Managing PsA and axSpA Comorbidities: From Heart Disease to Hidradenitis Suppurativa

Living with a condition like psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA) is challenging enough on its own. But often, these diseases come with additional comorbidities like heart disease, depression or anxiety, and even skin diseases like hidradenitis suppurativa (HS).

This adds additional layers to your diagnosis and treatment journey: Having comorbidities changes your quality of life, the medications you take, and your ability to achieve remission or minimal disease activity.

Here’s what to know about managing these conditions, plus advice from a patient who is coping with four life-altering diagnoses at once.

Common Comorbidities Associated with PsA and axSpA

PsA and axSpA are both autoimmune diseases. PsA is a type of arthritis present in some people who have psoriasis, a skin disease that causes red patches and silvery scales. Meanwhile, axSpA is a type of arthritis that affects the joints in your chest, spine, and pelvis, according to the Cleveland Clinic.

“Autoimmune diseases tend to occur with other autoimmune diseases,” says Lauren Eckert Ploch, MD, MEd, FAAD, board-certified dermatologist and fellow of the American Academy of Dermatology.

Signaling chemicals called cytokines, which cause inflammation, often overlap in autoimmune diseases. You can think of this cytokine storm as confetti exploding inside your body, causing inflammation in various nooks and crannies.

“It doesn’t just touch the places that we can see,” says Elizabeth Kiracofe, MD, FAAD, a board-certified dermatologist and Founder of Airia Comprehensive Dermatology. “It’s like receiving a birthday card with glitter in it. The glitter falls on the carpet and it’s very hard to pick out each individual piece of glitter.”

Because of this widespread inflammation, comorbidities such as the following are common in patients with axSpA and PsA.

• Cardiovascular disease and metabolic syndrome: Studies show a high prevalence of cardiovascular disease and risk factors such as metabolic syndrome (which includes hypertension, high cholesterol, and obesity) in these patients, says Kanika Monga, MD, FACR, Assistant Professor of Clinical Medicine at Houston Methodist.
• Depression and anxiety: “Patients may also have comorbid depression and anxiety,” adds Dr. Monga. As just one example, one in three PsA patients report anxiety, while one in five report depression, per a 2020 review in Clinical Rheumatology. What’s more, those who have anxiety or depression also report higher disease activity.
• Diabetes: The prevalence of type 2 diabetes in patients with PsA ranges from 6.1 to 20.2 percent, which is higher than the general population (2.4 to 14.8 percent), per a 2020 review in Rheumatology and Therapy. Meanwhile, axSpA patients had a 14 percent higher odds of diabetes compared to controls in a 2020 review in Rheumatology (Oxford).
• Hidradenitis suppurativa (HS): Dr. Monga highlights that HS is more prevalent among patients with PsA and axSpA compared to the general population. Eight percent of PsA patients had an HS diagnosis and 29 percent of patients with nr-axSpA (a certain type of axSpA) showed undiagnosed HS-like symptoms in a 2023 study in Annals of the Rheumatic Diseases. HS is a chronic skin disease that causes painful sores and scarring — and can lead to complications like obstructed lymph drainage and restricted movement, due to scar tissue.
• Inflammatory Bowel Disease (IBD): The prevalence of IBD in PsA patients is 3.8 percent, per 2018 research in Arthritis & Rheumatology. It also affected five to 10 percent of axSpA patients in a 2024 study that looked at Spanish and Ibero-American registry data in Annals of the Rheumatic Diseases. (Overall, IBD is diagnosed in less than 0.7 percent of Americans, per a 2023 study in Gastroenterology.)
• Obesity: PsA patients had much higher rates of obesity (27.2 percent) compared to the general population (11.3 percent) in a 2023 Swiss study published in Annals of the Rheumatic Diseases. Meanwhile, 22 percent of axSpA patients were obese in a 2016 Dutch study in The Journal of Rheumatology. “There’s also data that says if patients have a higher BMI, they are more resistant to systemic treatment options or going into remission compared to somebody that might have that normal range BMI,” says Saakshi Khattri, MD, a board-certified dermatologist, rheumatologist, and internist at Mount Sinai in New York City.

How Comorbidities Affect Quality of Life for Patients

 Comorbidities like metabolic syndrome can increase your risk of heart disease, stroke, and type 2 diabetes, per the Mayo Clinic. And even skin-related comorbidities like HS can severely affect your quality of life.

“HS can be extremely painful and lead to scarring that can limit mobility, in addition to the mobility limitations of inflammatory arthritis,” says Dr. Ploch. “Plus, we do not talk enough about the social stigma of psoriasis and HS.”

Because these conditions are not well-known, others may mistakenly think that they are the result of infection. This can lead to patients with psoriasis or HS being socially or even professionally isolated. For many, it also impacts intimacy with their partners, because they’re uncomfortable being seen with sores or rashes.

Dr. Kiracofe describes two different patients with HS who had to take jobs less than 10 minutes from where they lived. These patients pretended that they smoked, so that they could take smoke breaks to go home, replace the towels or maxi pads they put under their arms to collect drainage, shower, and drive back to work. “They did that two times every day during the work day,” says Dr. Kiracofe. “They told me how they wished they could someday have more job options.”

Meanwhile, Dr. Monga says she had a patient who moved to a less hot and humid climate altogether. While this patient’s axSpA was well-controlled, they struggled to find relief from HS. “Managing both conditions influenced their treatment journey,” says Dr. Monga. “They needed adjustments in their treatment plans and lifestyle modifications to cope with HS symptoms exacerbated by climate conditions.”

A Real Patient Story of Living with Comorbidities

Madeline McCollum, a 37-year-old in Houston, has faced multiple diagnoses since 2015 — including ankylosing spondylitis (a type of axSpA), PsA, HS, and pyoderma gangrenosum (a painful, rare skin condition that causes ulcers).

“There was a time where it felt like I was getting a new diagnosis every year,” says McCollum. “It escalated really quickly and I ended up needing to have several surgeries to remove grafts and so forth.”

In the last eight to 10 years, her life has changed drastically as a result of her diagnoses. A former bakery owner, McCollum is now on disability and not working. “That has improved my quality of life significantly, but it took a good therapist to help me see that my worth is not in my productivity and my ability to work,” says McCollum. “I shifted my perspective to almost view my health as a job.”

However, as the diagnoses grew in number, McCollum found it difficult to answer well-meaning questions around how she was feeling or what her pain levels were. “It’s kind of like, what pain do you want to know about?” says McCollum. “I have a long list — and if it’s not pain, it’s wound care. It’s really overwhelming.”

Today, McCollum is focusing on managing her conditions and mental health. She does wound care every morning and night, takes weekly biologic shots, and has daily pain medication. Her daily routine involves trying to get outside, being mobile with walking or yoga when she can, finding ways to be creative, and connecting with friends and family. “I try to find something that brings me joy throughout the day, so I don’t have to always feel like everything is hard, but that life is beautiful as well,” she says.

McCollum’s advice for others coping with multiple comorbidities: As you receive advice from several different specialists, speak up for yourself to get the right care and treatment. “There’s a lot of noise as you’re being sent to multiple doctors,” says McCollum. “Trust the knowledge that you’ve taken in on your own. You know your body better than anyone, so you have to be brave in those moments, speak up for yourself, and trust yourself.”

Treatment Considerations for Managing Comorbidities

 When developing a treatment plan aimed at remission, it’s essential for both the patient and provider to factor in comorbid conditions, adds Dr. Khattri. For instance, if a patient with PsA also has psoriasis, or a patient with axSpA has IBD, managing these together can involve similar treatment options. However, other conditions, such as diabetes or depression, may not have shared treatment options, and it’s critical to address them, as they can affect the patient’s ability to achieve remission.

“The goal is to prevent disease progression and maintain quality of life, despite the challenges posed by multiple conditions,” says Dr. Monga. “Managing multiple conditions presents challenges in finding an effective treatment regimen that addresses all comorbidities.”

“I am quick to pursue biologic therapies in my patients because they have usually tried topical medications from their primary physician or anti-inflammatory medications from their rheumatologist,” adds Dr. Ploch. “Due to the severe impact of these diseases on quality of life, systemic therapy is often needed immediately.”

Every patient needs an individualized treatment plan. Ask your doctor about potential interactions between treatments, especially biologics and immunosuppressants, used to manage multiple conditions.

Also make sure that all of the physicians in your care team — including your rheumatologist, dermatologist, psychiatrist, and primary care provider — are working together and aware of all the medications you’re taking. This can help you avoid being prescribed, say, two heavy-hitting biologic immunosuppressive medications at once.

When you’re working with multiple specialists, it can be easy to forget about your primary care doctor, but having a great one can help you connect the dots between your specialists. “I always remind my patients that they need a really good quarterback for their care team,” says Dr. Kiracofe. “They need a primary care doctor that they really like, respect, and can engage with. As a specialist, I’m a phenomenal wide receiver, but not the quarterback.”

Finally, be open with all of your doctors about how you’re feeling. For instance, bringing up feelings of anxiety even to a specialist like your dermatologist can help them take a more holistic approach to your care and guide you to the right treatment or resources. “One of the most rewarding things that I experience as a physician is seeing someone transition from being in pain and self-conscious about their disease, to knowing there’s hope, then to experiencing life without the disease burden,” says Dr. Ploch. “Treatment is life-changing. It’s like watching a flower bloom, but it is a thousand times better.”

Advances in Managing Comorbidities

Treatments are becoming more targeted, so there’s a lower risk of side effects with today’s medicine than in previous years. “We are constantly discovering new cytokines to target with treatments,” says Dr. Ploch. “Over the years, treatments have become safer and less immunosuppressive.”

There is also more research going into other comorbidities, such as infertility and inflammatory bowel disease, plus the psychiatric burden of diseases like PsA or axSpA and how they affect quality of life.

Other advancements include improved preventive care strategies for managing cardiovascular comorbidities and ongoing research into the pathophysiology of HS to develop more targeted biologic therapies. “These advancements aim to enhance overall patient care, improve treatment outcomes, and mitigate the impact of comorbidities on quality of life for individuals with axSpA and PsA,” says Dr. Monga.

Listen to The Psoriatic Arthritis Club

The Psoriatic Arthritis Club podcast series delves deep into the ups and downs of living with PsA. Through intimate conversations with fellow patients and insights from leading experts, the series offers valuable information on how to manage symptoms, collaborate with health care providers, advocate for better care, and emotionally cope with the disease. Along the way, listeners will also pick up life hacks, tips, and tricks to live better with psoriatic arthritis. Listen now.

This article was made possible with support from UCB.