Psoriatic arthritis: correlation between imaging and pathology

Psoriatic arthritis (PsA) is an archetypal type of spondyloarthritis, but may have some features of rheumatoid arthritis, namely a small joint polyarthritis pattern. Most of these features are well demonstrated on imaging, and as a result, imaging has helped us to better understand the pathophysiology of PsA. Although the unique changes of PsA such as the "pencil-in-cup" deformities and periostitis are commonly shown on conventional radiography, PsA affects all areas of joints, with enthesitis being the predominant pathology. Imaging, especially magnetic resonance imaging (MRI) and ultrasonography, has allowed us to explain the relationships between enthesitis, synovitis (or the synovio-entheseal complex) and osteitis or bone oedema in PsA. Histological studies have complemented the imaging findings, and have corroborated the MRI changes seen in the skin and nails in PsA. The advancement in imaging technology such as high-resolution "microscopy" MRI and whole-body MRI, and improved protocols such as ultrashort echo time, will further enhance our understanding of the disease mechanisms. The ability to demonstrate very early pre-clinical changes as shown by ultrasonography and bone scintigraphy may eventually provide a basis for screening for disease and will further improve the understanding of the link between skin and joint disease.