Determinants of Structural Joint Damage in Psoriatic Arthritis: Limited Association with Disease Activity and Modest Link with Health Impact

<b>Background/objectives:</b> Structural joint damage remains a major determinant of long-term disability in psoriatic arthritis (PsA). However, its relationship with current disease activity and patient-reported impact in routine clinical practice is not fully understood. We aimed to assess the prevalence and burden of structural joint damage in PsA and to examine its associations with disease activity, patient-reported impact, and clinical characteristics using complementary analytical approaches. <b>Methods:</b> This cross-sectional real-world study included 165 patients with PsA. Structural damage was assessed on conventional radiographs and defined as the presence of at least one joint with erosion, deformity/ankylosis, or joint space narrowing. Damage was analyzed as a binary outcome and as an ordinal burden (0, 1-2, ≥3 affected joints). Disease activity was evaluated using DAPSA, and patient-reported impact using PsAID and the ASAS Health Index (ASAS HI). Multivariable logistics and ordinal regression models were applied. Sensitivity analyses included alternative damage definitions, exclusion of joint space narrowing, restriction to longer disease duration, and adjustment for treatment exposure. <b>Results:</b> Structural damage was present in 26.7% of patients. Disease duration was consistently associated with the presence (OR 1.10 per year; 95% CI 1.05-1.15) and increasing burden of structural damage across all analyses. Distal interphalangeal involvement at presentation was strongly associated with higher damage burden (OR 4.29; 95% CI 1.88-9.78). No significant association was observed between structural damage and current disease activity as assessed by DAPSA, while PsAID showed only a non-significant trend. In contrast, ASAS HI scores were significantly higher in patients with structural damage and increased progressively with greater damage burden (ρ = 0.172; <i>p</i> = 0.027). Findings remained robust across sensitivity analyses, including restriction to erosive damage and exclusion of joint space narrowing. <b>Conclusions:</b> In PsA, structural joint damage is primarily driven by cumulative disease exposure rather than current inflammatory activity. Disease duration and distal interphalangeal involvement identify patients at higher structural risk, while health impact measured by ASAS HI reflects accumulated damage more closely than conventional activity indices.