Challenging the Dogma That Psoriasis Skin Lesions Occur Before Arthritis

Psoriasis skin lesions are generally thought to occur before psoriatic arthritis (PsA) develops. However, PsA may be challenging to diagnose in the absence of psoriasis and might be underdiagnosed when occurring before psoriasis. We tested the hypothesis that PsA may commonly occur before psoriasis, but without psoriasis skin lesions, is diagnosed as another form of arthritis.

A single-center retrospective chart review was performed to identify patients with qualifying diagnoses from January 1, 2023, until December 31, 2023. This study was performed using electronic health records at a large tertiary care medical center. Inclusion criteria were (1) the presence of inflammatory or non-inflammatory arthritic conditions, (2) prior to the diagnosis of psoriasis, atopic dermatitis, or rosacea. Diagnoses were screened using International Classification of Diseases, Tenth Revision (ICD-10) codes.

During 2023, we identified 2780 patients with rosacea, 1672 with psoriasis, and 5195 patients with atopic dermatitis, of whom 436 had preceding arthritis (239 with psoriasis [14.3%], 189 with rosacea [6.8%], and 126 with eczema [2.4%, p < 0.0001]).

Arthritic symptoms are common in psoriatic patients before psoriasis develops, and psoriasis skin lesions do not necessarily precede psoriatic arthritis.