Psoriatic arthritis (PsA) is a chronic, systemic inflammatory disease involving both the skin and the joints. It develops in up to 30% of people with psoriasis, though joint symptoms may appear first or concurrently with skin plaques. As an autoimmune condition causing inflammation throughout the body, PsA requires specialized and coordinated medical management. Treatment involves addressing joint inflammation to prevent permanent damage while managing symptoms on the skin and nails.
The Role of the Rheumatologist
The rheumatologist is responsible for the diagnosis and comprehensive management of psoriatic arthritis. Rheumatologists are experts in inflammatory diseases affecting the musculoskeletal system, including the joints, tendons, and ligaments. Their goal is to control systemic inflammation and prevent the progression of joint and bone damage, which can lead to functional disability.
The rheumatologist prescribes systemic medications that modify the course of the disease, often following a “treat-to-target” approach. Treatments include conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate, which suppress the immune system. They also use targeted therapies, including biologic DMARDs and targeted synthetic DMARDs, which focus on specific inflammatory pathways, such as blocking tumor necrosis factor (TNF)-alpha or interleukins. Biologics target precise proteins that drive the inflammation in PsA.
The rheumatologist’s focus extends beyond the peripheral joints to include the spine (axial disease) and the sites where tendons and ligaments attach to bone (enthesitis). They use diagnostic tools like imaging studies and blood tests to monitor disease activity and structural changes. Early treatment is crucial because delays can result in irreversible joint deformities and functional loss.
Addressing Skin and Nail Symptoms
The dermatologist specializes in managing the skin and nail manifestations of psoriatic arthritis. Since skin psoriasis often precedes joint symptoms, the dermatologist is frequently the first physician to suspect and screen for PsA. They monitor nail involvement, characterized by pitting, crumbling, or separation from the nail bed, as it is a recognized risk factor for joint disease development.
Dermatologists use topical medications, phototherapy, and coordinate systemic treatments with the rheumatologist. Many biologic medications prescribed for joint inflammation are also effective at clearing skin plaques and improving nail disease. This overlap necessitates close communication between the two specialists to ensure therapies are complementary. The goal is to manage the discomfort and visibility of skin lesions, which impacts a patient’s quality of life, while monitoring for signs of joint disease.
The Multidisciplinary Care Team
Psoriatic arthritis is a systemic disease with diverse manifestations, so comprehensive care relies on a multidisciplinary team beyond the primary specialists.
- A physical therapist designs personalized exercise programs to maintain joint mobility, muscle strength, and flexibility. They focus on improving range of motion and reducing stiffness.
- An occupational therapist helps patients adapt daily activities to manage joint pain and preserve joint function, often through the use of assistive devices.
- An ophthalmologist may be involved to screen for and manage uveitis, a form of eye inflammation that is a known complication of PsA.
- The primary care physician (PCP) coordinates overall health and addresses associated conditions, such as cardiovascular disease, metabolic syndrome, and mental health issues.
Navigating the Diagnostic Process
The process of receiving a confirmed psoriatic arthritis diagnosis typically begins with the primary care provider (PCP). A patient may visit their PCP with unexplained joint pain, stiffness, or persistent swelling in a finger or toe (dactylitis), especially if they have a history of psoriasis. The PCP uses screening tools, such as the Psoriasis Epidemiology Screening Tool (PEST), to assess the likelihood of PsA and determine the need for a referral.
Once PsA is suspected, a referral to a rheumatologist is required to prevent progressive joint destruction. Symptoms that trigger a specialist referral include inflammatory back pain, dactylitis, enthesitis, or inflammatory peripheral joint pain. Delays in this referral pathway can lead to greater disease severity and irreversible damage. The rheumatologist then conducts a thorough examination, including imaging and laboratory tests, to confirm the diagnosis and distinguish PsA from other forms of inflammatory arthritis.