A Clinical Review of Structural Damage in Psoriatic Arthritis for Dermatologists: From Pathogenesis to Ongoing Controversies.

Psoriatic arthritis (PsA) is a chronic inflammatory disease that often goes unrecognized in patients with psoriasis. As a result, patients may develop significant structural damage before diagnosis and initiation of adequate treatment. Dermatologists are in a unique position to identify early signs and symptoms of PsA. Here we briefly review the pathogenesis of PsA, differences in PsA presentation within real-world dermatology practice versus rheumatology clinical trials, and imaging modalities that can be used to assess structural damage. We then discuss several ongoing controversies related to prediction, assessment, and treatment of PsA structural damage. Debated questions include: 1) Does subclinical enthesitis predict progression from psoriasis to PsA?, 2) Does methotrexate inhibit progression of structural damage?, 3) Does structural damage correlate with clinical disease activity?, and 4) Can progression from psoriasis to PsA be prevented? Evidence presented herein suggests that dermatologists, together with rheumatologists, can play important roles in the early diagnosis and treatment of PsA, thereby potentially preventing irreversible structural damage.