Patient Case 2: Psoriasis and Emerging Psoriatic Arthritis

Experts discuss a second hypothetical case involving a 53-year-old woman with a 12-year history of psoriasis. She is now showing signs of psoriatic arthritis (PsA), including morning stiffness, fatigue, and nail pitting. Despite being on an IL-23 inhibitor, she has only a partial skin response (8% BSA) and active joint symptoms, having previously lost efficacy on two TNF-alpha inhibitors.

Experts emphasize that the presence of joint symptoms dramatically shifts treatment priorities. PsA can cause irreversible, destructive joint damage, making its control the primary concern over skin plaques. Dermatologists often serve as the first line of defense, especially with limited rheumatology access. A key tool is the Psoriasis Epidemiology Screening Tool (PEST), a validated 5-question screen that helps identify patients at high risk for PsA. The consensus is to act quickly, choosing a systemic therapy approved for both psoriasis and PsA to address the systemic nature of the disease comprehensively.