Guideline for the Diagnosis and Treatment of Psoriatic Arthritis (Arthropathic Psoriasis), 2026 Edition

(English Summary, Chinese expert consensus, published in Chinese Journal of Dermatology, 2026)PubMed

Overarching Principles

1. Psoriatic arthritis (PsA) is a chronic, immune‑mediated systemic inflammatory disorder, characterized by heterogeneous multi‑domain involvement: peripheral arthritis, axial spondyloarthritis, enthesitis, dactylitis, nail disease and cutaneous psoriasis. Early identification and treat‑to‑target (T2T) strategy are essential to prevent irreversible joint destruction, disability and extra‑articular organ damage.
2. Multidisciplinary collaboration between rheumatologists and dermatologists is recommended. Management should cover all active disease domains as well as comorbidities, with shared clinical decision‑making.
3. Treatment goals: achieve sustained low‑disease‑activity or remission, relieve pain and swelling, preserve joint function, improve skin/nail manifestations, reduce comorbidity burden and enhance quality of life.
4. Non‑pharmacological interventions are integral rather than adjunctive components of total care.

1. Diagnosis

1.1 Clinical suspicion

Suspect PsA in patients with any of the following:

• Inflammatory arthritis together with typical psoriasis skin or nail lesions;
• Seronegative inflammatory arthritis (RF negative or low‑titer positive), especially with distal interphalangeal joint involvement, asymmetric oligoarthritis, dactylitis (“sausage‑like digits”), enthesitis, or sacroiliac pain; psoriasis may appear after arthritis onset.

1.2 Classification criteria

CASPAR criteria are recommended for classification purposes. Inflammatory musculoskeletal disease (joint, spine or enthesis) plus ≥3 points from 5 domains:

1. Current psoriasis (2 points); personal history or family history of psoriasis (1 point)
2. Typical psoriatic nail dystrophy (1 point)
3. Negative rheumatoid factor (1 point)
4. Past or present dactylitis (1 point)
5. Radiographic juxta‑articular new‑bone formation on hand/foot films (1 point)

Note: CASPAR is for research/classification; clinical diagnosis requires comprehensive evaluation, not mechanical scoring alone.

1.3 Auxiliary examinations

1. Laboratory tests: CBC, ESR, CRP, RF, anti‑CCP antibody, liver and renal function. RF may be weakly positive in a minority of PsA patients; anti‑CCP positivity suggests higher likelihood of rheumatoid arthritis.
2. Imaging
   • Plain radiographs: evaluate joint erosion, periostitis, osteolysis, sacroiliitis.
   • Musculoskeletal ultrasound / MRI: detect synovitis, enthesitis, dactylitis, bone marrow oedema in early‑stage PsA when radiographs may be normal.
   • For suspected axial disease: sacroiliac joint MRI is preferred for early inflammatory changes.

1.4 Differential diagnosis

Rheumatoid arthritis, osteoarthritis, gout, reactive arthritis, ankylosing spondylitis, SAPHO syndrome, fibromyalgia.

2. Disease activity assessment

Assess all core domains: peripheral joints, axial involvement, enthesitis, dactylitis, skin, nails. Common tools:

• Peripheral arthritis: PsARC, DAPSA
• Axial disease: BASDAI, BASFI
• Skin: PASI for psoriasis severity
• Enthesitis: MASES / SPARCC enthesitis score
• Patient‑reported outcomes: pain VAS, patient global assessment, HAQ‑DI for function.

Treat‑to‑target: reassess response every 8‑12 weeks after therapy initiation or adjustment.

3. Non‑pharmacological management

1. Patient education: explain chronic relapsing nature of PsA; avoid alcohol and smoking; weight control for overweight/obese patients.
2. Physical and occupational therapy: regular physical exercise; preserve joint mobility and muscle strength. Local cold therapy for acute swelling; warm therapy for stiffness.
3. Topical care for psoriasis skin and nail lesions.

4. Pharmacological treatment

4.1 NSAIDs

• Indications: symptomatic relief for peripheral arthritis, axial disease and enthesitis.
• Principle: use lowest effective dose for shortest duration. Evaluate gastrointestinal, cardiovascular and renal risk. NSAIDs cannot prevent structural joint damage and should not be used as monotherapy for long‑term disease control.

4.2 Conventional synthetic DMARDs (csDMARDs)

Mainly for active peripheral arthritis; limited efficacy for axial disease, isolated enthesitis or dactylitis.

1. Methotrexate: preferred csDMARD for patients with concurrent moderate‑to‑severe cutaneous psoriasis. Give folic‑acid supplementation. Monitor liver function and blood counts.
2. Sulfasalazine: suitable for oligo‑ / poly‑articular peripheral PsA.
3. Leflunomide: alternative for methotrexate intolerance.
4. Apremilast (PDE‑4 inhibitor): for mild‑to‑moderate PsA; benefit for skin manifestations; limited potency for severe structural disease.

csDMARDs have poor efficacy for axial PsA. Patients with predominant axial involvement should not rely solely on csDMARDs.

4.3 Glucocorticoids

• Systemic GC: avoid long‑term high‑dose use. Short‑term low‑to‑moderate dose may be used for bridging severe flares, with rapid tapering.
• Intra‑articular GC injection: recommended for mono‑ / oligo‑articular flares; avoid repeated injections into the same joint.

4.4 Biologic DMARDs (bDMARDs)

Indications: active PsA with inadequate response / intolerance to ≥1 csDMARD; or high‑risk features (early erosions, multi‑domain involvement, severe skin disease, axial disease).

1. TNF‑α inhibitors (adalimumab, etanercept, infliximab, golimumab, certolizumab pegol): effective for peripheral arthritis, axial disease, enthesitis, dactylitis and skin psoriasis. Preferred for patients with concurrent uveitis. Screen tuberculosis and hepatitis B before initiationPMC.
2. IL‑17 inhibitors (secukinumab, ixekizumab, bimekizumab): good efficacy for joints, axial disease, enthesitis, dactylitis and skin/nail psoriasis. Caution in patients with active inflammatory bowel disease.
3. IL‑12/IL‑23 inhibitors (ustekinumab) and IL‑23‑specific inhibitors: improve musculoskeletal manifestations and psoriasis; favourable safety profile. May be considered in patients with concomitant IBD.

4.5 Targeted synthetic DMARDs (tsDMARDs: JAK inhibitors)

• Indicated for active PsA inadequate to csDMARDs and biologics.
• Caution: age‑related cardiovascular risk, thromboembolism, infection risk. Complete risk‑benefit assessment and informed consent before use. Not preferred as first‑line.

5. Domain‑oriented treatment recommendations

1. Predominant peripheral arthritis: csDMARD first‑line; switch / escalate to bDMARD/tsDMARD if no response.
2. Axial disease: NSAIDs first‑line; if inadequate response, use bDMARD (TNFi / IL‑17i). csDMARDs are not effective for axial inflammation.
3. Prominent enthesitis / dactylitis: bDMARD preferred over csDMARD when NSAIDs insufficient.
4. Severe skin‑nail psoriasis: prioritize agents with proven skin efficacy (IL‑17i, IL‑23i, TNFi, methotrexate).
5. Comorbid uveitis: prefer monoclonal TNF‑α inhibitors. Avoid IL‑17 inhibitors in active IBD.

6. Monitoring and follow‑up

1. After starting or adjusting therapy: clinical and laboratory assessment every 8‑12 weeks. Once target achieved, follow‑up every 3‑6 months.
2. Baseline and periodic screening: infection risk (TB, hepatitis B), liver‑renal function, blood counts.
3. Periodic imaging: radiographs / ultrasound/MRI when progressive joint damage is suspected.
4. Comorbidity screening: metabolic syndrome, cardiovascular risk, depression/anxiety, uveitis and inflammatory bowel disease.

7. Special populations

1. Reproductive‑age patients: contraception planning before immunosuppressants. Some biologics may be continued during pregnancy after specialist evaluation; JAK inhibitors, methotrexate and leflunomide must be stopped pre‑conception.
2. Juvenile‑onset PsA: refer to paediatric rheumatology; weight‑based dose adjustment.
3. Elderly patients: balance efficacy against infection, cardiovascular and gastrointestinal adverse risks.

8. Refractory PsA

Defined as persistent active disease despite adequate trials of multiple agents with different mechanisms of action. Confirm adherence, rule out infection, mechanical pain, fibromyalgia‑like overlap. Optimize existing therapy or switch to another class of bDMARD/tsDMARD; multidisciplinary evaluation is advised.

References

Chinese expert consensus group. Guideline for the diagnosis and treatment of psoriatic arthritis (arthropathic psoriasis, 2026 edition). Chin J Dermatol. 2026;59(4):301‑314PubMed.

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