Synopsis
Recognise the diverse peripheral, entheseal, dactylitic and axial patterns of psoriatic arthritis, coordinate skin and joint priorities, and escalate disease-modifying treatment according to the dominant active domain.
- Psoriatic arthritis may present as asymmetric oligoarthritis, symmetrical polyarthritis, DIP disease, dactylitis, enthesitis or axial inflammation; actively search all domains.
- Psoriasis may be subtle or appear after arthritis, so inspect scalp, umbilicus, natal cleft, ears and nails and ask about family history.
- Dactylitis is whole-digit inflammation and enthesitis affects insertion sites; neither is captured reliably by a standard rheumatoid joint count.
Key red flags
One abruptly hot restricted joint, fever or immunosuppression requires aspiration and culture even when established PsA explains other symptoms.
Investigation priorities
Define peripheral, entheseal, dactylitic, axial and cutaneous disease domains.
Management branches
Persistent peripheral synovitis, dactylitis or function-limiting inflammatory disease accompanies psoriasis or a strong psoriatic phenotype.
- Document joints, digits, entheses, skin, nails, axial, eye and bowel features and obtain treatment-safety baseline bloods and infection assessment.
- Refer promptly to rheumatology and coordinate dermatology; begin a conventional DMARD for active peripheral arthritis according to shared domain priorities and contraindications.
Key medicines
Methotrexate with folic acidUsually 7.5–15 mg once weekly initially, titrated by rheumatology within the product-specific maximum; record one fixed dosing day and prescribe folic acid at least 5 mg once weekly on a different day.
AdalimumabThe usual adult psoriatic-arthritis regimen is 40 mg subcutaneously every other week under specialist prescribing and product information.