23 July 2025
Hidden joint inflammation detected in psoriasis patients without symptoms
Subclinical synovitis is 2.5 times more likely in psoriasis patients without musculoskeletal signs, raising hopes for earlier PsA risk detection through imaging.
Emerging evidence suggests imaging may reveal early inflammatory changes in patients with psoriasis, even in the absence of musculoskeletal symptoms, say researchers.
Their recent systematic review and meta-analysis found patients with psoriasis who lacked musculoskeletal (MSK) symptoms may still harbour subclinical joint inflammation – specifically, synovitis – detectable through imaging technologies.
For adults, psoriasis typically precedes or is diagnosed concurrently with PsA in 85% of cases, although in paediatric patients more than 50% of patients develop PsA before psoriasis.
Subclinical synovitis is a hallmark of PsA and is thought to precede psoriatic arthritis and its detection among patients with psoriasis without MSK involvement through medical imaging modalities could offer valuable insights into the transition from psoriasis to PsA, the researchers said.
Their findings have been published this month in a brief report in JAMA Dermatology.
“In this systematic review and meta-analysis of 12 cross-sectional and case-control studies, synovitis was 2.5 times more likely to be detected using ultrasonography and magnetic resonance imaging among patients with psoriasis compared with controls,” the researchers wrote.
“Synovitis prevalence was higher among patients with psoriatic arthritis than those with psoriasis, but the difference was not statistically significant.
“This study suggests that subclinical synovitis is more prevalent among patients with psoriasis without musculoskeletal involvement than healthy controls, suggesting that imaging may help identify those at increased risk of transition to psoriatic arthritis.”
Psoriasis affects up to 3% of the population, with 30% of patients with psoriasis developing psoriatic arthritis (PsA). However, the transition between psoriasis and PsA has yet to be fully understood.
As part of the systematic review and meta-analysis, 12 studies were included comprising 1593 patients with psoriasis (mean [SD] age, 46.4 [7.5] years; 982 men [61.6%]), 327 patients with PsA (mean [SD] age, 50.2 [7.1] years; 210 men [64.2%]), and 686 healthy controls (mean [SD] age, 45.7 [6.9] years; 281 of 576 men [48.8%]).
Synovitis was 2.5 times more likely among patients with psoriasis than controls (RR, 2.55; 95% CI, 1.18-5.52). Detection rates were 6.4 times higher with MRI (RR, 6.40; 95% CI, 1.87-21.95) than ultrasound (RR, 2.50; 95% CI, 1.10-5.67). Synovitis was more frequent among patients with PsA than those with psoriasis, but the difference was not statistically significant (RR, 0.50; 95% CI, 0.13-1.87).
Routine imaging for asymptomatic patients is not currently recommended in clinical guidelines. However, this study suggests that targeted imaging, particularly among patients with long-standing or moderate-to-severe psoriasis, could provide critical prognostic information.
From a clinical management standpoint, early identification of subclinical synovitis may prompt closer monitoring, and risk stratification could inform decisions on early referral to rheumatology.
Preventive interventions, including immunomodulatory therapies, might also reduce the likelihood of joint damage and disability.
The researchers said the study did have some limitations, including a lack of standardised protocols, with potential variability in joint selection, imaging modalities, and diagnostic criteria for synovitis, as well as the lack of heterogeneity in the patient population, such as medication use and disease severity.
“Furthermore, most studies relied on cross-sectional designs, limiting the ability to assess the temporal association between synovitis and the progression from psoriasis to PsA,” they wrote.
And they did recommend a careful approach to the findings.
“This systematic review and meta-analysis found that, although imaging may serve as a valuable tool for identifying patients with psoriasis at higher risk of developing PsA, its role in routine clinical practice should be approached cautiously, given the aforementioned limitations, costs, and resource requirements,” they concluded.
“Future longitudinal studies are needed to better characterize the transition from psoriasis to PsA, determine the predictive value of subclinical synovitis, and assess whether early intervention strategies could modify disease progression and reduce the risk of PsA development.”
