Refractory psoriatic arthritis: emerging concepts in whole process management

Psoriatic arthritis (PsA) is a chronic and progressive inflammatory arthritis associated with psoriasis, mainly affecting the axial and peripheral joints, characterized by a wide range of complex phenotypes, significant heterogeneity, and a multifactorial etiology. To effectively address the distinct challenges in managing PsA, a pivotal emphasis is placed on clarifying the concept of refractory PsA. Here, we propose a distinction between refractory PsA, differentiating between difficult-to-treat PsA (D2T PsA) and Pseudo-D2T PsA. The former centers on the lack of efficacy of multiple disease-modifying anti-rheumatic drugs (DMARDs) and signs suggestive of active/progressive disease, while also considering the challenges posed by comorbidities. The latter focuses on misdiagnosis and mismanagement, detailing the difficulties caused by artificial factors, whether by clinicians or patients. Hoping the clarification of these distinctions will enable clinicians to manage patients with refractory PsA more effectively.