The silent threat in psoriatic arthritis: Only 1 in 6 rheumatologists knew its extent

By Lisa Marie Basile | Fact-checked by Davi Sherman

Published February 28, 2025

Key Takeaways

Industry Buzz

“Psoriatic arthritis [PsA] leads to long-term damage [from] the body's immune system attacking itself by bringing inflammation to the bones of the spine, pelvis, joints, and their surrounding soft tissues.”— Stella Bard, MD, a board-certified rheumatologist
“I believe most rheumatologists still use TNF inhibitors as first line treatment for most patients with PsA because of their track record and familiarity with their use.” — Anca D. Askanase, MD, MPH, Professor of Medicine in the Division of Rheumatology and Clinical Immunology at Columbia University Vagelos College of Physicians and Surgeons

Find more of your peers' perspectives and insights below.

Patients with psoriatic arthritis (PsA), a type of immune-mediated inflammatory arthritis, face the possibility of living with permanent joint damage. Because PsA is severely under-diagnosed, many patients are left untreated and experience worsening disease severity and joint damage.^[]

Even in patients using disease-modifying anti-rheumatic drugs (DMARDs), joint damage is seen in nearly half (47%) of patients in the first 2 years of the disease. But why? And how can physicians help their patients avoid this silent threat?

What percentage of untreated psoriatic arthritis patients experience permanent joint damage within 2 years of disease onset? Only 1 in 6 rheumatologists answered this question correctly. Can you?

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Rheumatologists respond

“[PsA] leads to long-term damage [from] the body's immune system attacking itself by bringing inflammation to the bones of the spine, pelvis, joints, and their surrounding soft tissues [and] the entheses,” Stella Bard, MD, a board-certified rheumatologist who manages complex rheumatologic conditions, tells MDLinx.

This inflammation leads to “destruction of cartilage and bone, resulting in joint deformities [and] reduced range of motion [and] causing loss of function.” The erosions can cause irreversible damage.

Patients can experience “exquisite pain during movement,” with swollen fingers and toes, according to Dr. Bard. They may also see spinal involvement, causing chronic back pain and stiffness. “Over time, this can permanently limit posture and spine mobility,” she says. The worst damage of all? Osteolysis. “It’s perhaps the scariest complication of psoriatic arthritis, causing bone erosion and bone destruction,” Dr. Bard says.

Treating PsA: What are the options?

“All people with PsA are at risk for joint damage,” says Anca D. Askanase, MD, MPH, Professor of Medicine in the Division of Rheumatology and Clinical Immunology at Columbia University Vagelos College of Physicians and Surgeons. “Early diagnosis and treatment with [DMARDs] prevent damage.”

Physicians often prescribe DMARDs as a first line of treatment.^[] Biologics are another option. “The presence of significant skin psoriasis should favor the use of IL-23 and IL-17 inhibitors after conventional DMARDs’ failure,” Dr. Askanase says.

Tumor necrosis factor (TNF) inhibitors seem to be favored. “For patients with PsA, I believe most rheumatologists still use TNF inhibitors as [a] first line treatment for most patients with PsA because of their track record and familiarity with their use,” Dr. Askanase says, adding that IL-23 inhibitors work well in cases of joint manifestations.

Your patients should know that biologics can take up to 12 weeks to work, with most still showing efficacy at 24-plus weeks.^[] There are also targeted DMARDs, such as apremilast (Otezla) and tofacitinib (Xeljanz).^[]

Going the natural route

“I will always support as many options as possible to heal, but it doesn’t mean every person can go straight to drugs if [they] can do an upstream intervention to improve what develops the disease in the first place: inflammation,” Aly Cohen, MD, tells MDLinx.

Aly Cohen, MD, a rheumatologist and integrative medicine practitioner and the author of Detoxify, offers another perspective: “Biologics are wonderful for many patients, but they're not in my world the reflexively used option, unless warranted clinically.” She says that physicians should encourage patients to switch from ultra-processed foods to whole foods, drink clean water, and manage stress and sleep. Some research has found an association between joint pain and dietary, sleep, and exercise changes.^[]