Psoriatic arthritis, or PsA, is a long-term condition that affects both the skin and the joints.
It’s part of a group of diseases called inflammatory arthritis, which means the body’s immune system mistakenly attacks its own tissues, causing pain, swelling, and stiffness.
People with PsA often also have psoriasis, a skin condition that causes red, scaly patches.
But this disease is more than just a skin problem—it can also affect the joints, tendons, and even organs. Managing PsA can be complicated, especially for those whose symptoms do not respond well to treatment.
For most people, there are effective medications called DMARDs, or disease-modifying antirheumatic drugs, that can help control inflammation and prevent damage. These include biologic and targeted synthetic drugs that have transformed how doctors treat PsA. However, not everyone benefits from them.
Some people continue to experience pain, swelling, and fatigue despite trying multiple medications. For these individuals, their condition is described as “difficult-to-manage” or “treatment-refractory.” Until recently, there was no clear medical definition of what those terms meant for PsA.
To address this gap, the European Alliance of Associations for Rheumatology (EULAR) has created new, evidence-based definitions and guidelines for identifying these hard-to-treat cases. Their goal is to help doctors better understand why some patients don’t respond to treatment and how to manage them more effectively.
The EULAR team included specialists from 15 countries—rheumatologists, dermatologists, and patient researchers—who worked together to develop these new definitions. Their findings were published in the Annals of the Rheumatic Diseases. The group created four main principles and six key points to consider when diagnosing difficult-to-manage PsA.
They emphasized that some people will not respond to standard treatment and that this ongoing inflammation can seriously affect mental health, physical well-being, and quality of life. These challenges can also impact work and social activities.
One of the main ideas in the paper is that treatment failure can have many causes. It may be due to active inflammation that hasn’t been fully controlled, other health issues like obesity or depression, or even lifestyle and psychological factors that make it harder to manage symptoms. Understanding these underlying reasons is crucial for improving care.
EULAR’s new framework includes two main definitions. The first is “difficult-to-manage PsA,” which is a broad term that includes anyone whose symptoms persist because of inflammation, other health problems, or emotional and social factors.
The second is “treatment-refractory PsA,” which refers specifically to patients who still have clear signs of inflammation even after trying at least two different types of advanced medications.
In both cases, patients often experience significant discomfort and frustration. However, it’s important to note that the term “difficult” applies to the disease itself—not the person living with it. This distinction helps avoid stigma and focuses attention on improving treatment rather than blaming the patient.
Professor Helena Marzo-Ortega from the University of Leeds, who led the study, explained that the new definitions will help guide future research.
She said that while difficult-to-manage PsA includes many different factors, the key to understanding treatment resistance is determining whether inflammation is still active. Once doctors can identify that, they can create more personalized and effective treatment plans.
In the long term, this new approach may help researchers develop better therapies and even ways to prevent treatment resistance altogether. By clearly defining what “difficult-to-manage” and “treatment-refractory” mean, EULAR’s work gives scientists and doctors a shared framework for studying these complex cases.
It also encourages healthcare professionals to look at PsA from a holistic perspective—considering not just medication but also lifestyle, emotional support, and other health factors.
In review, this study highlights the importance of personalized medicine in treating psoriatic arthritis. Instead of assuming one treatment fits all, the researchers stress the need to understand each person’s unique biological and emotional profile.
While new drugs continue to be developed, this kind of research shows that improving outcomes for people with PsA will require more than just medicine—it will take a whole-person approach that addresses the body, mind, and environment together.
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The study is published in Annals of the Rheumatic Diseases.
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