Psoriatic arthritis (PsA) remains one of the most consequential yet underrecognized comorbidities associated with psoriasis. Despite the availability of effective systemic therapies, PsA may be diagnosed late, sometimes after irreversible joint damage and functional impairment have occurred. The instructional video on administering the Psoriasis Epidemiology Screening Tool (PEST) underscores a critical message: dermatology clinicians are uniquely positioned to diagnosis PsA early, before long-term disability may develop.&nbsp;A persistent misconception in clinical practice is that PsA severity parallels cutaneous disease burden. In reality, PsA usually occurs independently of skin severity, and patients with minimal skin manifestations of psoriasis may harbor significant inflammatory joint disease. As highlighted in the video, evaluating psoriasis while assessing for PsA is important at nearly every initial and follow up visit. Dermatology visits often serve as the most consistent—and sometimes only—medical touchpoint for these patients, creating an urgent responsibility to screen proactively.&nbsp;The PEST exam provides a pragmatic, evidence-based approach that integrates seamlessly into routine dermatology workflows. The 5-question yes/no questionnaire can be administered efficiently by clinic staff or electronically, identifying patients at increased risk when three or more responses are positive. Screening tools such as the PEST have demonstrated effectiveness in identifying undiagnosed PsA in dermatology populations, supporting their routine use in clinical practice.²⁻⁴ Importantly, the PEST is not intended to replace rheumatologic evaluation but rather to prompt timely examination, referral, and treatment escalation when indicated.&nbsp;The focused physical examination that follows the questionnaire is equally critical. As demonstrated in the video, systematic palpation of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, paired with direct patient feedback, often reveals tenderness or swelling that patients may normalize or fail to report. Nail findings, including pitting and onycholysis, should not be dismissed, as nail disease is associated with PsA, particularly distal interphalangeal involvement. These findings alone should heighten clinical suspicion, even in the absence of overt joint complaints.&nbsp;Enthesitis represents another commonly overlooked manifestation of PsA. Heel pain involving the Achilles tendon or plantar fascia is frequently misattributed to mechanical conditions such as plantar fasciitis, particularly in primary care settings. In patients with psoriasis, however, these symptoms warrant a higher index of suspicion. The dermatology clinician is often the first to connect these musculoskeletal complaints to an underlying inflammatory process.&nbsp;Precise documentation serves as the bridge between screening and action. Recording specific joints, digits, laterality, and severity of tenderness creates an objective medical record and facilitates appropriate therapeutic decisions. A positive PEST exam should prompt consideration of systemic agents with dual skin and joint efficacy, including TNF inhibitors and IL-17 or IL-23 inhibitors. Treating cutaneous disease alone may temporarily control skin symptoms while joint inflammation progresses silently. Early systemic intervention, by contrast, has the potential to alter disease trajectory and prevent structural joint damage.¹⁻³&nbsp;Few interventions in dermatology offer a greater return on time invested. The PEST exam requires less than five minutes yet carries the potential to prevent decades of disability. Incorporating routine PsA screening into psoriasis visits transforms dermatologic care from reactive disease management to proactive disease interception. Mastery of this simple, targeted tool reinforces dermatology’s expanding role in preserving not only skin health, but long-term musculoskeletal function and quality of life.References&nbsp;<ol><li>Mease PJ. Psoriatic arthritis: update on pathophysiology, assessment, and management. Ann Rheum Dis. 2011;70(suppl 1):i77-i84.</li><li>Hioki T, Komine M, Ohtsuki M. Diagnosis and intervention in early psoriatic arthritis. J Clin Med. 2022;11(7):2051.</li><li>Coates LC, Aslam T, Al Balushi F, et al. Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study). Br J Dermatol. 2013;168(4):802–807.</li></ol>

Psoriatic arthritis is often missed until irreversible joint damage has occurred, but dermatology clinicians can change that. This article highlights how routine use of the PEST exam enables early interception of PsA and empowers dermatology practices to prevent long-term disability.

Intercepting Psoriatic Arthritis in Dermatology Practice: A Call to Action Using the PEST Exam 

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This PANP360 Monthly Themed Experience equips you with the knowledge and tools to detect psoriatic arthritis earlier and improve patient outcomes. Through an expert-led video and clinical article, you’ll learn how to use the PEST exam in routine psoriasis visits, identify high-risk patients, and take action to protect both skin and joints for more comprehensive care.

Psoriatic Arthritis

Download our free Psoriatic Arthritis Questionnaire 

Psoriasis Epidemiology Screening Tool (PEST)

How to Administer the PEST Exam 

Download the&nbsp;Psoriasis Epidemiology Screening Tool (PEST) to use in your practice:<a target="_blank" rel="noopener noreferrer" href="https://dermsquared.com/resources/toolkit/psoriasis-epidemiology-screening-tool"><img class="image_resized" style="aspect-ratio:730/944;width:17.03%;" src="https://d18uhdhjoz8by6.cloudfront.net/PEST_Exam_Rich_Test_b2aa7a3b3d.png" alt="PEST Exam Rich Test.png" srcset="https://d18uhdhjoz8by6.cloudfront.net/thumbnail_PEST_Exam_Rich_Test_b2aa7a3b3d.png 121w,https://d18uhdhjoz8by6.cloudfront.net/small_PEST_Exam_Rich_Test_b2aa7a3b3d.png 387w,https://d18uhdhjoz8by6.cloudfront.net/medium_PEST_Exam_Rich_Test_b2aa7a3b3d.png 580w," sizes="100vw" width="730" height="944"></a>A Practical Screening Tool for Psoriatic Arthritis&nbsp;<a target="_blank" rel="noopener noreferrer" href="https://dermsquared.com/conditions/psoriatic-arthritis">Psoriatic arthritis</a> is common, disabling, and still widely underdiagnosed. For patients with <a target="_blank" rel="noopener noreferrer" href="https://dermsquared.com/conditions/psoriasis">psoriasis</a>, missing it can mean irreversible joint damage and loss of function. For PAs and NPs, it represents both a challenge and a unique opportunity.&nbsp;In this video, Henry Yu, PA-C walks through how he uses the <a target="_blank" rel="noopener noreferrer" href="https://dermsquared.com/resources/toolkit/psoriasis-epidemiology-screening-tool">Psoriasis Epidemiology Screening Tool (PEST)</a> as part of routine psoriasis care. Not as a rheumatology workup, but as a focused, efficient screening approach that fits seamlessly into busy days in the clinic.&nbsp;Simple by design, the PEST exam is a brief five-question questionnaire paired with a targeted physical exam. But when used intentionally, and documented clearly, it becomes a powerful bridge from observation to strategic action.&nbsp;(Henry Yu likes to use the <a target="_blank" rel="noopener noreferrer" href="https://www.grappanetwork.org/">Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) app</a> to administer the PEST exam)&nbsp;Why the PEST Exam Matters&nbsp;As Yu explains, managing psoriasis without understanding a patient’s PsA status is incomplete care. Psoriatic arthritis can be present regardless of skin severity, and many patients see their dermatology provider more consistently than any other clinician.&nbsp;Used correctly, the PEST exam helps clinicians:&nbsp;<ul><li>Identify patients at higher risk for PsA earlier</li><li>Distinguish inflammatory joint symptoms from common misdiagnoses like plantar fasciitis</li><li>Prompt timely referral or treatment escalation</li><li>Initiate therapies that protect both skin and joints before permanent damage occurs&nbsp;</li></ul>What the Exam Includes&nbsp;<ol><li>Five yes/no questions that address joint swelling, arthritis history, nail changes, heel pain, and dactylitis. A score of three or more signals the need to move forward with further evaluation.</li><li>A focused, systematic physical assessment of:<ol><li>MCP, PIP, and DIP joints</li><li>Fingernails (pitting, onycholysis)</li><li>Toes and signs of dactylitis</li><li>Achilles insertion points and plantar fascia&nbsp;</li></ol></li></ol>He emphasizes specific documentation not just for accuracy, but because clear documentation forces a treatment decision and supports a shift toward dual-action systemic therapy when indicated.&nbsp;The full PEST exam takes less than five minutes. But, as Yu notes, it can change the entire trajectory of a patient’s life, allowing dermatology clinicians to intercept psoriatic arthritis years earlier than might otherwise occur.&nbsp;Editorial note: A substantial proportion of patients with psoriasis have undiagnosed psoriatic arthritis; meta-analysis suggests approximately 15% of psoriasis patients may have unrecognized PsA, with reported prevalence across studies ranging widely and, in some cohorts, approaching 30% or higher, depending on diagnostic criteria and screening methods.¹,²&nbsp;<ol><li>Villani AP, Rouzaud M, Sevrain M, et al. Prevalence of undiagnosed psoriatic arthritis among psoriasis patients: a systematic review and meta-analysis. J Am Acad Dermatol. 2015;73(2):242-248.</li><li>Alinaghi F, Calov M, Kristensen LE, et al. Prevalence of psoriatic arthritis in patients with psoriasis: a systematic review and meta-analysis of observational and clinical studies. J Am Acad Dermatol. 2019;80(1):251-265.e19.</li></ol>

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Intercepting Psoriatic Arthritis in Dermatology Practice: A Call to Action Using the PEST Exam

Psoriasis Epidemiology Screening Tool (PEST)

Psoriasis Epidemiology Screening Tool (PEST)

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