Reading the Pre-PsA Phase Through History
In special conference coverage from RAPIDS 2026 in Fort Lauderdale, Dr. Shikha Singla sat down to review her lectures on the interdisciplinary management of psoriasis and psoriatic arthritis. She emphasized that the pre-PsA phase—when patients are just beginning to develop early joint symptoms—is where derm providers can pick up subtle, meaningful clues if they slow down and listen to the history.
Singla's first question when a patient reports joint pain is always about duration: is it acute onset or chronic? That distinction helps separate an acute inflammatory process from a chronic inflammatory one. From there, she probes the character of the pain. Does it get worse with activity or better with activity? Is it worse in the morning or in the evening? These questions, she explained, help distinguish inflammatory joint pain from non-inflammatory joint pain—and listening carefully to those answers is key before moving on to any diagnostics.
Where Imaging and Labs Actually Fit
Singla was clear that psoriatic arthritis is a clinical diagnosis. Ultrasound and MRI are not diagnostic tools, but they are helpful confirmatory tools when the clinical picture is uncertain. She noted that ultrasound is user-dependent—how many joints you can evaluate depends on operator skill and available time—but studies support both ultrasound and MRI as useful in evaluating inflammatory arthritis of the joints.
On lab work, her message to derm providers was reassuring: she does not need labs before a referral, and specifically no ANAs. The diagnosis rests on examining the patient, asking the right questions, and hearing them out. She does not expect dermatology to run labs or imaging before sending a patient over, which she noted makes the referral process less overwhelming.
Exam Maneuvers and the Ideal Referral
Singla walked through underutilized physical exam maneuvers that can be done quickly in a derm clinic. She highlighted looking for joint effusions and synovitis of the hand joints—the MCPs, PIPs, and DIPs—along with enthesitis tests for lateral and medial epicondylitis, examining the Achilles tendon insertion at the heel, and checking for retrocalcaneal bursa enlargement. The interviewer noted that patients are often pleasantly surprised when a skin-focused provider puts hands on their joints, and that this can build buy-in and confidence in collaborative care.
An ideal referral, Singla said, poses a specific question—for example, a patient whose skin is well controlled on a biologic but who has persistent heel or tendon pain: is this wear-and-tear or psoriatic arthritis? When a specific question isn't possible, a good referral still includes a full exam noting any effusions and a history that leans toward inflammatory versus non-inflammatory pain.
She also reviewed the CASPAR criteria, clarifying that these are classification criteria used mostly for research and clinical trials—not everyday diagnosis. Points include active skin psoriasis (weighted more than history or family history), nail disease such as pitting or onycholysis, dactylitis, a negative rheumatoid factor, and characteristic bony changes.
When Skin Is Controlled but Joints Aren't—and a Complex Case
When skin is well controlled on a biologic but joint symptoms worsen, Singla urged providers to first confirm the pain is truly inflammatory arthritis and not another process like osteoarthritis, fibromyalgia, or gout. If PsA is confirmed and a therapy change is being considered, she said it matters whether there is axial involvement, since some drugs show more efficacy in axial disease, and comorbidities such as IBD should factor into the decision.
Singla closed by sharing a complex case: a 51-year-old woman with a seven-year history of psoriatic arthritis and well-documented past dactylitis, seen by multiple rheumatologists, with ongoing joint pain and functional limitations—yet normal CRP and ESR and no inflammation on ultrasound. The lesson she drew was to ask whether disease is truly treatment-refractory or whether other factors are driving the pain. This patient's ongoing pain turned out to be fibromyalgia. She was placed in a therapy program with regular physical therapy and improved after cognitive behavioral therapy and physical therapy.
Building Collaboration Without a Combined Clinic
Singla acknowledged the real barriers to combined derm-rheum clinics: differing treatment preferences (she noted many rheumatologists dislike IL-23 inhibitors that dermatologists favor), patient volume mismatches since dermatology sees far more patients in less time, and limited room availability. In her academic center, the dermatologist sees psoriasis patients first and screens for joint pain, then Singla examines the patient while the dermatologist sees two or three more, after which they discuss treatment together.
For providers without a combined clinic, she suggested rheumatology outreach and easy access—including virtual visits or a Zoom conversation with a rheumatologist when treatment direction is unclear.