Disparities in Psoriatic Arthritis Diagnosis and Treatment

Psoriatic arthritis (PsA) already has a lot going on: it’s an autoimmune disease,
it can attack both your joints and your skin, and it rarely reads the textbook
before it shows up. Unfortunately, it also doesn’t treat everyone equally.
Around the United States, who gets diagnosed quickly – and who gets the most
effective treatment – can depend on things that have nothing to do with biology:
race, income, insurance status, and even ZIP code.

In this article, we’ll unpack what psoriatic arthritis is, why early diagnosis
matters so much, and how disparities in health care lead to very different
outcomes for different people. We’ll also look at what patients, clinicians, and
health systems can actually do to close the gap – because “that’s just the way
it is” is not a treatment plan.

What Is Psoriatic Arthritis – and Why Does Timing Matter?

Psoriatic arthritis is a chronic inflammatory arthritis that typically occurs in
people with psoriasis, an immune-related skin condition that causes red,
scaly plaques. PsA can inflame joints, tendons, and the spots where tendons and
ligaments attach to bone (entheses), and it can cause symptoms ranging from
swollen fingers and toes to back pain and fatigue. It’s not “just aches and
pains” – it’s a progressive autoimmune disease.

Studies suggest that psoriatic arthritis is still underdiagnosed, even as its
prevalence has risen over time. In reviews of epidemiology data, researchers
found that many people living with psoriasis and joint symptoms never receive a
formal PsA diagnosis, despite clear signs of inflammatory arthritis.

That delay is not just annoying; it’s harmful. A large population-based study
reported that more than half of patients with PsA had a diagnostic delay of over
two years, and that this delay hasn’t significantly improved in recent
decades. Two years is a long time for ongoing, uncontrolled
inflammation, and delayed diagnosis is associated with more joint damage,
worse function, and lower quality of life.

Why Is Psoriatic Arthritis So Often Missed?

A Shape-Shifting Disease

PsA is a bit of a medical chameleon. It can look like rheumatoid arthritis,
osteoarthritis, mechanical back pain, gout, or simple overuse. There’s no
single definitive blood test. Imaging can help, but changes may show up late.
As a result, diagnosis is largely clinical – based on symptoms, physical exam,
and pattern recognition – which means it’s highly dependent on a clinician’s
experience and time.

A meta-ethnographic study of primary care providers found that many clinicians
felt unsure about recognizing psoriatic arthritis, especially in patients with
subtle or “non-classic” symptoms. Limited rheumatology training and the pressure
of short visits often led providers to label complaints as “wear and tear” or
generic back pain rather than inflammatory disease.

Underrecognition Among People with Psoriasis

You might assume that patients who already have psoriasis would be closely
monitored for joint problems, but that’s not always the case. One study in
primary care clinics estimated that about 3.2% of patients with psoriasis had
psoriatic arthritis – a number that rose to 4.6% when doctors specifically
looked for enthesitis, or inflammation where tendons attach to bone.

At the same time, large reviews show ongoing underdiagnosis, suggesting that
many patients with psoriasis and joint complaints never get coded or treated as
having PsA at all. That means they may receive pain
relievers or nonspecific anti-inflammatory drugs instead of targeted disease
modifying antirheumatic drugs (DMARDs) or biologics that can actually slow or
stop joint damage.

System-Level Barriers

Even once a clinician suspects psoriatic arthritis, there’s the small matter of
the American health-care system. Patients often wait months for rheumatology
appointments. A recent study found that people with PsA had longer delays both
from symptom onset to seeing primary care and from initial visit to specialist
referral compared with other rheumatic diseases.

Those delays were worse for patients living in small or medium-size cities and
for those who lacked regular access to specialty care – a clue that geography
and health-system structure already introduce inequality into the process.

Who Is Most Affected by Disparities?

Racial and Ethnic Disparities

A growing number of studies show that race and ethnicity influence who gets
diagnosed promptly and who receives advanced therapies for psoriatic arthritis.
In a Medicaid claims–based study, Black and Hispanic patients with PsA had
significantly longer delays in starting DMARD treatment compared with White
patients.

Another analysis found that the prevalence of PsA and its treatment patterns
differed by race, insurance coverage, and sex; non-White patients were less
likely to receive biologic therapies even when they had similar disease
severity. And a recent report on disease burden showed that
Hispanic and non-White patients often had higher tender joint counts, worse
disease activity, and more impaired quality of life than White patients.

For people with skin of color, even recognizing psoriatic disease can be harder.
Psoriasis and PsA rashes can look different on darker skin tones – sometimes
more purple or brown than bright red – and historically they’ve been
underrepresented in dermatology training materials and clinical trials. Patient
advocacy groups have highlighted that individuals with skin of color often face
delays, misdiagnosis, and undertreatment as a result.

Insurance Status, Income, and Access

Psoriatic arthritis is one of those conditions where the “good stuff” – modern
biologics and targeted therapies – tends to be expensive. A study of Medicaid
beneficiaries showed racial differences in DMARD use and time to treatment,
underscoring how public insurance populations can be particularly vulnerable to
delays and step-therapy rules.

A broader systematic review of access to biologics for immune diseases found
consistent disparities related to insurance type, high out-of-pocket costs,
prior authorization requirements, and race/ethnicity. Black, Hispanic, and
Asian patients were less likely to start or continue biologic therapies, and
financial barriers played a major role.

In simple terms: if you have better insurance and more money, you’re more likely
to get the latest targeted PsA medication. If you don’t, you may cycle through
older drugs, deal with more side effects, or go without treatment altogether.

Geography, Gender, and Health-Care Use

Where you live matters, too. Research on biologic access has found that rural
residence, limited specialist availability, and clinic distance all contribute
to lower use of advanced therapies.

A 2025 retrospective study also found that factors such as sex, race and
ethnicity, insurance type, and the total number of clinic encounters were all
associated with the likelihood of receiving a PsA diagnosis in the first
place. In other words, people who are already
heavily involved in the health-care system may be more likely to get diagnosed,
while those who face barriers to regular care can easily be missed.

Gaps in Psoriatic Arthritis Treatment

Who Gets Biologics – and Who Doesn’t

Biologic medications and newer targeted therapies have transformed psoriatic
arthritis treatment. They can reduce pain, protect joints, improve skin
disease, and prevent long-term damage. Unfortunately, access is far from
equal.

One analysis highlighted a dramatic gap: nearly half of White patients with
psoriasis and PsA were receiving biologic therapies, compared with only about
13% of Black patients. That’s not a small difference – it’s
a canyon.

Systematic reviews of biologic access in immune-mediated diseases show that
high out-of-pocket costs, stringent prior authorization requirements, and
formulary restrictions create major roadblocks, especially for people on
Medicaid, high-deductible health plans, or without insurance at all.

The Consequences of Undertreatment

When people with psoriatic arthritis don’t receive adequate treatment, the
disease doesn’t politely pause. It continues to inflame joints and tissues, and
over time that can lead to permanent joint damage, disability, and a much
lower quality of life.

Studies find that non-White patients often have higher disease activity, more
pain, and worse functional scores than White patients with PsA – outcomes that
line up uncomfortably well with lower rates of biologic use and longer time to
appropriate treatment.

The ripple effects are big: more missed work, higher mental-health burden,
increased health-care use for complications, and higher overall costs for
patients and the system alike.

Closing the Gap: What Can Be Done?

For Clinicians and Health Systems

• Use structured screening for PsA in people with psoriasis.
  Simple questionnaires and checklists in dermatology and primary care clinics
  can flag patients at risk and prompt referrals earlier.
• Improve education about PsA in skin of color.
  Training resources and photo libraries that show how psoriatic lesions appear
  on different skin tones can reduce misdiagnosis and delay.
• Streamline referral pathways.
  E-consults, tele-rheumatology, and clear referral criteria can help primary
  care clinicians get specialist input faster, especially in rural or
  underserved areas.
• Track equity metrics.
  Health systems can monitor timelines to diagnosis, treatment initiation, and
  biologic use by race, ethnicity, insurance type, and geography. If there’s a
  pattern, there’s a problem – and you can’t fix what you don’t measure.
• Advocate for fair coverage policies.
  Clinicians and professional societies can push back on overly restrictive
  step-therapy rules and prior-authorization requirements that disproportionately
  hurt patients with fewer financial resources.

For People Living with Psoriasis or Psoriatic Arthritis

• Know the early warning signs. Persistent joint pain and
  stiffness, swollen fingers or toes, heel or foot pain, lower-back stiffness,
  and nail changes like pitting or separation can all point toward PsA,
  especially if you have psoriasis.
• Bring up symptoms clearly and often. Keeping a brief symptom
  diary – when pain happens, which joints, how it affects your day – can help
  your clinician see patterns that might otherwise be chalked up to “getting
  older.”
• Ask directly about psoriatic arthritis. If you have psoriasis
  and joint symptoms, it’s reasonable to ask, “Could this be psoriatic
  arthritis, and should I see a rheumatologist?”
• Use advocacy resources. Patient organizations focusing on
  psoriasis and PsA often have tools to help with insurance appeals, copay
  support, and navigating prior authorizations when biologics are recommended.
• Don’t underestimate mental health. Chronic pain, visible skin
  disease, and feeling dismissed because of race, income, or appearance can all
  take a toll. Counseling, peer support groups, and online communities can help
  you feel less alone while you fight for better care.

Lived Experiences: How Disparities Show Up in Real Life

Research numbers are important – but behind the percentages are real people
whose stories often follow a familiar pattern. The examples below are
composites based on common experiences described by patients, rather than any
one individual.

Maria’s story: “It’s just your psoriasis acting up.”
Maria is a 38-year-old Latina woman who has had scalp psoriasis for years.
Between working a retail job and raising two kids, she doesn’t have much
flexibility for appointments. When she starts waking up with stiff fingers and
painful heels, she mentions it quickly at a rushed clinic visit. Her primary
care provider, running behind schedule, reassures her it’s “probably from being
on your feet all day” and suggests new shoes and over-the-counter pain
relievers.

Over the next two years, the pain worsens. Her fingers swell so much that
customers comment when she hands them change. By the time she finally sees a
rheumatologist – after a long wait for a referral and several missed workdays –
imaging shows joint damage that can’t be reversed. With earlier recognition,
Maria might have started disease-modifying treatment before that damage
occurred.

Jamal’s story: Insurance hurdles and biologic roadblocks.
Jamal, a 45-year-old Black man, has both psoriasis and psoriatic arthritis. His
rheumatologist recommends a biologic medication after several conventional
drugs fail to control his disease. The catch? Jamal is on a high-deductible
plan through his employer. The out-of-pocket cost for the biologic is more than
his monthly rent.

Together with his care team, he applies for patient-assistance programs and
navigates a maze of prior authorization forms. Even with help, it takes months
to get approval, and during that time his disease continues to flare. He misses
work, feels exhausted, and starts to question whether the fight for treatment
is worth it. Jamal eventually gets on the biologic and feels better, but the
delay leaves him skeptical of a system that seemed designed to slow him down.

Linda’s story: Geography as a risk factor.
Linda lives in a small rural town several hours from the nearest
rheumatologist. She has long-standing psoriasis and now has aching knees and
lower-back stiffness that makes it hard to care for her grandkids. Her local
clinic has one nurse practitioner who rotates between sites. Appointments are
short, and referrals to specialists can take months, especially when they
involve long travel and time away from work or family.

When Linda finally gets a rheumatology appointment, she’s overwhelmed by the
information on different treatment options and overwhelmed by the logistics of
coming back frequently for lab tests. Telehealth visits help a little, but
limited internet access and transportation still create barriers. For Linda,
living far from specialty care doesn’t just mean inconvenience – it means a
higher risk of delayed diagnosis, undertreatment, and preventable disability.

These stories highlight how race, income, insurance status, and geography can
interact with the biology of psoriatic arthritis. None of these factors
determine who “deserves” good care – but in practice, they strongly influence
who gets it. Recognizing these patterns is the first step toward changing them.

Bringing Equity into Psoriatic Arthritis Care

Psoriatic arthritis is already complicated enough without adding inequity to
the mix. Yet the data are clear: people from racial and ethnic minority groups,
those with lower income or limited insurance, and those living far from
specialists face longer diagnostic delays and less access to effective
therapies.

The good news is that these disparities are not inevitable. Better screening in
primary care, more inclusive dermatology and rheumatology training, telehealth
expansion, fairer insurance policies, and strong patient advocacy can all help
narrow the gap. On an individual level, learning the signs of PsA, documenting
symptoms, asking direct questions, and seeking second opinions when necessary
are powerful tools.

Psoriatic arthritis doesn’t care what you look like, how much money you make,
or where you live. Our health-care system shouldn’t either.