Managing a flare

A flare (you may also hear "flare-up") is a temporary rise in the activity of your underlying condition. Joints that were manageable become more painful, more swollen and noticeably stiffer, morning stiffness stretches out, and fatigue often deepens at the same time, sometimes with lower mood and poorer sleep alongside. That fatigue tends to ride along with flares rather than being a separate problem, and our guide to fatigue and arthritis covers it in its own right. Flares vary widely: in conditions from rheumatoid arthritis and psoriatic arthritis to gout, some involve one or two joints, others sweep across the body; some pass within days, others need help to settle.

A flare is not the ordinary soreness that follows doing more than usual. After-activity soreness arrives within a day of the activity, affects muscles as much as joints, and eases over a day or two without real swelling, warmth or prolonged stiffness. And a flare is not an infection. Fever, shivering and feeling genuinely unwell are not flare symptoms, and their arrival alongside a hot joint changes everything about what to do next, as set out below.

Some flares follow a recognisable trigger. An infection, even a cold or a stomach upset, can stir the immune system into wider activity. Stressful periods, poor sleep and emotional strain are commonly reported in the run-up to a flare. Overdoing it physically, whether one heavy day or a stretch of them, can set joints off. And missing doses of your regular medicines, or stopping them altogether, is one of the more avoidable triggers: disease-modifying treatment works by keeping inflammation suppressed day in, day out, and it can only do that if it is actually taken.

Just as often, though, no trigger can be found. A flare arriving out of a clear blue sky does not mean you did something wrong, and hunting for a cause that is not there is a poor use of limited energy. What matters more is having a plan for the flare itself. One footnote: in gout, flares have their own particular triggers and their own specific treatment, covered in that guide, but the general approach on this page still applies.

The first few days of a flare reward simple measures done consistently.

• Rest the worst joints, not the whole of you. Give the most inflamed joints relative rest, but keep the rest of your body gently moving: short walks, light stretching, changing position often. Complete rest tends to stiffen everything and makes the return to normal slower.
• Use temperature sensibly. A cold pack wrapped in a cloth eases a hot, swollen joint; warmth, such as a heat pad or a warm shower, suits stiff, aching areas that are not visibly swollen.
• Pace the days. Break tasks into smaller pieces with rests between, let the less urgent things wait, and tell the people around you what is happening so they can pick up some of the load.
• Keep taking your regular medicines as prescribed, unless your team has told you otherwise. A flare is never a reason to stop treatment on your own, and stopping usually makes things worse. The exception territory is infection, where some medicines are sometimes paused on your team's advice, covered in our guide to infections and arthritis medicines.

If your team has already agreed a flare plan with you, or prescribed rescue treatment to keep at home, start it promptly: flares are generally easier to settle when they are tackled early.

Simple pain relief has an honest, useful role while a flare settles. Paracetamol helps take the edge off pain. An anti-inflammatory such as ibuprofen or naproxen can ease both pain and stiffness, with the usual cautions these tablets carry: care over the stomach, the kidneys and blood pressure, and particular caution if you are older, pregnant, have other conditions or take other medicines. A pharmacist or your GP can advise quickly if you are unsure. If you already take a prescribed anti-inflammatory, do not add another from the chemist on top: the two double up the risks rather than the benefit.

Pain relief is a bridge, not a destination. If a flare needs more than a few days of regular painkillers, that is a signal to contact your team rather than simply to keep taking them.

Steroids are often part of how a flare is settled, and your team may use them deliberately: a short course of tablets, an injection into a muscle, or an injection into the joint itself, as covered in steroid injections: when they help. Used this way, at the right moment, they are a valuable tool.

What you should not do is reach for them yourself. Do not start, increase or add steroid tablets on your own initiative during a flare, including leftover tablets from a previous course. Whether to bridge a flare with steroids, and how, depends on your overall treatment, your other conditions and what the flare is telling the team, so the decision belongs with them, made together with you. Equally, if you take steroid tablets long term, never stop them suddenly: any reduction is made gradually, under guidance.

Contact your rheumatology team, or your GP if you are not under a team, when a flare is severe, when it is not clearly settling after a few days, or when flares keep returning. Recurring flares are not a personal failure and not something to quietly endure. They are information: often the earliest sign that a condition is less well controlled than it was, and that treatment deserves a review, whether that means adjusting a dose, adding something, or moving to a different medicine among the DMARDs or biologics and JAK inhibitors. There is a harder reason not to put up with them, too: every flare is a period of active inflammation, and joints do not tolerate repeated inflammation indefinitely. Flares that keep returning will, over time, cause lasting joint damage, and preventing exactly that is what a treatment review is for.

You can make that review much more useful. Keep brief notes: when the flare started, which joints were involved, anything that seemed to set it off, and what helped. Above all, photograph visible swelling while it is there. Swelling has a habit of settling by the day of the appointment, and a clear photograph of a swollen knuckle or knee, ideally next to its normal partner, genuinely changes consultations in a way a description from memory cannot.

Timing matters too. Inconvenient as it is, a flare is often the most informative moment to be assessed. Because Dr Borukhson performs point-of-care ultrasound during the consultation, a flaring joint can be examined and scanned in the same visit: ultrasound can confirm whether there is active inflammation in the joint lining or tendon sheaths, and where one joint is driving the trouble, an ultrasound-guided injection can often treat it there and then, where that is appropriate.

Most flares can be managed with the steps above and a planned call to your team. A few situations must not wait.

Seek same-day emergency assessment, through A&E or NHS 111, if one joint is hot, swollen and very painful and you have a fever, shivering or feel unwell. A joint infection (septic arthritis) can look exactly like a flare, it can damage a joint within days, and it is never something to watch overnight or book a routine appointment for. This rule holds however many flares you have had before: a single joint behaving differently from your usual pattern deserves the same caution as a first episode.

Call 999 if you become severely unwell with a suspected infection: confusion or unusual drowsiness, breathing very fast, or skin that is cold, mottled or blue-tinged can be signs of sepsis.

Arrange urgent same-day advice from your GP or NHS 111 for:

• New weakness or new numbness during a flare, whether in a limb or spreading
• New eye pain, redness or any change in vision. Several rheumatological conditions can inflame the eye, as covered in our guide to uveitis, and eye inflammation needs same-day assessment to protect sight
• Fever with a flare that is not centred on a single joint but is making you progressively more unwell

And contact your rheumatology team, or your GP, within a few days if a flare is severe, is not settling, or keeps returning despite treatment.

A flare can feel like a defeat, especially after a long stretch of good control, and it is easy to turn it inward: something you ate, something you skipped, something you should have done differently. Sometimes there is a trigger worth learning from, and more often there is not. Either way, blame is the least useful response and usually the least accurate one. Modern treatment aims to make flares rare, but it does not always make them extinct, and a flare says something about the disease, not about you. Handled well, it even earns its keep: a documented flare, with notes and photographs, shows your team exactly what your condition does when it moves, and that is the evidence on which good treatment decisions are made. Settle the joints, keep yourself safe with the red lines above, and then let the flare do the one useful thing it can: inform the review that makes the next one less likely.

How can I tell the difference between a flare and a joint infection?

You should not try to settle that question at home. A flare and a joint infection (septic arthritis) can look very similar, but an infection can damage a joint within days. If one joint is hot, swollen and very painful and you have a fever, shivering or feel unwell, seek same-day emergency assessment through A&E or NHS 111, never a routine appointment. A flare affecting your usual joints in your usual pattern, without fever, can generally be managed with your flare plan and a call to your team.

Can I take a few extra steroid tablets to settle a flare?

No. Steroids can be the right tool for a flare, but starting, increasing or adding them is a decision for your rheumatology team, based on your overall treatment and what the flare is telling them. Taking leftover tablets, or increasing your current dose on your own, can cause harm and can also muddy the picture your team needs in order to treat you well. If you take steroid tablets long term, never stop them suddenly either: changes are always made gradually, under guidance.

Should I rest completely or keep moving during a flare?

Both, in the right proportions. Give the most inflamed joints relative rest, but keep the rest of your body gently moving with short walks, light stretching and frequent changes of position. Complete rest tends to stiffen everything and makes the recovery slower. As the flare settles, build activity back up gradually; our guide to arthritis and exercise covers how.

The swelling always disappears before my appointment. How do I show anyone?

Photograph it. A clear photo of the swollen joint, ideally next to its normal partner, taken while the swelling is present, genuinely changes consultations and is far more useful than a description from memory. Brief notes on when the flare started, which joints were involved and what helped will complete the picture. Ultrasound can also detect inflammation that has quietened but not fully gone, so an examination soon after a flare is still worthwhile.

Why do I keep flaring even though I take my medicines properly?

Because flares are part of how these conditions behave, not proof that you are doing something wrong. Occasional flares can happen even on good treatment. But flares that keep returning are information: they often mean the condition is less well controlled than it could be and that treatment deserves a review, whether that means adjusting a dose or considering a different medicine. That review matters, because every flare is a period of active inflammation, and flares that keep returning will, over time, cause lasting joint damage. Tell your team about every significant flare, including the ones that settled on their own.