A 50-year-old housewife presented with severe pain, early-morning stiffness and swelling over the joints of her left ring and little fingers. The symptoms started 3 months earlier and gradually worsened. The pain was worse in the morning and not relieved with rest. Pain score using IASP Pain Scale [] ranged from 6 to 8 with temporary improvement after analgesics (paracetamol and diclofenac). She noticed that the joints were painlessly deformed 1 year earlier and had sought medical attention. The attending general practitioners had diagnosed her as having hand osteoarthritis. There was no history of trauma, fever, hair loss or oral ulcers. She had no known prior medical illnesses. There was no family history of hand osteoarthritis or any other skin or joint diseases. There was no personal or family history of atopic eczema, asthma, allergic rhinitis and allergic conjunctivitis. The patient also noticed multiple pruritic skin rashes over both ankles and knees for the last 1 year. According to her, the rashes were hardly scaly. She was diagnosed with lichen planus by her general practitioners. However, treatment with topical agents was to no avail. Physical examination revealed deformity of the distal interphalangeal (DIP) joints of the left ring and little fingers. There was fixed flexion of both joints. The little finger’s distal phalanx was curved inward. The joints were swollen, erythematous and tender on palpation. Range of motion was also limited due to pain. Left hand radiograph showed abnormalities at the DIP joints of the ring and little fingers. Both appeared irregular with sclerotic joint margin, narrowed joint space and marginal osteophytes. Her blood investigations showed normal white cell counts (7.42 × 109/L); slightly elevated erythrocyte sedimentation rate (ESR) (22 mm/hour; normal 1–20 mm/hour); antinuclear antibody (ANA), rheumatoid factor (RF) and anticyclic citrullinated protein antibody (ACCPA) were all negatives. The other blood cell counts, renal and liver profiles were normal. There were multiple red-violaceous, flat-topped papules and plaques with minimal scales on the ankles (left more than right) and superficial excoriation. There were also hyperpigmented scaly plaques over both knees and vertical ridges on her fingernails. Oral examination showed normal dentition with no mucosal streaks, erosion or ulcers. The rest of the skin, scalp and other systems examinations were unremarkable. Dermoscopic examination using DermLite DL4 (3Gen Inc., San Juan Capistrano, 92,675, America) revealed dermoscopic Auspitz sign over a light red background, minimal white scales with a regularly distributed dotted blood vessel. Punch biopsy of the skin lesion on the left ankle showed parakeratosis at the surface of the epidermis with elongation of the rete ridges; spongiosis of the epidermal layer and small capillaries proliferation seen in the papillary dermis with surrounding mixture of inflammatory cells, predominantly lymphocytes. These findings are consistent with psoriasis. We diagnosed her as having psoriatic arthritis (PsA). Treatment consisted of weekly oral methotrexate 7.5 mg titrated up to 15 mg with folic acid supplement and topical betamethasone valerate cream 0.5%. Her skin rash and joint pain had improved markedly after 4 weeks of treatment.