Is this a "bouttonneire"?

[northern_techie]

So I'm curious if anyone has this going on with any of their fingers:


It's kinda got a hump type shape and the tip points up a bit:


I think this is a "bouttonneire" but I'm not sure.... I'm curious if this kind of thing would reduce at all if I was on a DMARD or bio? I'm guessing not since the "knot" on my nuckle is hard like bone.

For what its worth, I do have nail involvement, though its more on my other hand:


I seem to be one of the ones that has very mild skin and nail involvement. Though my toenails are more involved; but I'm sure we don't want a pic of my ugly feet.

I always wonder if my symptoms are "bad enough" to warrant more aggressive treatment than just NSAIDs.

Thanks!
Tyler

[szorzi]

Tyler, your nails look just like mine, only a little better maybe. Not crumbly like some pictures show, but awful just the same, huh?

Is it bad enough for DMARDs? You'll have to make that decision for yourself, but I wouldn't want the rest of my fingers to go where that one has gone. For most people the truth is that it only gets worse if you don't treat it agressively.

[Ranger05]

Whats a bouttonneire? Do your fingers hurt? My middle finger swells up from time to time and looks like the side view pic you show. My Rheumy said a cortisone shot should do the trick, but i declined. I also have very mild skin involvement and no nail changes.

[northern_techie]

Tyler, your nails look just like mine, only a little better maybe. Not crumbly like some pictures show, but awful just the same, huh?

Is it bad enough for DMARDs? You'll have to make that decision for yourself, but I wouldn't want the rest of my fingers to go where that one has gone. For most people the truth is that it only gets worse if you don't treat it agressively.

Yes, I certainly don't have "model hands". But I guess any time I see pics online of "psoriatic nails", they usually show the most extreme cases.

Same with the deformities; they always show the most severe ones in reference pics online.

Would I want to go to DMARD or Bio treatment? Most definitely! I don't want my other fingers to do what this one has done (although my right ring finger has been progressing that way in the past 6-8 months). My hands are more tender now than they were before, and I am having to adapt to various everyday things like undoing my seatbelt, lifting trays out of the oven, opening jars, etc.

I guess my thing is my symptoms seem mild in comparison to what I've always read about online and I half expect the rheum to just say, "it's not so bad, NSAIDs are all you need". Sorta like how my GP said it to me.

Yet to know I know between the hands, and my ever increasing back issues, there is definitely progression enough to go to DMARDs in my eyes.

Tyler

[northern_techie]

Whats a bouttonneire? Do your fingers hurt? My middle finger swells up from time to time and looks like the side view pic you show. My Rheumy said a cortisone shot should do the trick, but i declined. I also have very mild skin involvement and no nail changes.

According to wikipedia:
Boutonniere deformity is a deformed position of the finger, in which the joint nearest the knuckle is permanently bent toward the palm while the furthest joint is bent back away.

The idea is that my nuckle is kinda semi-bent, and the tip of the finger is bent back up. Kinda hard to explain..


The joint is tender to the touch as are a good number of my other finger joints (except they're not this big or anything like that). I think if anything I'd take a cortisone shot in my neck.

Good to know I'm not the only one with mild skin and nail involvement...

[ginnylee]

My pinky fingers bow out slightly away from my hands and then the top section bends back in. My ring finger on my left hand is trying to bend like the picture. My fingers are swollen - just not to the same degree as your's.

I have very little skin involvement and no nail involvement. My fingers are sore to the touch. More joints than not are involved, I think.

[sandita]

[QUOTE=northern_techie;465764]So I'm curious if anyone has this going on with any of their fingers:


I'd say YES, or at least call the Rheumy's nurseline. I don't recall the name, but it's common in PsA and can cause permanent joint damage without heavier tx. The NSAID's won't prevent any permanent damage (according to research).
Good luck! sandita

[Ranger05]

I actually have no skin involvement any longer. When I started MTX I had 3 very small spots about the size of a dime, but they have since gone away. Unfortunatly, lack of nail involvement indicates a poor prognosis in the long run.

[northern_techie]

My pinky fingers bow out slightly away from my hands and then the top section bends back in. My ring finger on my left hand is trying to bend like the picture. My fingers are swollen - just not to the same degree as your's.

I have very little skin involvement and no nail involvement. My fingers are sore to the touch. More joints than not are involved, I think.

I can manually adjust the finger into a proper position with my other hand (sore, but possible), but I can't actually flex the finger into the right position on its own.

Is your finger swelling "soft" or "hard"? Where that knuckle is enlarged it feels hard as bone.

[northern_techie]

I'd say YES, or at least call the Rheumy's nurseline. I don't recall the name, but it's common in PsA and can cause permanent joint damage without heavier tx. The NSAID's won't prevent any permanent damage (according to research).
Good luck! sandita

I have my first appt with the Rheumy in June, but I do have a followup with my GP on Monday. I'll ask him if there is anything I can do to prevent joint damage; or for that matter if the damage has already been done. Its been this way for over a year now though, so I have a feeling I already know the answer.

Okay, good to know though, thanks. I'm getting hope that more aggressive treatment will be something the rheum will be willing to entertain.

Thanks!
Tyler

[northern_techie]

I actually have no skin involvement any longer. When I started MTX I had 3 very small spots about the size of a dime, but they have since gone away. Unfortunatly, lack of nail involvement indicates a poor prognosis in the long run.

Sounds like we have similar P. Mine is quarter sized on the knees, and then a couple small patches on my face.

Really? I thought it was the other way around.
Ah, my grad studies library access pays off.
According to Williamson et al. [1], "In patients with PsA, the severity of nail disease correlates with indicators of severity of both skin and joint disease." Also according to Serarslan [2], "However, the prevalence of bone involvement was higher in patients with finger and toenail involvement than without finger and toenail involvement".


[1] Williamson L, Dalbeth N, Dockerty JL, Gee BC, Weatherall R, Wordsworth BP. Extended report: nail disease in psoriatic arthritis--clinically important, potentially treatable and often overlooked. Rheumatology (Oxford). 2004 Jun;43(6):690-1. (http://www.ncbi.nlm.nih.gov/pubmed/15113998)
[2]Serarslan, G., Güler, H and Karazincir, S. The relationship between nail and distal phalangeal bone involvement severity in patients with psoriasis. Clinical Rheumatology, Volume 26, Number 8 / August, 2007 (http://www.springerlink.com/index/8P931X67511W2687.pdf)

[Ranger05]

Unfortunatly, most studies report nail involvement as protective for some reason. There is one study out there you can find if you look hard enough that says being female and having clear nails are the two worst prognosis factors. Not sure why.

[blessed4life]

Tyler - this does look like the boutonneire type of deformity. My middle & ring fingers on the left hand and middle finger on the right have that same kind of bending up at the PIP joint and dipping at the DIP joint (pun not really intended!). However, my joints aren't that swollen, nor are they very tender. I credit that to my rheumy starting me on Plaquenil in August for an "undifferentiated connective tissue disease." However at the beginning of Dec. my joints looked normal - just some mild swelling - and by Feb. my fingers had noticeable "deformity" (my rheumy's comforting words!). At that point I started on 10mg of MTX per week and in March increased to 12.5. Unfortunately it seems to be gradually getting worse. I have another appt. at the beginning of June. I definitely recommend trying the D-MARDS. I can't imagine how badly off I would have been if I hadn't started them early on.

[Ranger05]

What is the long-term prognosis for psoriatic arthritis?
Most people with psoriatic arthritis will have ongoing problems with arthritis throughout the rest of their life. Remissions are uncommon; occurring in les than 20% of patients with less than 10% of patients having a complete remission off all medication with no signs of joint damage on X-rays.

Features associated with a relatively good prognosis are:

Male sex
Fewer joints involved
Good functional status at presentation (this relates to ability to carry out normal daily tasks at work and home)
Previous remission in symptoms
Some genetic subtypes (this can determined by a blood test looking at a genetic marker called an HLA-group)
Features associated with a poor prognosis include:

ESR >15 mm/hr at presentation
Use of medication prior to initial consultation
Absence of nail changes
Joint damage on x-rays

[szorzi]

Features associated with a poor prognosis include:

ESR >15 mm/hr at presentation
Use of medication prior to initial consultation
Absence of nail changes
Joint damage on x-rays

Ranger, I've always wondered if that is a typo or something. Every other site or pamphlet I've read has said the opposite.

Nail involvement increases your chance of developing PA in the first place. How could it, at the same time, indicate a good prognosis?

[Ranger05]

mmm, no I don't think it's a typo szorzi. I wish that was the case but I have read several excerts that say the same thing. But i've come to learn that just about everything can be contridicted in PsA. I'm afraid it's a very misunderstood disease. For example, I can post about a billion web pages that say PsA is a mild condition and we certainly know thats not always the case. Very confusing researching this thing. I finally stopped researching the web because it was becomming pointless.

[northern_techie]

I did a little digging; one of the references I found to nail pitting being a protective factor was this article:
Gladman DD, Farewell VT, Wong K, Husted J: Mortality studies in psoriatic arthritis: results from a single outpatient center. II. Prognostic indicators for death. Arthritis Rheum 1998, 41:1103–1110. (http://www.ncbi.nlm.nih.gov.proxy1.l...?dopt=Abstract)
The abstract of the article mentions this at the end.

However that's a pretty old article. I'm sure there is more recent data available though.

Still an interesting thing to note.

[northern_techie]

Tyler - this does look like the boutonneire type of deformity. My middle & ring fingers on the left hand and middle finger on the right have that same kind of bending up at the PIP joint and dipping at the DIP joint (pun not really intended!). However, my joints aren't that swollen, nor are they very tender. I credit that to my rheumy starting me on Plaquenil in August for an "undifferentiated connective tissue disease." However at the beginning of Dec. my joints looked normal - just some mild swelling - and by Feb. my fingers had noticeable "deformity" (my rheumy's comforting words!). At that point I started on 10mg of MTX per week and in March increased to 12.5. Unfortunately it seems to be gradually getting worse. I have another appt. at the beginning of June. I definitely recommend trying the D-MARDS. I can't imagine how badly off I would have been if I hadn't started them early on.

Well, I'm definitely going to push for aggressive treatment when I see the Rheum in June.
It sounds like my symptoms are on par with what a lot of people who are using dmards and bios are experiencing.

This is good! It means I CAN do something to help get some much needed relief and prevent things from getting worse!

Thanks!
Tyler

[sandita]

Unfortunatly, most studies report nail involvement as protective for some reason. There is one study out there you can find if you look hard enough that says being female and having clear nails are the two worst prognosis factors. Not sure why.

Damn. I'm female and I have clear nails (and I have PsA). Whaddya know? I'll have to dig for the article....
:-) sandita

[northern_techie]

Damn. I'm female and I have clear nails (and I have PsA). Whaddya know? I'll have to dig for the article....
:-) sandita

Keep in mind that these are statistical trends; doesn't mean you aren't falling outside the bell curve and have a perfectly fine prognosis.

Tyler

[Ranger05]

Damn. I'm female and I have clear nails (and I have PsA). Whaddya know? I'll have to dig for the article....
:-) sandita

I seriously wouldn't worry about it. I did ask my Rheumy about this a while back. She said that in her expierence she has not seen any significance either way when it comes to nail involvement. She was perplexed that my nails were completely clear however. In her opinion this is extremely rare. She believes it's even much more common then the quoted 80-85%. She says nail changes can almost always be seen if one looks hard enough.

[moe34]

That is pretty much what my middle finger on my left hand looks like also, and it is called buttoniares. I had physical therapry a few years ago and that is exactly what my therapist called it. I have been on methotrexate and it has not helped to straighten the finger out at all, I think the only thing that would help would possibly be surgery to straighten the ligament or something like that!

[northern_techie]

That is pretty much what my middle finger on my left hand looks like also, and it is called buttoniares. I had physical therapry a few years ago and that is exactly what my therapist called it. I have been on methotrexate and it has not helped to straighten the finger out at all, I think the only thing that would help would possibly be surgery to straighten the ligament or something like that!

I guess i'm not surprised it won't get better. I guess the damage has really been done.

It doesn't seem to functionally impair the way I use my hands so far so I should be fine with just living with it. However, I'd clearly like to prevent it from getting any worse or having other fingers do that.

Has the MTX helped with the pain? I find mine is tender and sore when flexed certain ways.

Any idea if the "thick nuckle" is bone changes or just soft tissue? My nuckle is rock hard as if its bone, but who knows.

Tyler

[szorzi]

Tyler, it really upsets me that you are still waiting to get in to see a rheumy while possible permanent damage is being done. Can't your regular doctor do anything to speed this up? Can't he see what is happening?

[chrisr01]

I had a finger that looked like this not quite as bad
but i have been on prednisone and the swelling and pain went down considerably
still waiting for mtx to kick in.

have been on it almost 12 weeks now