The Clinical Significance and Therapeutic Management of Dactylitis and Enthesitis in Psoriatic Arthritis

Dactylitis and enthesitis are hallmark musculoskeletal manifestations of psoriatic arthritis, often signifying a more severe disease phenotype. These domains not only aid early diagnosis but are also associated with radiographic progression, functional impairment, and reduced quality of life.

This review aims to synthesise current insights into the pathophysiology, clinical impact, imaging assessment, and targeted therapeutic strategies for dactylitis and enthesitis in PsA, within the framework of precision medicine.

A comprehensive analysis of the literature was conducted, focusing on the immunobiology, imaging modalities (ultrasound, MRI), validated clinical scoring systems, and the efficacy of conventional, biologic, and targeted synthetic DMARDs in the treatment of dactylitis and enthesitis.

Both manifestations arise from inflammation at the bone-entheseal interface, mediated by biomechanical triggers and the IL-23/IL-17 axis. Dactylitis involves tenosynovitis, soft tissue oedema, and synovitis, while enthesitis reflects inflammation at tendon and ligament insertions. Imaging enhances diagnostic accuracy and monitors subclinical disease. TNF and IL-17 inhibitors demonstrate high efficacy in these domains, whereas IL-23 and JAK inhibitors offer promising alternatives. Personalised treatment algorithms now integrate domain predominance, prognostic markers, comorbidities, and patient preferences.

Dactylitis and enthesitis represent pivotal, prognostically relevant domains in PsA. Their early recognition and domain-specific management are critical to optimising outcomes. Advances in imaging, novel therapeutic targets, and biomarker-driven strategies hold promise for more effective, individualised care.