Synopsis
Screen every person with psoriasis for peripheral and axial musculoskeletal disease, understand PEST limitations, identify urgent mimics, and refer suspected psoriatic arthritis before structural damage accumulates.
- Offer annual psoriatic arthritis assessment to everyone with psoriasis, especially during the first ten years after psoriasis begins, and reassess whenever musculoskeletal symptoms change.
- Ask about swollen joints, morning stiffness, dactylitis, heel or other enthesis pain and inflammatory back pain; examine rather than relying on the word arthritis.
- Use a validated adult tool such as PEST in primary and specialist care, but remember that PEST does not detect axial arthritis or inflammatory back pain.
Key red flags
A hot, very painful swollen joint with fever, rigors or immunosuppression is septic arthritis until urgently assessed and sampled.
Persistent swelling, pain and stiffness may be asymmetric, oligoarticular or polyarticular. Morning stiffness and improvement with movement support inflammation, but examine for synovitis rather than using duration alone.
Investigation priorities
Identify peripheral synovitis, dactylitis, enthesitis and axial features in every person with psoriasis.
Management branches
Any person with psoriasis, regardless of current skin severity or treatment.
- Ask about new or recurrent joint swelling, morning stiffness, whole-digit swelling, heel pain and back or buttock pain with night waking or improvement on movement.
- Use PEST in adults, then deliberately add axial questions because the tool does not assess inflammatory back pain.