Screening every psoriasis patient for early psoriatic arthritis (PsA) — before irreversible joint damage develops — belongs at the center of treatment selection, according to Adam Friedman, MD, professor and chair of dermatology at the George Washington University School of Medicine and Health Sciences in Washington, DC.

Speaking in a Dermatology Times Expert Perspectives video, Friedman laid out practical strategies for identifying comorbid disease and individualizing systemic therapy in psoriasis. His core argument: psoriasis is a systemic inflammatory disease, and the dermatologist's job does not end at PASI improvement.

Screening Beyond the Skin

Friedman emphasized that intervening before significant joint damage occurs may improve long-term outcomes in PsA. In his own practice, screening starts with a short set of targeted questions: prolonged stiffness at rest, previous arthritis diagnoses, unexplained swelling of the fingers or toes, heel pain, and nighttime lower back pain.

Certain psoriasis presentations also raise PsA risk. That makes nail examination plus assessment of scalp and inverse psoriasis particularly relevant at each visit. Friedman noted that embedding simple screening questions into the clinical workflow can make the evaluation efficient rather than burdensome.

Gastrointestinal screening is harder. Symptoms such as nausea, vomiting, diarrhea and weight loss are nonspecific, and Friedman highlighted the need for improved guidance to help dermatologists recognize patients who may have concomitant inflammatory bowel disease or other gastrointestinal conditions.

The Whole Patient Drives Oral Therapy Choice

For patients who prefer oral treatment, efficacy is only one variable. Friedman stressed that clinicians should weigh monitoring requirements, tolerability, and how adverse effects may influence a patient's willingness or ability to stay on therapy. These practical factors ultimately determine adherence and long-term disease control.

As newer targeted oral therapies arrive, clinicians may increasingly honor a patient's preference for oral versus injectable administration without automatically accepting a substantial trade-off in efficacy. Historically, orals have sometimes been viewed as a step toward biologic treatment, particularly when efficacy expectations differed between the two approaches. Friedman described that distinction as increasingly blurred as the efficacy of targeted oral therapies improves — an evolution that creates space to incorporate patient preference more fully into shared decision-making.

Can Earlier Intervention Alter the Disease Trajectory?

Friedman framed one of the major open questions in chronic inflammatory disease: whether earlier intervention can alter its trajectory. Clinicians cannot reliably predict which comorbidities an individual patient will develop, but moderate to severe psoriasis carries a broader systemic inflammatory burden.

Rather than waiting for complications to emerge, Friedman supports treating systemic inflammation appropriately and earlier in the disease course. He also urged colleagues to maintain the distinction between association and causation when discussing psoriasis and its comorbidities with patients — a nuance that matters for honest counseling.

Family Planning and Vaccination

Circumstances change, and therapy selection should anticipate that. Pregnancy planning and vaccination status both shape the choice of systemic agent. Friedman noted that limited pregnancy data for newer therapies complicate counseling, and he pointed to pregnancy registries as essential for building the evidence base that will inform future practice.

For patients who require live vaccines, three drug properties influence decisions: the medication's half-life, the time to elimination, and the ability to recapture response after treatment interruption. Oral therapies with relatively rapid onset and offset may offer additional flexibility in these situations — a practical advantage over agents with long washout periods.

The Goal: Effective and Sustainable

The objective, Friedman emphasized, is not simply to identify an effective systemic therapy, but to choose a treatment approach that patients can realistically and comfortably maintain over time. Expanding the systemic toolkit — and matching it to comorbidity risk, reproductive plans, vaccination needs and administration preference — moves psoriasis care closer to that goal.

As targeted oral therapies close the efficacy gap with injectables, expect treatment selection conversations to shift further toward individualized, preference-driven decisions grounded in early comorbidity detection.