What specialist should a patient with arthropathic psoriasis see?

Specialist Care for Patients with Psoriatic Arthritis

Patients with psoriatic arthritis should primarily be cared for by a rheumatologist, and when clinically relevant skin involvement is present, a collaborative approach between a rheumatologist and dermatologist is recommended. 1

Primary Specialist Care

Rheumatologists are the specialists who should take primary responsibility for the care of patients with psoriatic arthritis for several key reasons:

• They possess optimal expertise in diagnosing and managing musculoskeletal manifestations of the disease 1
• They have extensive experience with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic, biological, and targeted synthetic agents 1
• They are best equipped to assess disease activity, structural damage, and treatment response 1
• They have comprehensive knowledge of safety considerations and comorbidity management 1

Collaborative Care Model

When psoriatic arthritis presents with clinically relevant skin involvement, a collaborative approach is essential:

• The rheumatologist should manage the musculoskeletal manifestations (peripheral arthritis, axial disease, enthesitis, dactylitis) 1
• A dermatologist should be involved in the diagnosis and management of skin and nail manifestations 1
• This collaborative approach ensures comprehensive care addressing all disease domains 1

Multidisciplinary Considerations

Psoriatic arthritis is a heterogeneous and potentially severe disease that may require additional specialists depending on specific manifestations:

• Ophthalmologists: When uveitis or other eye manifestations are present 1
• Gastroenterologists: When inflammatory bowel disease is present 1
• Other healthcare professionals: Physical therapists, occupational therapists, and nurses may be involved in comprehensive care 2

Decision Algorithm for Specialist Care

1. Initial presentation:

   • Patient with confirmed psoriatic arthritis → Refer to rheumatologist

2. Assessment of skin involvement:

   • If clinically relevant skin psoriasis → Add dermatologist to care team
   • If minimal/no skin involvement → Rheumatologist manages independently

3. Additional specialist considerations:

   • Eye symptoms → Ophthalmology consultation
   • Gastrointestinal symptoms → Gastroenterology consultation
   • Significant functional limitations → Physical/occupational therapy

Practical Considerations

• Early referral to a rheumatologist is crucial for timely diagnosis and treatment initiation to prevent structural damage 1
• Dermatologists are often the first to identify psoriatic arthritis in patients with psoriasis and should screen for joint symptoms 3
• A single therapeutic agent that controls both skin and joint manifestations is optimal when both manifestations are present 4
• Regular communication between specialists is essential for coordinated care 5

Common Pitfalls to Avoid

• Delayed referral to rheumatology, leading to disease progression and irreversible joint damage
• Focusing only on skin manifestations while overlooking joint disease
• Using treatments that address only one domain of the disease when both skin and joints are affected
• Failing to screen for psoriatic arthritis in patients with psoriasis (occurs in up to 30-40% of psoriasis patients) 6, 3
• Neglecting to consider comorbidities that may influence treatment decisions 1

The evidence clearly supports that rheumatologists should be the primary specialists managing psoriatic arthritis, with dermatologist collaboration when skin disease is clinically relevant, to ensure optimal outcomes for morbidity, mortality, and quality of life.