Psoriatic arthritis (PsA) is a systemic inflammatory condition affecting the joints, spine, and entheses, as well as the skin and nails. It affects about 6–42% of patients with psoriasis (PsO), with a prevalence of 1–2 per 1000. PsA can precede skin disease in 7–14% of patients. Different clinical domains may be involved, including psoriatic skin disease, peripheral arthritis, axial involvement, dactylitis, enthesitis, and nail disease. Psoriatic arthritis is a complex, systemic inflammatory condition. While the exact mechanisms underlying PsA are not fully understood, it is believed that the disease arises from a combination of genetic predisposition and environmental triggers that lead to inflammatory processes in both the skin and joints. The treatment approach for PsA focuses on controlling inflammation, improving symptoms, and preventing joint damage. Early initiation of treatment is crucial for achieving better functional outcomes. Various therapeutic agents are available that target different inflammatory pathways. In this review article, various treatment options, focusing on biologic and targeted synthetic disease-modifying antirheumatic drugs, are discussed.

Introduction and importance: Rheumatoid arthritis (RA) presents with extra-articular manifestations in 15–25% of cases. Intra-osseous rheumatoid nodules occur in <1% of patients and mimic metastatic disease on imaging. When extra-articular features precede joint symptoms, diagnostic delays are common. Case presentation: A 78-year-old male smoker presented with chronic cough and dyspnea. CT revealed interstitial lung disease and a pulmonary nodule. PET-CT demonstrated multiple FDG-avid osteolytic lesions in ribs, scapula, and spine (SUV 4.2–8.7), suggesting metastatic malignancy. Initial biopsies showed inflammation without malignancy. Four months later, the patient developed polyarthralgia, morning stiffness, and 8-kg weight loss. Hand radiographs revealed erosive arthropathy. Laboratory tests showed rheumatoid factor 240 IU/mL, anti-CCP 185 U/mL, ESR 68 mm/hr, and CRP 42 mg/L. Repeat scapular biopsy identified necrobiotic granulomas consistent with rheumatoid nodules. Clinical discussion: Intra-osseous rheumatoid nodules result from immune complex-mediated tissue necrosis. Inflammatory cytokines activate osteoclasts, creating lytic lesions with high metabolic activity indistinguishable from metastases on PET imaging. Extra-articular manifestations precede joint symptoms in 10–15% of RA cases. Anchoring bias toward malignancy in an elderly smoker with pulmonary nodules and osteolytic lesions delayed alternative diagnoses. Negative initial biopsies and subsequent development of erosive arthropathy prompted diagnostic reconsideration. Conclusion: Extra-articular RA can masquerade as metastatic disease. Intra-osseous rheumatoid nodules represent rare manifestations requiring histological confirmation. Clinicians should consider systemic autoimmune diseases when evaluating unexplained interstitial lung disease with multiple osteolytic lesions, particularly when malignancy screening is negative. Early recognition enables appropriate immunosuppressive therapy and prevents irreversible organ damage.

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disorder primarily affecting joints. Methotrexate (MTX) and hydroxychloroquine (HCQ) are common disease-modifying antirheumatic drugs, yet more comparative outcome studies are needed. This study aimed to compare associations of HCQ versus MTX initiation with mortality, cardiovascular events, and other major health outcomes in RA patients. This retrospective cohort study utilized the TriNetX database (electronic health records from 142 global health care organizations) to compare selected 10-year outcomes in RA patients starting HCQ or MTX therapy. Methods: Patients aged 18–75 years diagnosed with RA (ICD-10 codes) were studied. This retrospective, multi-center cohort study used data from the TriNetX Research Network (analysis: 23 March 2025). Two cohorts, HCQ initiators and MTX initiators, were created. Propensity score matching (PSM) balanced cohorts for age, sex, race, pre-specified comorbidities, and concomitant medications. Primary outcomes were 10-year cumulative incidences of all-cause mortality, non-ST elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI), pulmonary hypertension (PAH), end-stage renal disease (ESRD), interstitial lung disease (ILD), osteoporosis, and Alzheimer’s dementia. Results: After PSM, 56 362 patients were in each cohort. HCQ initiation was associated with significantly higher 10-year relative risks (RR) for NSTEMI (RR: 1.217), ESRD (RR: 2.624), ILD (RR: 1.377), PAH (RR: 1.625), and all-cause mortality (RR: 1.379) compared to MTX. No statistically significant RR differences were observed for Alzheimer’s dementia, STEMI, or osteoporosis. Conclusion: In this large, real-world observational study, RA patients initiating HCQ had a higher 10-year risk association for ESRD, ILD, PAH, NSTEMI, and all-cause mortality versus MTX initiators. These findings highlight potential differences in systemic risk profiles and are hypothesis generating. However, the results must be interpreted with significant caution due to major limitations, including the potential for residual confounding from unmeasured variables like disease severity and the absence of adherence data. Further prospective research that addresses these limitations is warranted to confirm these associations and explore underlying mechanisms.