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Psoriatic Arthritis (PsA)

Checked: 08-05-2024 by Vicky Ryan Next Review: 07-05-2026

Overview

Psoriatic arthritis (PsA) is an inflammatory arthritis with a heterogenous clinical prognosis ranging from mild synovitis to severe progressive erosive arthropathy. PsA has a number of musculoskeletal manifestations including: peripheral arthritis, spinal involvement, dactylitis (inflammation of a whole digit) and enthesitis (inflammation at the point of insertion of a tendon or ligament). It is associated with psoriasis of the skin and nails but occasionally can happen in the absence of skin disease. Psoriatic nail disease and severe skin psoriasis are more closely linked with development of PsA. Approximately one quarter of people with skin psoriasis will develop PsA. It can develop at any age but is most common in those age 35-55.

There is a useful article on Psoriatic Arthritis on the Patient.info website.

Who to refer

NICE guidelines (CG153 2017) for psoriasis recommend an annual assessment for PsA in all patients with psoriasis using the PEST tool below. Patients should be referred if they respond YES to 3 or more of the following questions:

Have you ever had a swollen joint (or joints)?
Has a doctor ever told you that you have arthritis?
Do your fingernails or toenails have holes or pits?
Have you had pain in your heel?
Have you had a finger or toe that was completely swollen and painful for no apparent reason?

When else to suspect PsA

In patients with a personal or family history of psoriasis with any of the following:

Morning stiffness in any joint >30 minutes
Painful or swollen joint(s)
Dactylitis (sausage digit)
Inflammatory spinal pain
Enthesis (e.g. plantar fasciitis, Achilles tendonitis)

Please consider referring through EIA pathway if the patient meets the EIA clinical referral criteria and use the corresponding form instead.

Before referral

All patients with suspected PsA should have a physical examination in primary care before referral.

Tests to be considered at the time of referral:

Blood tests - FBC, UE, LFT, TFT, CRP, Rheumatoid Factor, antiCCP and urate. (If the rheumatoid factor/antiCCP are positive please consider referral via EIA instead).

Radiology - Xrays of affected joint(s).

Please note there is no specific test for PsA and CRP is often normal.

Referral

Referrals for patients with suspected psoriatic arthritis, who do not meet referral criteria for the EIA service, can be referred to a general rheumatology clinic via eRS using the Suspected psoriatic arthritis referral form.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.