Review of an Advanced Case of Psoriatic Arthritis and Barriers to Management of Chronic Disease in the West Texas Region

Background: Psoriatic arthritis is a debilitating, inflammatory musculoskeletal spondyloarthritis associated with the skin condition psoriasis that affects the hands, feet, spine, and other parts of the body. Nearly 80% of patients develop the associated arthritis after skin lesions of psoriasis develop. Management of psoriatic arthritis can be difficult, with severe variants recommended to receive specialized care from a rheumatologist for optimal treatment. The clinical case that will be discussed refers to a patient presenting with psoriatic exacerbation, which progressed from skin lesions to psoriatic arthritis with unmanaged pain. Despite the severity of this progression, he received minimal education on psoriatic arthritis management. Case Presentation: A 34-year-old male presented to clinic with a primary complaint of pain for uncontrolled psoriatic arthritis that had been diagnosed one year prior, two years after an original diagnosis of psoriasis. He reports the diagnosis of psoriatic arthritis was made after diffuse rashes spread over his body and extensor surfaces with increasing joint pain. At the clinic, the patient complained of weakness in his extremities; severe pain at elbow, ankle, knee, and toe joints bilaterally; a diffuse erythematous rash particularly at the ankles; and difficulty with daily activity due to pain. Notable physical exam findings included a personal history of psoriasis, joint pain, nodules growing past the distal interphalangeal joint of his hands and feet along with dactylitis and nail dystrophy consistent with psoriatic arthritis. Based on Classification for Psoriatic Arthritis criteria (CASPAR), he would be due to a score above 5 classified as having psoriatic arthritis. He has a known history of epilepsy, spinal stenosis, generalized anxiety disorder, chronic PTSD, and type 1 bipolar disorder. Patient reported recurrent methamphetamine use along with frequent use of marijuana for pain control. His social history was significant for lack of employment and symptoms worsening while uninsured. He stated an inability to attend scheduled appointments due to lack of transportation, the distance from Terlingua to the clinic in Alpine, TX, and inability to obtain telemedicine visits with his current provider. Conclusion: This case study on management of advanced psoriatic arthritis examines the health disparities faced by patients in rural west Texas regions, including lack of patient education, access to qualified rheumatologists, and adequate resources to manage disease exacerbation. A literature search on PubMed was conducted to clarify the current standard of care for treatment of advanced psoriatic arthritis, as well as current restrictions in management within the West Texas area. For social determinant factors, the social vulnerability index for west Texas regions was reviewed using public Center for Disease Control and Prevention data to note qualified health centers for this level of need and found appropriate services are lacking within the town of Terlingua and its neighboring areas. In addition to the healthcare team, an appropriate and safe environment for those suffering with psoriatic arthritis also includes stable infrastructure, social support, and public transportation. Without public health measures and capable providers, there are increased barriers to care of chronic disease for those living in rural areas like Terlingua.