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Understanding Psoriatic Arthritis Mutilans: Causes, Symptoms, and Treatment

Medically reviewed by Florentina Negoi, M.D.
Written by Laurie Berger
Updated on November 1, 2024

Arthritis mutilans is the most severe form of psoriatic arthritis (PsA). About 5 percent of people with PsA develop this form of the disease either from the start or as it progresses. Arthritis mutilans causes the bones and tissues around the joints to break down, making fingers and toes look shorter or bent. Though it’s uncommon, arthritis mutilans can be very painful and disabling.

This article will explain why arthritis mutilans develops, its symptoms, and how it can be treated.

Causes of Psoriatic Arthritis Mutilans

Although the exact cause of arthritis mutilans is unknown, it typically develops in people with PsA. Some people with rheumatoid arthritis also develop it. In arthritis mutilans, the immune system mistakenly attacks healthy cells in joints. The resulting inflammation causes bone tissue to break down and be reabsorbed into the body.

In general, a family history of psoriasis or PsA is a significant risk factor for getting PsA. In fact, about 40 percent of people with PsA have a family member with psoriasis or arthritis, suggesting a strong genetic link.

Symptoms of Psoriatic Arthritis Mutilans

Arthritis mutilans typically affects the small bones in the hands and feet, specifically:

  • Distal interphalangeal joints (the ends of the fingers)
  • Metacarpophalangeal joints (knuckles)
  • Metatarsophalangeal joints (“toe knuckles”)

Unlike rheumatoid arthritis, which affects both sides of the body, arthritis mutilans usually doesn’t affect the same joints on each side of the body.

Arthritis mutilans is a polyarthritis condition, meaning most people who develop it have multiple affected joints (more than five). In a study of 67 people with arthritis mutilans, the average number of damaged joints per person was 8.2.

Although it’s rare for PsA to become arthritis mutilans, when it happens, the progression can be rapid and destructive. It may develop within a few months or several years after PsA first appears.

Early Symptoms of Psoriatic Arthritis Mutilans

Arthritis mutilans starts with severe inflammation that makes it hard to bend and straighten your joints. You may have trouble making a tight fist, buttoning a shirt, or cooking a meal. Arthritis mutilans is often a progression of PsA, especially when treatment wasn’t used or didn’t work.

Hand Symptoms

Arthritis mutilans can cause fingers to shorten and bunch together, a symptom known as “opera-glass hands” or “telescopic fingers.” (CC BY-SA 4.0/Jojo at Polish Wikipedia)

Arthritis mutilans can cause the fingers to shorten and bunch together, a symptom called “opera glass hands” or “telescopic fingers.” This occurs when the connective tissues no longer support the joints, making the fingers collapse. Pulling on the fingers may cause them to lengthen or open up like opera glasses, and the joints can move in unusual directions. The collapsed fingers may also lead to excess skin, which folds like a telescope.

Severe joint deterioration from arthritis mutilans can cause pencil-in-cup deformity, where the end of a bone narrows like a pencil, and the top of the neighboring bone erodes into a cuplike shape. This damage is typically seen in X-rays. (Science Photo Library)

Foot Symptoms

Telescoping and pencil-in-cup deformities can also affect the toes, which can affect walking. Sometimes, orthopedic inserts or a walking aid can help prevent further stress and damage to the lower extremities.

Additional Symptoms

Other symptoms of arthritis mutilans include:

  • Ankylosis (fused joints)
  • Multiple joint involvement
  • Loss of range of motion
  • Nail changes, such as pitting
  • Lesions

Diagnosing Psoriatic Arthritis Mutilans

Because psoriatic arthritis mutilans and rheumatoid arthritis have similar symptoms, a diagnosis can be mistaken or delayed. Diagnosis is typically based on a family history of psoriasis, genetic markers, and the presence of such PsA symptoms as dactylitis (swollen “sausage” fingers or toes) and enthesitis (inflammation of tendons and ligaments that attach to bone).

A rheumatologist will start with a physical exam to confirm the type of arthritis and check joints for swelling or tenderness. A blood test can check for specific antibodies or a protein called rheumatoid factor, which can indicate rheumatoid arthritis. Imaging tests (also called radiographic imaging), such as X-rays, are also used to assess the type and severity of bone damage.

Treatments for Psoriatic Arthritis Mutilans

Although no specific medications are approved for treating arthritis mutilans, early treatment is essential to manage symptoms and slow the progression. Depending on how severe the condition is, rheumatologists may recommend a combination of treatment options commonly used for PsA.

Biologics

Guidelines developed by the National Psoriasis Foundation and the American College of Rheumatology currently recommend biologic drugs as the first-line treatment of severe PsA. Biologic drugs are medications made from living organisms or their cells. They target specific parts of the immune system to reduce inflammation and control disease. They are either injected or given intravenously (through a vein). They’re usually taken long term as maintenance drugs to prevent flares and disease progression. Biologics can reduce inflammation and protect joints, but they don’t reverse joint damage and deformity.

There are more than a dozen FDA-approved biologics to treat PsA and psoriasis that target various parts of the immune system. Your doctor will determine the right option for you based on your specific health needs.

Disease-Modifying Antirheumatic Drugs

Disease-modifying antirheumatic drugs (DMARDs) are systemic drugs, which means they work throughout the body rather than targeting one particular area. DMARDs are prescribed for moderate to severe PsA, including arthritis mutilans. They help reduce joint and tissue damage, slow disease progression, and relieve symptoms. Methotrexate is the DMARD most commonly prescribed for arthritis mutilans, used alone or also associated with biologic therapy.

Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to manage the symptoms of PsA, including arthritis mutilans. They help reduce swelling and pain, making it easier to walk and move, but they do not slow disease progression or prevent joint damage. Common NSAIDs include aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve).

Long-term use of NSAIDs may lead to side effects, such as gastrointestinal bleeding and ulcers.

Other Medications

In addition to biologics and DMARDs, other medications may be used to treat psoriatic arthritis mutilans, including:

JAK Inhibitors

Janus kinase (JAK) inhibitors are a newer option for treating PsA. These medications are taken by mouth rather than being injected.

Currently, two JAK inhibitors are FDA-approved to treat PsA:

Doctors usually prescribe JAK inhibitors for people with PsA when certain biologic drugs haven’t worked well enough or have caused side effects. JAK inhibitors are generally not recommended for older adults or people with heart problems.

PDE4 Inhibitors

Phosphodiesterase-4 (PDE4) inhibitors are another type of oral medication.

The only PDE4 inhibitor currently FDA-approved for PsA is apremilast (Otezla). This medication is not typically the first choice for treating PsA. It’s often used along with other treatments, especially for those who can’t safely use some of the other options.

Corticosteroids

Also known as steroids, corticosteroids may be injected into joints to reduce ongoing inflammation in people with arthritis mutilans. Injections allow doctors to deliver a higher dose than is possible with oral medications and are usually used in those with a single joint involvement. Because people with PsA often have skin lesions, injections should be given carefully, avoiding areas affected by psoriasis patches.

Long-term use of steroids can increase joint damage, as well as the risk of infection, bone fractures, and long-term diseases such as osteoporosis, high blood pressure, obesity, diabetes, and heart disease.

Physical Therapy

To help delay the progression of arthritis mutilans, rheumatologists recommend early and aggressive therapy. Hand therapy is particularly important because it strengthens muscles around the joints, improving dexterity and overall use of fingers and hands.

Surgery

Joint replacement surgery, bone grafts, or arthrodesis (joint fusion) may be an option for severely damaged joints. These procedures can help relieve symptoms, restore some function, and improve quality of life with arthritis mutilans. Surgery should be considered a last resort because it typically requires downtime for recovery, and there are risks of infection.

Lifestyle Changes

Arthritis mutilans can greatly affect daily life, but good self-care may help reduce symptoms and improve mobility. Strategies such as maintaining a healthy weight, eating an anti-inflammatory diet, and engaging in gentle exercise can help manage inflammation. Quitting smoking is also important for overall health.

Complementary therapies, like acupuncture, and stress management techniques have helped some people better manage pain and other symptoms of PsA.

Talk With Others Who Understand

On MyPsoriasisTeam, the social network for individuals diagnosed with PsA and psoriasis and their loved ones, more than 131,000 members come together to ask questions, give advice, and share their stories with others who understand life with psoriasis.

Do you have psoriatic arthritis mutilans? Do you have any tips for reducing the symptoms? Share your experience in the comments below, or start a conversation on your Activities page.

Florentina Negoi, M.D. attended the Carol Davila University of Medicine and Pharmacy in Bucharest, Romania, and is currently enrolled in a rheumatology training program at St. Mary Clinical Hospital. Learn more about her here.
Laurie Berger has been a health care writer, reporter, and editor for the past 14 years. Learn more about her here.

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