In psoriatic arthritis (PsA), fatigue is an underestimated and debilitating symptom, and is often reported as the second-most distressing symptom, even above psoriasis. The frequency of fatigue is similar to those with psoriasis and occurs in approximately 50% of individuals¹. However, fatigue that occurs in patients with PsA is often more severe than in people with psoriasis who don’t have inflammatory joint disease. Severe fatigue has been seen in over 30% of patients with PsA^2-3.

What does fatigue feel like?

With PsA and other chronic illnesses, fatigue is different from feeling tired at the end of the day. Being tired is often solved by sleeping, but chronic fatigue is a combination of exhaustion and reduced mental and physical capacity. Many people with PsA report that their fatigue makes them feel tired, but they can only rest, not sleep. Fatigue can also make people feel unmotivated².

Why do I feel fatigued and what causes it?

One of the ways to address fatigue in PsA is to treat the underlying cause. With PsA, there can be multiple causes, so it is valuable to consider several pieces to your treatment plan. 

The causes can include:

• Inflammation: Fatigue can worsen with PsA flare-ups. In a flare-up, the body is using more of its energy to increase the circulation of pro-inflammatory proteins, which can make you feel less able to stay motivated or active.⁴
• Pain: Chronic pain in PsA can make it difficult to get proper sleep. It can also make people hesitate to exercise, which contributes further to poor sleep and deconditions the body. Similarly, concomitant fibromyalgia can contribute to disrupted sleep and difficulty with memory and focus.⁵
• Depression and Anxiety: Fatigue is commonly associated with depression and anxiety. There is a biological link between the systemic inflammation associated with PsA and the development of depression and anxiety, in addition to the mental burden of living with a chronic illness. Depression and anxiety are more common in those with PsA than those with psoriasis without a joint disease.⁶
• Anemia : fewer red blood cells from either pain relief medication (NSAIDs) or chronic inflammation can result in less oxygen reaching your muscles and tissues, resulting in fatigue.⁷
• Medications: some patients taking treatments for PsA, including disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate, see a marked increase in fatigue. This is especially true if you only recently began taking the medication. Speaking with your health care provider and telling them about your fatigue is important, as there are alternatives that may improve your energy.⁷

What can I do to manage and overcome fatigue that comes with PsA?

Ultimately, addressing the underlying cause of the fatigue can help greatly. However, if the cause is difficult to figure out, some general treatments may help:

• Physical activity: It is recommended that all patients with PsA engage in some form of exercise. Low-impact exercise, such as tai chi, yoga, and swimming, are great options. High-impact exercise, such as running, may be done, but should be avoided if you have existing tendon/muscle injury, or multiple inflamed symptomatic joints. If your pain gets worse when you exercise, look for an alternate way of staying active.⁷
• Stop Smoking: consider smoking cessation aids to help in quitting or reducing the frequency of smoking.⁸
• Weight loss: Among individuals with a high body mass index (BMI), weight loss can help with pain relief as well as improve the efficacy of psoriasis medications. ⁹
• Hydration: dehydration can be a hidden source of fatigue. Increasing water intake, especially during exercise and on hot days, can potentially reduce fatigue. 
• Improve sleep hygiene: Avoid alcohol, nicotine, and caffeine well before bedtime. Try to create a screen-free, dark, cool sleeping environment. Get up and go to bed at a similar time each night, if possible.
• Diet: Aim for 5-10 servings of fruit and vegetables, reduce sugar and saturated (animal) fat intake, and avoid processed food when possible. These changes can assist with reducing pain and inflammation, as well as general quality of life and reducing BMI.¹⁰
• Treat yourself with kindness: Seek support during episodes of fatigue and communicate your needs to others. Rest when you need to, do something you love, and recognize and express your limitations. 
• Speak to your doctor: Always report fatigue to your doctor and keep track of when episodes of severe fatigue are occurring. They may be able to adjust your treatments to assist with relieving your fatigue, or with depression, anemia, and pain that might be contributing to fatigue.

It is also important to know

• Supporting a loved one with PsA means recognizing episodes of fatigue and approaching their needs with a shame-free attitude. 
• Dealing with your PsA early, including through medicine and other methods, can help reduce or delay the joint damage that occurs over time. Those who seek help for PsA sooner are more likely to experience improvements in their pain, fatigue, depression, and overall quality of life.¹¹
• Knowing about your fatigue can help your doctor predict the future appearance of PsA in people with psoriasis without a joint disease, so always let your doctor know if you are feeling symptoms of fatigue.⁴

References

¹ Gudu, T., Etcheto, A., de Wit, M., Heiberg, T., Maccarone, M., Balanescu, A., Balint, P. V., Niedermayer, D. S., Cañete, J. D., Helliwell, P., Kalyoncu, U., Kiltz, U., Otsa, K., Veale, D. J., de Vlam, K., Scrivo, R., Stamm, T., Kvien, T. K., & Gossec, L. (2016). Fatigue in psoriatic arthritis – a cross-sectional study of 246 patients from 13 countries. Joint Bone Spine, 83(4), 439–443. https://doi.org/10.1016/j.jbspin.2015.07.017

² Husted, J. A., Tom, B. D., Schentag, C. T., Farewell, V. T., & Gladman, D. D. (2009). Occurrence and correlates of fatigue in psoriatic arthritis. Annals of the Rheumatic Diseases, 68(10), 1553–1558. https://doi.org/10.1136/ard.2008.098202

³Tobin, A. M., Sadlier, M., Collins, P., Rogers, S., FitzGerald, O., & Kirby, B. (2017). Fatigue as a symptom in psoriasis and psoriatic arthritis: An observational study. The British Journal of Dermatology, 176(3), 827–828. https://doi.org/10.1111/bjd.15258

⁴Krajewska-Włodarczyk, M., Owczarczyk-Saczonek, A., & Placek, W. (2017). Fatigue – an underestimated symptom in psoriatic arthritis. Reumatologia, 55(3), 125–130. https://doi.org/10.5114/reum.2017.68911

⁵Ulus, Y., Akyol, Y., Bilgici, A., & Kuru, O. (2019). The impact of the presence of fibromyalgia on fatigue in patients with psoriatic arthritis: Comparison with controls. Advances in Rheumatology, 60(1), 1. https://doi.org/10.1186/s42358-019-0104-6

⁶McDonough, E., Ayearst, R., Eder, L., Chandran, V., Rosen, C. F., Thavaneswaran, A., & Gladman, D. D. (2014). Depression and Anxiety in Psoriatic Disease: Prevalence and Associated Factors. The Journal of Rheumatology. https://doi.org/10.3899/jrheum.130797

⁷Singh, J. A., Guyatt, G., Ogdie, A., Gladman, D. D., Deal, C., Deodhar, A., Dubreuil, M., Dunham, J., Husni, M. E., Kenny, S., Kwan-Morley, J., Lin, J., Marchetta, P., Mease, P. J., Merola, J. F., Miner, J., Ritchlin, C. T., Siaton, B., Smith, B. J., … Reston, J. (2019). 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis & Rheumatology, 71(1), 5–32. https://doi.org/10.1002/art.40726

⁸Anthonisen, N. R., Skeans, M. A., Wise, R. A., Manfreda, J., Kanner, R. E., & Connett, J. E. (2005). The Effects of a Smoking Cessation Intervention on 14.5-Year Mortality. Annals of Internal Medicine, 142(4), 233–239. https://doi.org/10.7326/0003-4819-142-4-200502150-00005

⁹Al-Mutairi, N., & Nour, T. (2014). The effect of weight reduction on treatment outcomes in obese patients with psoriasis on biologic therapy: A randomized controlled prospective trial. Expert Opinion on Biological Therapy, 14(6), 749–756. https://doi.org/10.1517/14712598.2014.900541

¹⁰Ko, S.-H., Chi, C.-C., Yeh, M.-L., Wang, S.-H., Tsai, Y.-S., & Hsu, M.-Y. (2019). Lifestyle changes for treating psoriasis. The Cochrane Database of Systematic Reviews, 7, CD011972. https://doi.org/10.1002/14651858.CD011972.pub2

¹¹Batko, B. (2020). Patient-Centered Care in Psoriatic Arthritis—A Perspective on Inflammation, Disease Activity, and Psychosocial Factors. Journal of Clinical Medicine, 9(10), 3103. https://doi.org/10.3390/jcm9103103

Medically Reviewed by:  Dr. Vinrod Chandran, Feb 2022