August is Psoriasis Awareness/Action Month, a time to spotlight the challenges and opportunities in advancing care for individuals living with psoriatic disease. Psoriasis and psoriatic arthritis (PsA) are 2 sides of the same coin, with patients living with psoriasis facing the possibility of developing PsA.
Psoriasis, a chronic inflammatory skin disease, impacts an estimated 2–3% of the global population. Approximately 25-30% of patients with psoriasis develop PsA, and dermatologists are often the first to encounter such patients.1 Given that skin disease can precede joint disease in so many patients, dermatologists are consequently placed in a critical position to identify PsA early.2,3
PsA can result in progressive joint damage, disability, and impaired quality of life, often appearing years after symptoms in patients’ skin. If left untreated, PsA can cause irreversible joint damage and disability, underscoring the importance of early detection and co-management.
Dermatologists have long focused on the skin, while rheumatologists manage joints. For patients living with psoriatic disease, however, this siloed care model often results in missed opportunities for early detection. It can also mean delayed diagnosis and even fragmented treatment pathways. Diagnostic delays remain one of the most significant unmet needs in PsA – currently, diagnoses are made on average 2 – 6 years from symptom onset, during which time irreversible joint damage may occur.4
Today, there is an increasing body of evidence and expert consensus that makes 1 thing clear: collaboration between dermatology and rheumatology is not just beneficial, it is essential. To address such an issue, dermatologists and rheumatologists will have to collaborate to recognize risk factors, apply screening strategies, and coordinate medication options. The HCPLive team spoke with 3 leading dermatology and rheumatology experts on how clinicians can bridge the divide between specialties to improve early detection and coordinated care.
In this feature, the team interviewed Saakshi Khattri MD, the Director of Center for Connective Tissue Diseases at the Icahn School of Medicine at Mount Sinai, as well as April Armstrong, MD, MPH, Chief of the Division of Dermatology at UCLA Health and the David Geffen School of Medicine at UCLA, and Andrew Alexis, MD, MPH, and Andrew Alexis, MD, MPH, Professor of Clinical Dermatology and Vice-Chair for Diversity and Inclusion at Weill Cornell Medicine.
Psoriasis as a Systemic Disease: Dermatology’s Role in Risk Assessment
Psoriasis is often the entry point for patients, and dermatologists are uniquely positioned to spot early PsA risk. Patients often present first to dermatology clinics with skin symptoms, years before any form of arthritis emerges. If dermatologists are not actively screening for early signs of joint disease, the window for any type of intervention can close rapidly.
April Armstrong, MD, MPH, emphasized the timing of patients’ interactions with clinicians.
“Many of our patients with psoriasis actually present to dermatologists when they first have PsA signs and symptoms,” Armstrong explained. “…In fact, about 80% of them will have skin signs of psoriasis before they develop PsA.”
Recognizing psoriasis as a systemic disease shifts the dermatologist’s role: from managing visible lesions to also monitoring invisible risks. Armstrong underscored just how predictive psoriasis can be for PsA.
“We know that about 80 percent of the time psoriasis comes before PsA,” she said. “For dermatologists, that means risk assessment must be embedded in every patient interaction. PsA isn’t a rare complication—it’s a common and expected trajectory for many psoriasis patients. Early recognition may be the difference between preserving joint function and lifelong disability.
“[European Alliance of Associations for Rheumatology] guidelines advocate for asking questions associated with PSA at every visit,” Saakshi Khattri, MD, said. “Even if you’re not doing the [Psoriasis Epidemiology Screening Tool] questionnaire, just asking a patient how they feel, are they having morning stiffness? Do their joints hurt?”
Khatri highlighted that if these questions are continuously asked and if there is a notable change from a patient’s previous baseline, then this should clue clinicians in that the patient may be progressing to PsA. Certain skin phenotypes also carry an increased risk. Khattri pointed out that clinicians should pay close attention to sites and features associated with PsA.
“Very importantly, we also look for nail findings…if they have pitting in their nail…that can all be suggestive of PsA,” Khattri highlighted. She also echoed the importance of stratifying risk among patients. Khattri, Armstrong, and Alexis all emphasized the importance of dermatologists’ role in recognizing psoriasis as systemic and actively assessing PsA risk at each visit.
Bridging Specialties: Spotting and Managing PsA Early
One of the most persistent challenges in PsA is the delay in one’s diagnosis, sometimes stretching years from first joint symptoms to a confirmed PsA diagnosis. Patients may normalize stiffness or pain. Clinicians may also avoid asking the right questions, leading to issues down the road. This gap matters: irreversible joint damage may already be underway by the time rheumatologists are brought in.
“One of the things that we think about in terms of when to suspect patients may have signs and symptoms of psoriatic arthritis is when they start to develop stiffness in their joints in the morning, and that lasts for greater than 30 minutes,” Armstrong said. “Then, when they notice that with movement, this stiffness starts to get better. This suggests an inflammatory arthritis. Also, if they start to develop sausage digits or swelling of the entire digit in the fingers or the toes, or if they notice inflammation in the tendon insertion site.”
Andrew Alexis, MD, MPH, also stressed the importance of basic, consistent history-taking among patients. He echoed Khattri and Armstrong’s sentiments about the necessity of asking questions, the PEST questionnaire, and getting a strong overview of patients’ symptoms.
“One of the things that I think is important is to just ask very basic questions about joint pain, joint stiffness, morning stiffness, because patients are not always going to volunteer that information…” Alexis explained. “There’s also the PEST questionnaire, and that can be a useful screening tool. It’s very short, it’s easy to administer, and it can help flag patients who might need further evaluation.”
The barrier, Alexis emphasized, is time. In a busy dermatology clinic, skin often dominates the visit. Building in a moment to ask about joints may feel secondary, but it can be life-altering for the patient. By combining pointed history-taking with validated tools, dermatologists can bridge the gap and flag patients earlier who require rheumatology referrals.
Mapping the trajectory from first plaque to PsA diagnosis often reveals a variety of drop-off points: referrals that never get scheduled, dermatology visits that do not probe for joint pain, rheumatology waitlists that stretch months. Patients with psoriatic disease are often left to connect the dots by themselves.
“Rheumatology private practices are siloed,” Khattri noted. “Dermatology private practices are siloed… the onus [is placed] on the patient to be that interface between 2 distinct providers, which might not necessarily be a fair ask of a patient who [may be] overwhelmed with all this medical jargon and their disease, which they deal with every day.”
Ultimately, integrated care is the linchpin of better psoriatic disease outcomes. Dermatologists and rheumatologists share the same patients, but fragmented systems can create obstacles. Combined clinics, shared EMRs, and patient navigators are tools that bring silos together. But even absent these systemic changes, small steps—like consistent screening questions, or proactive follow-up calls—can make a difference.
“Co-management with rheumatology is really important, but it does require communication, and it requires some understanding of what each other’s priorities are in terms of therapeutic goals,” Alexis expressed.
As awareness grows, multidisciplinary clinics, shared screening protocols, and proactive referral networks may offer solutions to dismantle the barriers of siloed care.
Shared Patients, Shared Pathways: Optimizing Treatment
The therapeutic landscape has shifted dramatically in the last decade as biologics and systemic therapies targeting IL-17, IL-23, and TNF pathways now show efficacy across skin and joint domains. This overlap means that therapeutic decisions are no longer the sole province of one specialty—they must be coordinated. Furthermore, emerging data has begun to reframe early systemic therapy not only as a skin intervention but potentially as PsA prevention.
“We have biologics or systemic therapies, both oral as well as injectable, that do have an indication for both psoriasis and psoriatic arthritis,” Khattri said. “So if a dermatologist has any doubt that [about whether] this patient has PsA, and they’re already considering something systemically for skin disease, then it sort of covers both bases…We have retrospective data suggesting that systemic therapy in psoriasis may reduce the incidence of PsA.”
Alexis also emphasized how this convergence creates opportunities for early, comprehensive intervention, saying that with “a biologic agent that treats both PsA and psoriasis…we might get the patient on track…even before seeing the rheumatologist.”
This shared therapeutic space strengthens the case for coordinated management strategies across specialties.
Conclusion: Uniting Skin and Joint Care
Psoriasis and PsA are not separate conditions but intertwined manifestations of a systemic inflammatory process. The data make it clear that skin disease precedes joint involvement in most patients and that early detection and treatment can dramatically alter the course of disease.1,2,3 . For clinicians, that means breaking old habits of siloed care and embracing a collaborative model.
In HCPLive’s conversations with Armstrong, Alexis, and Khattri, all 3 highlighted how much progress has been made in recognizing PsO as a systemic disease, developing effective therapies that target both skin and joint inflammation, and establishing straightforward screening strategies that dermatologists can implement in routine practice.
Coordinated communication, proactive referral pathways, and shared decision-making between dermatologists and rheumatologists offer the best chance at preserving long-term outcomes for patients. By acting together and playing an active role in their patients’ psoriasis management, clinicians can ensure PsA is identified sooner, treated more effectively, and managed with a holistic approach that addresses both skin and joint manifestations of disease. Through this approach, clinicians may be able to personalize therapy more effectively and ultimately preserve quality of life for patients living with these conditions.
References:
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Gladman DD, Antoni C, Mease P, Clegg DO, Nash P. Psoriatic arthritis: epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 2005;64 Suppl 2(Suppl 2):ii14-ii17. doi:10.1136/ard.2004.032482