Synopsis
Recognise peripheral spondyloarthritis from arthritis, enthesitis and dactylitis plus associated features, exclude urgent infection, and select therapy according to the dominant peripheral and extra-articular domains.
- Peripheral spondyloarthritis is recognised from asymmetric arthritis, enthesitis or dactylitis plus psoriasis, uveitis, bowel disease, recent infection, axial symptoms or family history.
- Inspect skin, scalp, nails and hidden flexures and ask about eye, bowel and genitourinary disease even when the referral says isolated tendon pain.
- HLA-B27 and inflammatory markers can support but neither confirm nor exclude peripheral disease.
- Aspirate a newly hot effusion because septic and crystal arthritis can mimic or coexist with spondyloarthritis.
- Use exercise, physiotherapy and load modification for function while avoiding prolonged immobilisation of inflammatory enthesitis.
- NSAIDs may reduce symptoms when safe; local corticosteroid injection can be considered after infection exclusion and with care around high-risk tendon sites.
- Persistent peripheral arthritis may require a conventional DMARD; refractory arthritis, enthesitis or dactylitis may need specialist targeted therapy.
- Coordinate medicine choice with psoriasis, inflammatory bowel disease and uveitis because efficacy and adverse effects differ across classes.
Key red flags
Pain, photophobia, redness and blurred vision needs same-day ophthalmic assessment and should be communicated to rheumatology.
One severely painful hot restricted joint, particularly during immunosuppression, needs urgent aspiration and culture.
Investigation priorities
Document peripheral joints, entheses, dactylitis, axial signs, skin, nail, eye and bowel associations.
Management branches
Persistent asymmetric arthritis, dactylitis or multisite enthesitis lacks an acute infection signal.
- Map joints, entheses, digits, spine, skin, nails and eye or bowel history and obtain baseline treatment-safety tests.
- Refer to rheumatology through the peripheral spondyloarthritis pathway, highlighting psoriasis, uveitis, IBD, infection and family history.
- Begin safe symptom and functional care while preserving diagnostic visibility and arranging urgent review for one hot joint or eye symptoms.
Key medicines
NaproxenCommon adult dosing is 250–500 mg orally twice daily with food for a reviewed trial when risk permits.Review ulcer, renal, cardiovascular, anticoagulant and bowel risks and use the lowest effective dose with gastroprotection when indicated. From 20 weeks of pregnancy, avoid systemic NSAIDs unless necessary and then keep exposure minimal; after 28 weeks naproxen is contraindicated.
SulfasalazineCommonly started at 500 mg once daily and increased gradually toward 1 g twice daily under specialist monitoring.Monitor FBC, renal and liver function; counsel about serious rash, gastrointestinal intolerance, blood dyscrasia and reversible oligospermia, and review sulfonamide allergy and azathioprine or 6-mercaptopurine interaction. Pause it for a serious infection until recovery and specialist review. In pregnancy, give folic acid 5 mg daily during periconception and the first trimester.