Dermatologic Manifestations of Reactive Arthritis Treatment & Management

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: William D James, MD   more...
 
Updated: May 2, 2011
 

Medical Care

No curative treatment for reactive arthritis exists. Almost two thirds of patients have a self-limited course and need no treatment other than symptomatic and supportive care. However, reactive arthritis may be associated with chronic recurrent ocular inflammation that mandates systemic therapy (including immunosuppressive treatment) to control the ocular inflammation and to prevent progressive visual loss.[28]

Urethritis usually is treated with tetracyclines or macrolides because of the frequency of coexisting infections. The treatment of urethritis has not been shown to modify the course of the disease, but, in the absence of contraindications, treatment is commonly recommended. The antibiotic treatment of enteritis is even more controversial.

Arthritis in reactive arthritis is amenable to successful treatment with nonsteroidal anti-inflammatory drugs (eg, indomethacin). Occasionally, intra-articular injections of corticosteroids are prescribed. Treatment with methotrexate, azathioprine, gold salts, and penicillamine is proposed in severe cases of reactive arthritis.

Cutaneous lesions can be treated as those of psoriasis vulgaris. The author recommends beginning with topical 0.1% triamcinolone cream 3 times per day for adults and 2.5% hydrocortisone cream twice per day for children. A topical keratolytic, such as 10% salicylic acid ointment, can be added if needed. Topical salicylic acid and hydrocortisone with oral aspirin has also been suggested.[16]

Systemic therapy, if required, consists of the administration of oral acitretin and/or psoralen plus UVA (PUVA), methotrexate, or cyclosporine.

In one pediatric series of 22 patients from the Republic of China, nonsteroidal anti-inflammatory agents and sulfasalazine were the mainstays of treatment, with cyclophosphamide used in 14 patients and methotrexate and corticosteroids added in a few.[29] Most achieved full remission within 6 months.

The treatment of reactive arthritis in the setting of HIV infection poses special problems. However, potentially immunosuppressive therapies (eg, cyclosporine, methotrexate, PUVA) have been used in some cases, with variable success and a relative scarcity of severe complications.

The phenomenon of persistence plays an important role in the pathogenesis of reactive arthritis, as many as 30% of patients develop chronic symptoms, posing a therapeutic challenge.[30] Combination antibiotic treatment has shown a response in as many as 63% of patients. Biologics may be an therapeutic option for a severe and highly active disease course.

The clinical trial, New Immunomodulatory Therapy Strategies in Chronic Reactive Arthritis, is currently recruiting and may be of interest.

Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Jorge Romaní, MD  Assistant Professor, Department of Dermatology, Hospital De Palamós Faculty of Medicine, Spain

Disclosure: Nothing to disclose.

Lluís Puig, MD, PhD  Program Director, Assistant Professor, Department of Dermatology, Hospital De La Santa Creu I Sant Pau, Universitat Autónoma De Barcelona

Lluís Puig, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, European Academy of Dermatology and Venereology, and International Society of Dermatopathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Robin Travers, MD  Assistant Professor of Medicine (Dermatology), Dartmouth University School of Medicine; Staff Dermatologist, New England Baptist Hospital; Private Practice, SkinCare Physicians

Robin Travers, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Informatics Association, Massachusetts Medical Society, Medical Dermatology Society, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

References

  1. Wu IB, Schwartz RA. Reiter's syndrome: the classic triad and more. J Am Acad Dermatol. Jul 2008;59(1):113-21. [Medline].

  2. Fiessinger N, Leroy E. Contribution a l etude d'une epidemie de dysenterie dans la somme. Bull Soc Med Hop. 1916;40:2030-2069.

  3. Reiter H. Spirochateninfektion (Spirochaetosis arthritica). Deutsche Medizinische Wochenschrift. 1916;42:1535-6.

  4. Bauer W, Engelman EP. A syndrome of unknown etiology characterized by urethritis, conjunctivitis, and arthritis (so-called Reiter's disease). Trans Assoc Am Physicians. 1942;57:307-313.

  5. Panush RS, Wallace DJ, Dorff RE, Engleman EP. Retraction of the suggestion to use the term "Reiter's syndrome" sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum. Feb 2007;56(2):693-4. [Medline].

  6. Wallace DJ, Weismann M. Should a war criminal be rewarded with eponymous distinction?. J Clin Rheumatol. 2000;6:49-54.

  7. Weyers W. The fame and infamy of Hans Reiter. Dermatopathol Pract Concept. 2000;6:340-343.

  8. Ackerman AB. Reiter syndrome and Hans Reiter: Neither legitimate!. J Am Acad Dermatol. Mar 2009;60(3):517-8; author reply 518. [Medline].

  9. Mahmood A, Ackerman AB. Reiter's syndrome is psoriasis!. Dermatopathol Pract Concept. 2000;6:337-339.

  10. Kousa M, Saikku P, Richmond S, Lassus A. Frequent association of chlamydial infection with Reiter's syndrome. Sex Transm Dis. Apr-Jun 1978;5(2):57-61. [Medline].

  11. Berlau J, Junker U, Groh A, Straube E. In situ hybridisation and direct fluorescence antibodies for the detection of Chlamydia trachomatis in synovial tissue from patients with reactive arthritis. J Clin Pathol. Nov 1998;51(11):803-6. [Medline].

  12. Russell AL. Glycoaminoglycan (GAG) deficiency in protective barrier as an underlying, primary cause of ulcerative colitis, Crohn's disease interstitial cystitis and possibly Reiter's syndrome. Med Hypotheses. Apr 1999;52(4):297-301. [Medline].

  13. Savolainen E, Kettunen A, Narvanen A, et al. Prevalence of antibodies against Chlamydia trachomatis and incidence of C. trachomatis-induced reactive arthritis in an early arthritis series in Finland in 2000. Scand J Rheumatol. Mar 18 2009;1-4. [Medline].

  14. Townes JM, Deodhar AA, Laine ES, et al. Reactive arthritis following culture-confirmed infections with bacterial enteric pathogens in Minnesota and Oregon: a population-based study. Ann Rheum Dis. Dec 2008;67(12):1689-96. [Medline].

  15. Hanova P, Pavelka K, Holcatova I, Pikhart H. Incidence and prevalence of psoriatic arthritis, ankylosing spondylitis, and reactive arthritis in the first descriptive population-based study in the Czech Republic. Scand J Rheumatol. May 17 2010;[Medline].

  16. Arora S, Arora G. Reiter's disease in a six-year-old girl. Indian J Dermatol Venereol Leprol. Jul-Aug 2005;71(4):285-6. [Medline].

  17. Satko SG, Iskandar SS, Appel RG. IgA nephropathy and Reiter's syndrome. Report of two cases and review of the literature. Nephron. Feb 2000;84(2):177-82. [Medline].

  18. Lin RY. Reiter's syndrome and human immunodeficiency virus infection. Dermatologica. 1988;176(1):39-42. [Medline].

  19. Romaní J, Puig L, Baselga E, De Moragas JM. Reiter's syndrome-like pattern in AIDS-associated psoriasiform dermatitis. Int J Dermatol. Jul 1996;35(7):484-8. [Medline].

  20. Kober C, Richardson D, Bell C, Walker-Bone K. Acute seronegative polyarthritis associated with lymphogranuloma venereum infection in a patient with prevalent HIV infection. Int J STD AIDS. Jan 2011;22(1):59-60. [Medline].

  21. Thielen AM, Barde C, Janer V, Borradori L, Saurat JH. Reiter syndrome triggered by adalimumab (Humira) and leflunomide (Arava) in a patient with ankylosing spondylarthropathy and Crohn disease. Br J Dermatol. Jan 2007;156(1):188-9. [Medline].

  22. Siala M, Gdoura R, Younes M, et al. Detection and frequency of Chlamydia trachomatis DNA in synovial samples from Tunisian patients with reactive arthritis and undifferentiated oligoarthritis. FEMS Immunol Med Microbiol. Mar 2009;55(2):178-86. [Medline].

  23. Prati C, Bertolini E, Toussirot E, Wendling D. Reactive arthritis due to Clostridium difficile. Joint Bone Spine. Mar 2010;77(2):190-2. [Medline].

  24. Okamoto K, Hamano T, Kawaguchi T. [Reiter's syndrome following intravesical instillation of Bacillus Calmette-Guerin]. Hinyokika Kiyo. Feb 2010;56(2):111-3. [Medline].

  25. Shimamoto Y, Sugiyama H, Hirohata S. Reiter's syndrome associated with HLA-B51. Intern Med. Feb 2000;39(2):182-4. [Medline].

  26. [Guideline] U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. Jul 17 2007;147(2):128-34. [Medline].

  27. Kim SH, Chung SK, Bahk YW, Park YH, Lee SY, Sohn HS. Whole-body and pinhole bone scintigraphic manifestations of Reiter's syndrome: distribution patterns and early and characteristic signs. Eur J Nucl Med. Feb 1999;26(2):163-70. [Medline].

  28. Kiss S, Letko E, Qamruddin S, Baltatzis S, Foster CS. Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome. Ophthalmology. Sep 2003;110(9):1764-9. [Medline].

  29. Li CW, Ma JJ, Yin J, Liu L, Hu J. [Reiter's syndrome in children: a clinical analysis of 22 cases.]. Zhonghua Er Ke Za Zhi. Mar 2010;48(3):212-5. [Medline].

  30. Rihl M, Kuipers JG. [Reactive arthritis: from pathogenesis to novel strategies]. Z Rheumatol. Dec 2010;69(10):864-70. [Medline].

 
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