Defending My Psoriatic Arthritis Diagnosis without Psoriasis

By Elizabeth Medeiros

2 min read

Last updated: July 2023

For the first time in years, my nails are nearly free of psoriasis. There are no deep ridges, and my few pits are barely noticeable. I'm relishing not having to keep my fingernails painted! And I'm already counting down the days to summer when I can show off my toenails.

But my nails clearing up came at an inconvenient time. Because while I'm so happy to have pretty fingers and toes, I'm sad to have lost my only visible symptom of psoriasis. And, of course, it came when I had to see a new rheumatologist after my old one left the hospital.

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When you have PsA without skin symptoms

Seeing a new rheumatologist made me nervous since nail psoriasis was my only visible symptom of PsA. I don't have psoriasis on the skin, and I was afraid that my doctor would dismiss me or take me off of my medication without my pitted nails.

While it sounds silly since I've dealt with this disease for over half my life, it had happened before with one doubting physician. While I've seen plenty of doctors who all confirmed my PsA since I still get nervous seeing new doctors.

But people can and do present with psoriatic arthritis without psoriasis. It's more common for children to develop arthritis symptoms either before or simultaneously as skin symptoms, but it can happen to anyone. For many people, PsA will precede psoriasis.

But not everyone; I've had my arthritis symptoms for years but never had issues with my skin.

Criteria for a PsA diagnosis

A good doctor knows psoriatic disease is more than skin deep. The Classification Criteria for Psoriatic Arthritis (CASPAR) criteria is used to diagnose psoriatic arthritis and takes more than your skin into account.

To get a diagnosis of PsA without current psoriasis, you must have inflammatory arthritis and meet at least three of the following criterion:

Having a history of psoriasis.
Having a family history of psoriatic disease.
Nail psoriasis.
Dactalysis.
New bone formation near the joints.
Being negative for rheumatoid factor.

In my case, having nail involvement was the red flag. While my mother's diagnosis of psoriatic disease and negative RF factor were suspicious, doctors still weren't sure. Was it juvenile rheumatoid arthritis (a now-dated term for juvenile idiopathic arthritis)? It was also curious that I had enthesitis.

No one quite put it together until a doctor who treated many patients with juvenile psoriatic arthritis looked at my toenails. They were separating (onycholysis) and very thick (hyperkeratosis). It finally clicked, and I was diagnosed with JPA!

Psoriatic arthritis is confirmed diagnosis, and I stand by it

After living without a diagnosis for so long, I'm a little defensive about my diagnosis. So I've taken care to see rheumatologists and dermatologists who are very experienced in treating psoriatic disease, and I highly recommend others do the same.

When I found out I had to find a new doctor, I was so scared I wouldn't find one who was as experienced. But thankfully, with the help of the internet, I found a rheumatologist specializing in psoriatic disease.

She looked at my files, listened to my health history carefully, and caught a few small pits in my nails I hadn't even noticed. And she confirmed- yes, Elizabeth, you can have psoriatic arthritis without psoriasis.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Psoriatic-Arthritis.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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lcnelson Member
Similar situation here! I've not had a problem with psoriasis (thankfully), and it was actually my dermatologist who made the connection on a PSA diagnosis for because of my nails.
1. Vickie Wilkerson Moderator & Contributor
 <inline-mention username="lcnelson" user-id="3296027"/> did that dermatologist refer you to a rheumatologist? How are you doing? Vickie W., Team Member
lcnelson Member
If I recall correctly, I was referred to the dermatologist by my PCP for the nail issues, while my PCP was already on the case trying to figure out my seemingly random joint pain. It was their collaboration that led to the referral to rheumatology and further testing, and eventually the PSA diagnosis. I'm currently doing mostly okay - minor flares now and then with the last major one about 3 1/2 years ago, which led me to switch to a rheumatologist who didn't dismiss me and my pain, and the new one started me on a different medication which has worked very well ever since. 
1. Vickie Wilkerson Moderator & Contributor
 Sounds like you made the right choice to switch rheumatologist @Icnelson. Flares are going to happen. I am not sure there is a treatment out there that will stop that. I am glad the new rheumatologist got you on a treatment that is working for you. Vickie W., Team Member
Mary Lynn Member
 My diagnosis changed about 2 years ago from sero positive RA (high anti CCP numbers and slightly elevated RF factor) to PsA . A bout of severe scalp psoriasis prompted my rheumatologist to run some ANA/ENA labs and dig into my family history. I have 2 cousins who are HBLA-27 positive, as am I. They have axial spondylitis. I have some small nail pits but my scalp and skin are clear. I have chronic Uveitis and my arthritis remains active in spite of being on a biologic and DMARD. I appreciate reading about others who don't "present" in typical way. It's been a struggle to explain my diagnosis change to some of my friends and family. Sometimes I don't bother trying because they likely won't understand that RA and PsA are 2 different animals 😀 
1. Lori.Foster Community Admin
 I think you are right about that, <inline-mention username="Mary Lynn" user-id="4513411"/>. Most people don't understand RA or PsA, so they probably are not going to understand the differences between them. Have you considered trying a different biologic in hopes that it will relieve your arthritis? There are so many biologics out there and doctors have no way of knowing which will be most effective for each patient. It's really just a game of trial and error. It takes a lot of patience to find the right medication, but it can be lifechanging when you do. Wishing you the very best. - Lori (Team Member)
Mary Lynn Member
 I'm on my 3rd biologic...and have been on several DMARDS and Xeljanz. Sometimes I feel like I am "flunking" PsA medications 😀. Then a community such as this reminds that I am not the only in search of a treatment that works with their unique system. I appreciate your responses and compassion, Lori!
marcyd Member
My rheumatologist would not diagnose me with PsA until my forearms had psoriasis scales. Under great physical and emotional stress due to husband's health, I thought it was an allergic reaction to my fitness band. I'd never seen psoriasis, so didn't know what it truly was. Even now my rheumy won't discuss any nail symptoms. I only see the dermatologist twice a year. Long time to wait for any help. I wish all the docs would get on the same page about symptoms. I feel for everyone who struggles to get an accurate diagnosis and effective treatment. 
1. Vickie Wilkerson Moderator & Contributor
 Hi @marcyd. That sounds very frustrating. Please check into seeing another rheumatologist. They should never dismiss your symptoms just because there is no rash. You need a doctor that will listen and discuss everything with you. If your symptoms have gotten worse you can always call your dermatologist office about being seen before your next appointment. Please keep us updated on how you are doing. Vickie W., Team Member
kimberly.ellison Member
My PSA is definitely the abnormal kind. The only type of Psorasis I have ever had is Palmoplantar Psorasis. I also have this weird swelling issue. When I am unresponsive to meds and or just having a hard time my legs will swell up with edema. The type of edema that water pills will not help. As soon as I take my shot it goes away. My Xrays show I have a spondyloarthritis with secondary Disc Disease and osteoarthritis. I also have Sjrogrens Syndrome. Chronic Idioparhic hives. Secondary hypothyroidism. (2) tumors of the Pituitary gland. My ANA is positive. One thing I didn't test positive for is HLA B27. Sometimes found in PSA. All of my diagnosis started same exact time. All diagnosed at age 35. I do now also have really dry skin that flakes & flakes. My whole body changed. I never even really used lotion prior to 35. I have reoccurring episodes of Anaphylaxis. The list just goes on and on. I'm overall happy with my diagnosis. Currently on Imuran & Cosentyx for PSA. Separate biologic for chronic hives called Xolair. It's been a wild ride these past 5 years.
threaddesigns Member
If you dig a little deeper into the research, you'll find that in most cases the ridges and pitting of the nails is actually the Enthesitis showing it's horrible effects. Psoriasis of the nails is definitely a "thing" but usually it's much more invasive and symptoms are not pretty....
Lynnie T Member
I visited many, many dermatologist before one finally diagnosed my psa! It was the condition of my nails that did it! So many Doctors didn’t believe that’s what my issue was. So frustrating! Thank goodness I’m now on a medication that works!
1. Jill.Brodie Community Admin
 I can understand your frustration @Lynnie T, I am so glad you finally got a diagnosis. What medication is helping you? Jill, team member
julaid Member
I was diagnosed with both Psoriatic AND Rheumatoid arthritis many years ago. I do not have psoriasis either. I was grateful to find a Rheumatologist who tested me constantly and checked all the markers for both diseases. This can present issues with medications and I find that one works for 6 months and then slowly stops working. Flares are a frequent occurance and really depress me. The only answer is another Prednisone taper. It has truly impacted my life on a daily basis. I have finally come to a place of acceptance and definitely advocate for my health.
1. Jill.Brodie Community Admin
 Hi @julaid, I can hear your frustration about the short term benefits of medicine. Having to deal with flares frequently is a lot to handle. I am so glad to hear you have such a positive mindset! Thanks for being here. Jill, team member
Lynnie T Member
<a href='http://Jill.Brodie' target='_blank' rel='noopener noreferrer ugc'>Jill.Brodie</a>, I’m on Otezla. Lynnie T
Wannaberunning Member
Great article, thank you for writing it. I had to change rheumatologists to get the diagnosis even tho I had all but the skin symptoms to the extreme. I had a hand surgeon, my General practitioner and a covid doctor all told me that my hands and feet with bony painful growths and pitted nails were tell tale signs of psa. Luckily my new rheumatologist diagnosed it with tests within a month
1. Vickie Wilkerson Moderator & Contributor
 <inline-mention username="Wannaberunning" user-id="6724753"/> we are so glad you found relevance in this article. It sounds like you made the right choice changing Rheumatologists when you did. What treatment are you on and is it helping you? Vickie W., Team Member
Wannaberunning Member
Actually I need to do an Otezla update here, I’ll do it in the morning. I said I would and have been back on it for a month, it’s going so much better. I’ll pull up the post and update. 
1. Wannaberunning Member
 Clair I wrote my update the day you replied then it disappeared! I guess I hit the wrong key or? My fat fingers causing grief again.. I’ll try today to rewrite. But it’s kind of good it disappeared because new things have happened and I have more to add..
2. ClairG Moderator & Contributor
 <inline-mention username="Wannaberunning" user-id="6724753"/> you will see I replied to your other update! don't worry it is there. Let me know if you don't get it. Gentle hugs- Clair ( Team Member)

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