Shanmugarajah S, Thavaneswaran A, et al. The association between smoking and the development of psoriatic arthritis among psoriasis patients. Ann Rheum Dis. 2012;71(2):219-224. doi:10.1136/ard.2010.147793
  7. Højgaard P, Glintborg B, Hetland ML, et al. Association between tobacco smoking and response to tumour necrosis factor α inhibitor treatment in psoriatic arthritis: results from the DANBIO registry. Ann Rheum Dis. 2015;74(12):2130-2136. doi:10.1136/annrheumdis-2014-205389
  8. Di Lernia V, Ricci C, Lallas A, Ficarelli E. Clinical predictors of non-response to any tumor necrosis factor (TNF) blockers: a retrospective study. J Dermatolog Treat. 2014;25(1):73-74. doi:10.3109/09546634.2013.800184
  9. Veale DJ, Fearon U. The pathogenesis of psoriatic arthritis. Lancet. 2018;391(10136):2273-2284. doi:10.1016/S0140-6736(18)30830-4
  10. Meer E, Merola JF, Fitzsimmons R, et al. Does biologic therapy impact the development of PsA among patients with psoriasis?. Ann Rheum Dis. 2022;81(1):80-86. doi:10.1136/annrheumdis-2021-220761
  11. Pezzolo E, Naldi L. The relationship between smoking, psoriasis and psoriatic arthritis. Expert Rev Clin Immunol. 2019;15(1):41-48. doi:10.1080/1744666X.2019.1543591
  12. Yanagita M, Kobayashi R, Kojima Y, Mori K, Murakami S. Nicotine modulates the immunological function of dendritic cells through peroxisome proliferator-activated receptor-γ upregulation. Cell Immunol. 2012;274(1-2):26-33. doi:10.1016/j.cellimm.2012.02.007
  13. Singh JA, Guyatt G, Ogdie A, et al. Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2019;71(1):5-32. doi:10.1002/art.40726
  14. Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev. 2004;(1):CD003041. doi:10.1002/14651858.CD003041.pub2
  15. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA. 2003;290(1):86-97. doi:10.1001/jama.290.1.86

Nutrition

It is estimated that one third of psoriasis patients suffer from psoriatic arthritis (PsA), which involves swelling of the joints (e.g., knees, elbows, hand joints) as well as the skin symptoms associated with psoriasis.1,2. While nutrition is not a medical treatment of PsA, it may help lower and/or control your symptoms when paired with your medication. As PsA is often associated with other conditions such as obesity, diabetes and cardiovascular diseases, maintaining healthy food habits can only be beneficial for your general well-being and physical state2,3. 

To help control joint swelling and other associated symptoms, here are some recommended anti-inflammatory foods to include in your diet: 

  • Fruits and vegetables, especially green vegetables
  • Beans, whole grains 
  • Nuts
  • Olive oil
  • Fatty acids (e.g., fish, avocado, seed oils, etc.) that are rich in omega-3 acids 
  • Specific anti-inflammatory spices (e.g., garlic, ginger, cinnamon, cayenne)
  • Green tea 

Foods to avoid 

It is important to highlight that some nutrients can worsen your joint pain and inflammation.. Since PsA is a progressive inflammatory disease, it is recommended that you to avoid consuming high-inflammatory foods on a regular basis:  

  • Alcohol 
  • Processed foods (trans fat) and refined carbohydrates (e.g., white bread, pastries, desserts) 
  • Processed meat (e.g., sausage, pepperoni) and red meat (saturated fat) 
  • Fried foods (trans fat) 

Dietary supplements 

In PsA, some dietary supplements may help improve or control your symptoms when taken with your standard medication. For instance, some studies have found that a weekly intake of vitamin D may help with PsA symptoms4,5. However, it is important to consult your doctor before starting to take any supplements as it could interfere with your medical therapies or not be beneficial at all. Some dietary supplements are not recommended due to a lack of evidence and/or results such as fish oil and selenium supplements4. 

Special diets 

The scientific literature suggests that weight-loss can help control disease severity for overweight and obese PsA patients4,6,7. A recent study found that a 5-10% weight reduction in overweight and obese patients could help achieve minimal disease activity6. It is also known that obesity is associated with an increase of PsA disease activity2,8. Interestingly, body composition could also influence PsA activity. Patients with more lean mass (a lower percentage of body fat) were found to have fewer joint symptoms compared to patients with a higher fat mass (higher percentage of body fat) proportion2. 

Despite few studies on the topic, the Mediterranean diet could be a promising approach to reduce inflammation associated with PsA9. This diet includes most of the above-mentioned healthy foods (fruits and vegetables, whole-grain cereals, fish, olive oil) which all have anti-inflammatory and antioxidant properties. Similarly, despite few studies being available, intermittent fasting on its own could potentially contribute to reducing PsA activity by lowering proinflammatory mechanisms10. 

 

References
  1.   Gladman DD. Psoriatic arthritis. Moderate-to-Severe Psoriasis, Third Edition. 2008;8:239-258. doi:10.12688/F1000RESEARCH.19144.1/DOI
  2.  Leite BF, Morimoto MA, Gomes CMF, et al. Dietetic intervention in psoriatic arthritis: the DIETA trial. Adv Rheumatol. 2022;62(1). doi:10.1186/S42358-022-00243-6
  3. Haddad A, Zisman D. Comorbidities in Patients with Psoriatic Arthritis. Rambam Maimonides Medical Journal. 2017;8(1):e0004. doi:10.5041/RMMJ.10279
  4.  Ford AR, Siegel M, Bagel J, et al. Dietary Recommendations for Adults With Psoriasis or Psoriatic Arthritis From the Medical Board of the National Psoriasis Foundation: A Systematic Review. JAMA Dermatol. 2018;154(8):934-950. doi:10.1001/JAMADERMATOL.2018.1412
  5.    Huckins D, Felson DT, Holick M. Treatment of psoriatic arthritis with oral 1,25-dihydroxyvitamin D3: a pilot study. Arthritis Rheum. 1990;33(11):1723-1727. doi:10.1002/ART.1780331117
  6.   di Minno MND, Peluso R, Iervolino S, Russolillo A, Lupoli R, Scarpa R. Weight loss and achievement of minimal disease activity in patients with psoriatic arthritis starting treatment with tumour necrosis factor α blockers. Annals of the Rheumatic Diseases. 2014;73(6):1157-1162. doi:10.1136/ANNRHEUMDIS-2012-202812
  7.  Abou-Raya A, Abou-Raya S, Helmii M. OP0076 Effect of Exercise and Dietary Weight Loss on Symptoms and Systemic Inflammation in Obese Adults with Psoriatic Arthritis: Randomized Controlled Trial. Annals of the Rheumatic Diseases. 2014;73(Suppl 2):89-90. doi:10.1136/ANNRHEUMDIS-2014-EULAR.2760
  8.  Kumthekar A, Ogdie A. Obesity and Psoriatic Arthritis: A Narrative Review. Rheumatology and Therapy. 2020;7(3):447. doi:10.1007/S40744-020-00215-6
  9. Caso F, Navarini L, Carubbi F, et al. Mediterranean diet and Psoriatic Arthritis activity: a multicenter cross-sectional study. Rheumatol Int. 2020;40(6):951-958. doi:10.1007/S00296-019-04458-7
  10. Adawi M, Damiani G, Bragazzi NL, et al. The Impact of Intermittent Fasting (Ramadan Fasting) on Psoriatic Arthritis Disease Activity, Enthesitis, and Dactylitis: A Multicentre Study. Nutrients 2019, Vol 11, Page 601. 2019;11(3):601. doi:10.3390/NU11030601
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