Beyond the Joints: A Whole Health Approach to Psoriatic Arthritis

Psoriatic arthritis is more than a joint disease. It is a systemic inflammatory condition that affects approximately 30% of patients with psoriasis, causing pain and stiffness in the joints, tendons, and spine—but its impact extends far beyond the musculoskeletal system.

At Whole Health Rheumatology, we understand that treating psoriatic arthritis effectively means addressing the whole person: the joints, the skin, the metabolic health, and the mental well-being. This comprehensive approach is not optional—it is essential for achieving the best possible outcomes.

Understanding Psoriatic Arthritis

Psoriatic arthritis is an inflammatory arthropathy that can affect multiple domains: peripheral joints (hands, feet, knees), the spine (axial involvement), the sites where tendons attach to bone (enthesitis), entire fingers or toes ("sausage fingers" or dactylitis), and the skin and nails. The disease is driven by dysregulated immune responses which create chronic inflammation throughout the body.

This systemic inflammation doesn't stay confined to the joints. It spills over into the blood vessels, the liver, the metabolic system, and even the brain—contributing to a constellation of comorbidities that significantly affect quality of life and longevity.

The Comorbidities That Travel With Psoriatic Arthritis

Research consistently shows that patients with psoriatic arthritis carry a higher burden of associated conditions than the general population. These are not coincidences—they share common inflammatory pathways with the underlying disease.

Cardiovascular Disease: Patients with psoriatic arthritis have a higher risk of cardiovascular disease, including myocardial infarction, stroke, and cardiovascular death. Chronic low-grade inflammation promotes atherosclerosis, and patients with psoriatic disease have greater vascular inflammation and more coronary artery plaques than healthy individuals. Cardiovascular risk factors are often undertreated in this population, making screening and prevention critically important.

Metabolic Syndrome and Obesity: Metabolic syndrome—the combination of obesity, hypertension, elevated blood sugar, and abnormal cholesterol—is significantly more common in patients with psoriatic arthritis. Obesity affects approximately half of patients with psoriatic disease and functions as both a trigger and a disease modifier. Importantly, obesity is associated with lower rates of remission and poorer responses to treatment. Weight loss can improve both disease activity and treatment response in a dose-dependent manner: the more weight lost, the greater the improvement.

Depression and Anxiety: Mental health disorders are strikingly common in psoriatic arthritis. A systematic review and meta-analysis found that the pooled prevalence of depression is 17-20% and anxiety is 19-33% among patients with psoriatic arthritis—significantly higher than in the general population. One in three patients has at least mild anxiety, and one in five has at least mild depression. These conditions are often unrecognized and undertreated, yet they significantly affect treatment response, remission rates, and quality of life. A bidirectional relationship exists: psoriatic disease increases the risk of depression, and depression worsens disease outcomes.

Other Comorbidities: Psoriatic arthritis is also associated with inflammatory bowel disease, fatty liver disease, uveitis, kidney disease, osteoporosis, and gout. Each of these requires monitoring and management as part of comprehensive care.

How Much Can Medications Help?

The good news is that we now have highly effective treatments for psoriatic arthritis. The goal of modern therapy is remission—or at minimum, low disease activity—achieved through a "treat-to-target" approach with disease-modifying medications.

TNF Inhibitors: These were the first biologics approved for psoriatic arthritis and remain highly effective. Medications like Humira (adalimumab), Enbrel (etanercept), and Cimzia (certolizumab) work by blocking tumor necrosis factor, a key driver of inflammation. In clinical trials, these medications achieve ACR20 responses (at least 20% improvement in joint symptoms) in 60-65% of patients, compared to approximately 20% with placebo. They are also proven to halt structural joint damage, preventing the erosions that lead to permanent disability.

IL-17 Inhibitors: Cosentyx (secukinumab), Taltz (ixekizumab), and the newer Bimzelx (bimekizumab) target interleukin-17, a cytokine central to psoriatic disease. These medications show impressive efficacy for both joints and skin. In head-to-head trials, Taltz demonstrated superior combined joint and skin responses compared to Humira. Bimzelx, which targets both IL-17A and IL-17F, has shown enhanced efficacy compared to traditional biologics in recent trials.

IL-23 Inhibitors: Tremfya (guselkumab) and Skyrizi (risankizumab) target interleukin-23, working upstream in the inflammatory pathway. These medications are particularly effective for skin disease and have shown superiority over TNF inhibitors for enthesitis (tendon inflammation). They also have favorable safety profiles with less frequent dosing—as infrequently as every 8-12 weeks.

IL-12/23 Inhibitor: Stelara (ustekinumab) blocks both IL-12 and IL-23 and is effective for peripheral arthritis, enthesitis, dactylitis, and skin disease. It is dosed every 12 weeks after initial loading.

JAK Inhibitors: Rinvoq (upadacitinib) and Xeljanz (tofacitinib) are oral medications that work inside cells to block multiple inflammatory signals. In the SELECT-PsA trial, Rinvoq demonstrated superior ACR20 responses compared to Humira at week 12. These oral options are convenient for patients who prefer not to inject.

Oral Options: Otezla (apremilast) is an oral medication that works differently from biologics, inhibiting an enzyme called phosphodiesterase-4. While generally less potent than biologics, it offers a convenient oral option with a favorable safety profile for patients with milder disease or those who prefer to avoid injections and more intensive immunosuppression.

Response Rates: Many patients achieve minimal disease activity or even remission with appropriate treatment.

Why Lifestyle Matters—Even With Effective Medications

Here is the critical point that many patients don't hear: medications work better when combined with lifestyle optimization.

Weight Loss Improves Treatment Response: A systematic review confirmed that weight loss following lifestyle interventions improves psoriasis and psoriatic arthritis. One randomized controlled trial demonstrated that patients who achieved diet-induced weight loss were four times more likely to reach minimal disease activity (odds ratio 4.20). In an interventional study, patients with psoriatic arthritis and obesity who lost an average of 18.7 kg (about 41 pounds) saw the percentage achieving minimal disease activity nearly double—from 29% to 54%. The effect was dose-dependent: greater weight loss produced greater improvement.

Importantly, the efficacy of TNF inhibitors like Humira and Enbrel is affected by body mass index—obese patients have lower response rates. In contrast, IL-17 inhibitors (Cosentyx, Taltz), IL-23 inhibitors (Tremfya, Skyrizi), and JAK inhibitors (Rinvoq) appear less affected by weight, which may influence treatment selection in obese patients.

Exercise Is Recommended: The 2018 American College of Rheumatology/National Psoriasis Foundation guidelines recommend that patients with active psoriatic arthritis engage in exercise, with low-impact activities (tai chi, yoga, swimming) preferred over high-impact exercise. Physical therapy and occupational therapy are also conditionally recommended.

Smoking Cessation Is Strongly Recommended: The ACR guidelines make a strong recommendation for smoking cessation in patients with psoriatic arthritis, supported by moderate-quality evidence. Smoking worsens disease outcomes and cardiovascular risk.

Mediterranean-Style Diet: While evidence is still emerging, a Mediterranean diet has been inversely associated with psoriasis severity, and dietary modifications that reduce systemic inflammation may support overall disease management.

Addressing Mental Health

Given the high prevalence of depression and anxiety in psoriatic arthritis—and their impact on treatment response and quality of life—mental health screening and management should be part of comprehensive care. Dermatologists and rheumatologists should educate patients about this association, screen for mental health conditions on an ongoing basis, and refer to mental health professionals when needed.

The Whole Health Rheumatology Approach

At Whole Health Rheumatology, Dr. Olga Pinkston takes a comprehensive approach to psoriatic arthritis that addresses all domains of the disease:

Disease-Modifying Treatment: We use evidence-based medications—including biologics like Humira, Cosentyx, Taltz, Tremfya, Skyrizi, Stelara, and Rinvoq—to control inflammation, relieve symptoms, and prevent joint damage. Treatment is tailored to your specific disease manifestations (peripheral joints, spine, entheses, skin) and adjusted based on response.

Cardiovascular Risk Management: We screen for and address cardiovascular risk factors, recognizing that controlling inflammation with systemic therapy may itself reduce cardiovascular risk.

Weight Management: We discuss the impact of weight on disease activity and treatment response, and support patients in achieving and maintaining a healthy weight. Weight loss intervention should be included as an integral part of psoriatic disease treatment. We prescribe brand name GLP-1 medications when appropriate.

Mental Health Awareness: We screen for depression and anxiety and ensure appropriate referrals, recognizing that mental health is integral to overall disease management.

Lifestyle Optimization: We provide guidance on exercise, smoking cessation, and nutrition as part of a comprehensive treatment plan.

You Deserve Comprehensive Care

Psoriatic arthritis is a complex, multisystem disease that requires more than a prescription. It requires a partner who understands the full scope of the condition and addresses every factor that influences your health and quality of life.

If you are living with psoriatic arthritis and want care that goes beyond the joints, schedule your evaluation at Whole Health Rheumatology today.