Skip to content

Clinicians › General-Health

Psoriatic Arthritis

Psoriatic arthritis of the hand for the surgeon (corpus-synthesised).

28 citationsUpdated Sep 2026
Illustration: Psoriatic Arthritis

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Psoriatic arthritis is a distinct clinical entity and chronic inflammatory arthropathy that typically follows a moderate course [1, 8]. It is a clinically heterogeneous disease spectrum consisting of skin changes and joint involvement, common among patients with psoriasis [4, 5]. The condition is characterized by clinical and roentgenographic findings different from rheumatoid arthritis [1]. Joint involvement is often an asymmetrical polyarthritis [5], with a particular predilection for distal joints [1]. Up to 47% of cases develop into destructive arthritis [8].

The proportion of patients with current inflammatory back pain is substantial in psoriatic arthritis [13]. Health reports in these patients are similar or worse compared to the ankylosing spondylitis group, supporting the severity of inflammatory back pain in non-AS spondyloarthritis groups [13]. In patients with psoriasis and psoriatic arthritis, the severity of fatigue decreased along with the duration of psoriasis [11]. The prevalence of physician-diagnosed psoriasis and psoriatic arthritis confirms other population-based studies after adjustment for misclassification of disease [10].

Both manifestations of cutaneous psoriasis are associated with risks of complications following total hip arthroplasty [12]. The SOLAR score is a suitable instrument for the qualitative and quantitative evaluation of large joint involvement in psoriatic arthritis patients [17]. It also allows for treatment monitoring in psoriatic arthritis patients [17].

Background & Causes

Metabolic syndrome is significantly more prevalent in patients with psoriatic arthritis than in those with ankylosing spondylitis [28]. Genetic factors also influence disease susceptibility; specifically, the T allele of VEGF in +936 may act as a protective allele in the development of psoriatic arthritis [30].

Symptoms & Presentation

Psoriatic arthritis is a distinct clinical entity characterized by specific clinical and roentgenographic findings that differentiate it from rheumatoid arthritis, particularly regarding the involvement of distal joints [1]. It represents a disease spectrum encompassing both cutaneous changes and joint involvement, with the latter frequently manifesting as an asymmetrical polyarthritis [5]. As a chronic inflammatory arthropathy, the condition typically follows a moderate course; however, up to 47% of cases progress to destructive arthritis [8]. Population-based data confirm the prevalence of physician-diagnosed psoriasis and psoriatic arthritis, a finding that remains consistent even after adjustments for disease misclassification [10].

Functional impairment and systemic symptoms are significant components of the presentation. One fifth of patients experience deterioration in physical function over time, with joint damage and baseline physical function serving as key factors associated with poor outcomes [18]. Grip and pinch strength are significantly lower across all subparameters in patients with PsA, demonstrating a moderate association with disease activity [24]. Fatigue is a prevalent symptom, with levels often exceeding 5/10; this fatigue is primarily associated with disease-related factors but also involves patient-related variables, indicating a multifactorial etiology [25]. Notably, the severity of fatigue has been observed to decrease alongside the duration of psoriasis in affected patients [11].

Inflammatory back pain is a substantial feature in PsA populations. The proportion of patients reporting current inflammatory back pain is significant across all three groups studied. Health reports in non-ankylosing spondylitis (non-AS) groups are similar to or worse than those in the AS group, supporting the severity of inflammatory back pain in these non-AS spondyloarthritis groups [13].

Management

General Principles and Disease Characterization

Psoriatic arthritis is a definite clinical entity that requires recognition and treatment according to its specific needs [3].

Pharmacologic Therapy

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios [7]. Biologic agents offer good value for money and are cost-effective for treating patients with active Psoriatic Arthritis compared to traditional treatments, with etanercept identified as the most cost-effective option [9]. Biologics are shown to be cost-effective for treating patients with active PsA compared with the conventional management strategy [14]. A good clinical response for arthritis, skin and nail disease was seen with anti-TNF therapy, but persistent ongoing subclinical inflammation (osteitis, synovitis and enthesopathy) was observed at six months [23]. The GOLMePsA study protocol postulates that very early treatment with golimumab reduces disease activity in PsA compared to conventional therapy [20]. Celastrol was identified as a potential therapeutic drug for PsA via regulating immunity and inflammation [27].

Monitoring and Assessment

MMP-3 and MIA could serve as soluble biomarkers associated with inflammation as well as joint remodelling and destruction and may, together with clinical evaluation and in combination with other biomarkers, assist in distinguishing between effective and ineffective therapy in small, proof-of-principle studies of short duration in PsA [16]. The SOLAR score is a very suitable instrument for the qualitative and quantitative evaluation of large joint involvement in PsA and AS patients and allows for treatment monitoring [17]. In the studied PsA cohort, disease activity was an independent predictor of 10-year probability for a major osteoporotic fracture, and complemented assessment of volumetric and areal BMD assured better efficacy at identifying those with low bone mineral density [21].

Non-Pharmacologic and Supportive Management

In PsA patients with a low to moderate disease activity, there was no clear evidence of objectively measured increased inflammation after high intensity interval training, as evaluated by US and MRI [22]. To meet the foot health needs of people with psoriatic arthritis, reducing diagnostic delay, improving knowledge and awareness about the disease among people with psoriatic arthritis and health professionals, and increasing specialist podiatry service provision may be required [2].

Functional Outcomes and Comorbidities

MetS was significantly more prevalent in PsA than in AS [28]. Both manifestations of psoriasis are associated with risks of complications following THA [12].

Key Considerations

Disease Burden and Fracture Risk: The proportion of patients with current inflammatory back pain is substantial across ankylosing spondylitis, psoriatic arthritis, and other spondyloarthritis groups, with health reports in non-AS groups similar to or worse than those in the AS group [13]. In psoriatic arthritis cohorts, disease activity serves as an independent predictor of the 10-year probability for a major osteoporotic fracture [21]. Complemented assessment of volumetric and areal bone mineral density (BMD) ensures better efficacy at identifying patients with low bone mineral density [21].

Surgical and Pharmacological Management: Both cutaneous psoriasis and psoriatic arthritis are associated with risks of complications following total hip arthroplasty [12]. Biologics are shown to be cost-effective for treating patients with active psoriatic arthritis compared with the conventional management strategy [14]. While the majority of patients receive only one line of anti-TNFα therapy, a subset switches to multiple lines of therapy during the 3-year follow-up period [29]. Anti-TNF therapy yields a good clinical response for arthritis, skin, and nail disease; however, persistent ongoing subclinical inflammation, including osteitis, synovitis, and enthesopathy, remains evident at six months [23].

Prognostic Trials and Biomarkers: The TICOPA trial will provide direct evidence as to whether early and intensive treatment in routine clinical care leads to improved disease activity and reduced radiological joint damage [15]. A study protocol postulates that very early treatment with golimumab reduces disease activity in psoriatic arthritis compared to conventional therapy [20]. MMP-3 and MIA may serve as soluble biomarkers associated with inflammation, joint remodelling, and destruction; together with clinical evaluation and other biomarkers, they may assist in distinguishing between effective and ineffective therapy in small, proof-of-principle studies of short duration [16].

Quality of Life Assessment: The adapted English and Chinese versions of the PsAQoL can be used in clinical studies with psoriatic arthritis patients in Singapore [19].

Key Evidence

  • [L4] To meet the foot health needs of people with psoriatic arthritis, reducing diagnostic delay, improving knowledge and awareness about the disease among people with psoriatic arthritis and health professionals, and increasing specialist podiatry service provision may be required. [2] (10.1186/s12891-019-2572-6)
  • [L5] Psoriatic arthritis is a definite entity that should be recognized and treated according to its special needs. [3] (10.1016/s0749-0712(21)00346-2)
  • [L4] Psoriatic arthritis (PsA) is a clinically heterogeneous inflammatory arthritis that is common among patients with psoriasis. [4] (10.1016/j.rdc.2015.07.001)
  • [L5] Psoriatic arthritis is a disease spectrum consisting of skin changes and joint involvement, the latter often being an asymmetrical polyarthritis. [5] (10.1016/s0749-0712(21)00801-5)
  • [L1] The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. [7] (10.1002/art.40726)
  • [L5] Psoriatic arthritis is a chronic inflammatory arthropathy that typically follows a moderate course, though up to 47% of cases develop into destructive arthritis. [8] (10.5435/jaaos-20-01-028)
  • [L1] Biologic agents offer a good value for money and are cost-effective for treating patients with active Psoriatic Arthritis compared to traditional treatments, with etanercept identified as the most cost-effective option. [9] (10.1186/1471-2474-15-25)
  • [L3] The prevalence of physician-diagnosed psoriasis and PsA confirms other population-based studies, also after adjustment due to misclassification of disease. [10] (10.1371/journal.pone.0098024)
  • [L4] In patients with psoriasis and PsA, severity of fatigue decreased along with the duration of psoriasis. [11] (10.5114/ada.2019.83629)
  • [L3] This study showed both manifestations of psoriasis are associated with risks of complications following THA. [12] (10.1016/j.arth.2026.03.054)
  • [L3] The proportion of patients with current inflammatory back pain was substantial in all three groups and health reports in the non-AS groups were similar or worse compared to the AS group supporting the severity of IBP in these non-AS SpA groups. [13] (10.1186/s12891-016-0960-8)
  • [L1] The economic analysis agrees with the conclusions from the previous models, in that biologics are shown to be cost-effective for treating patients with active PsA compared with the conventional management strategy. [14] (10.1186/1471-2474-15-26)
  • [L1] The TICOPA trial will provide direct evidence as to whether the use of early and intensive treatment in PsA in routine clinical care leads to an improvement in patients' disease activity and a reduction in radiological joint damage. [15] (10.1186/1471-2474-14-101)
  • [L1] MMP-3 and MIA could serve as soluble biomarkers associated with inflammation as well as joint remodelling and destruction and may, together with clinical evaluation and in combination with other biomarkers, assist in distinguishing between effective and ineffective therapy in small, proof-of-principle studies of short duration in PsA. [16] (10.1371/journal.pone.0012556)
  • [L4] The SOLAR score is a very suitable instrument for the qualitative and quantitative evaluation of large joint involvement in PsA and AS patients and allows for treatment monitoring. [17] (10.1186/1471-2474-14-358)
  • [L3] One fifth of patients experienced deterioration of physical function over time, with joint damage and baseline physical function being important factors associated with poor physical function. [18] (10.1186/1471-2474-15-284)
  • [L4] This study provides evidence that the adapted English and Chinese versions of the PsAQoL can be used in clinical studies with PsA patients in Singapore. [19] (10.1186/s12891-016-1292-4)
  • [L2] The study protocol postulates that very early treatment with golimumab reduces disease activity in PsA compared to conventional therapy. [20] (10.1186/s12891-017-1659-1)
  • [L3] In the studied PsA cohort, disease activity was an independent predictor of 10-year probability for a major osteoporotic fracture, and complemented assessment of volumetric and areal BMD assured better efficacy at identifying those with low bone mineral density. [21] (10.1186/s12891-021-03952-z)
  • [L1] In PsA patients with a low to moderate disease activity, there was no clear evidence of objectively measured increased inflammation after HIIT, as evaluated by US and MRI. [22] (10.1186/s12891-023-06871-3)
  • [L4] A good clinical response for arthritis, skin and nail disease was seen with anti-TNF therapy, but the study shows persistent ongoing subclinical inflammation (osteitis, synovitis and enthesopathy) at six months. [23] (10.1186/1471-2474-14-s1-a7)
  • [L3] All subparameters of grip and pinch strength were significantly lower in patients with PsA and were moderately associated with disease activity. [24] (10.1111/1756-185x.14241)
  • [L4] Fatigue levels were high in these patients and fatigue > 5/10 was mainly associated with disease-related factors but also patient-related variables, indicating that the etiology of fatigue in PsA is multifactorial. [25] (10.1016/j.jbspin.2015.07.017)
  • [L5] Celastrol was identified as a potential therapeutic drug for PSA via regulating immunity and inflammation. [27] (10.1186/s13018-023-03843-0)
  • [L3] MetS was significantly more prevalent in PsA than in AS. [28] (10.1186/s12891-021-04222-8)
  • [L3] While the majority of patients received only one line of anti-TNFα therapy, a subset of patients switched to multiple lines of therapy during the 3-year follow-up period. [29] (10.1186/s12891-016-1102-z)
  • [L3] The T allele of VEGF in +936 may act as a protective allele in the development of PsA. [30] (10.1186/1471-2474-8-1)

References

[1] PSORIATIC ARTHRITIS: Observations on the Clinical, Roentgenographic, and Pathological Chances.. The Journal of Bone and Joint Surgery. American Volume. 1952.

[2] Health professional views on the assessment and management of foot problems in people with psoriatic arthritis in Australia and New Zealand: a qualitative investigation. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2572-6

[3] SURGERY OF PSORIATIC ARTHRITIS OF THE HAND. Hand Clinics. 1996. DOI: 10.1016/s0749-0712(21)00346-2

[4] The Epidemiology of Psoriatic Arthritis. Rheumatic Disease Clinics of North America. 2015. DOI: 10.1016/j.rdc.2015.07.001

[5] Psoriatic Arthritis in the Hand. Hand Clinics. 1989. DOI: 10.1016/s0749-0712(21)00801-5

[7] 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis & Rheumatology. 2018. DOI: 10.1002/art.40726

[8] Psoriatic Arthritis. American Academy of Orthopaedic Surgeon. 2012. DOI: 10.5435/jaaos-20-01-028

[9] Pharmacoeconomic burden in the treatment of psoriatic arthritis: from systematic reviews to real clinical practice studies. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-25

[10] Validity of Diagnostic Codes and Prevalence of Physician-Diagnosed Psoriasis and Psoriatic Arthritis in Southern Sweden – A Population-Based Register Study. PLoS ONE. 2014. DOI: 10.1371/journal.pone.0098024

[11] Prevalence and severity of fatigue in psoriasis and psoriatic arthritis. Advances in Dermatology and Allergology. 2020. DOI: 10.5114/ada.2019.83629

[12] Outcomes Following Total Hip Arthroplasty in Patients with Cutaneous Psoriasis and Psoriatic Arthritis. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.054

[13] Back pain and health status in patients with clinically diagnosed ankylosing spondylitis, psoriatic arthritis and other spondyloarthritis: a cross-sectional population-based study. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0960-8

[14] Systematic review, network meta-analysis and economic evaluation of biological therapy for the management of active psoriatic arthritis. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-26

[15] The TICOPA protocol (TIght COntrol of Psoriatic Arthritis): a randomised controlled trial to compare intensive management versus standard care in early psoriatic arthritis. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-101

[16] Soluble Biomarkers of Cartilage and Bone Metabolism in Early Proof of Concept Trials in Psoriatic Arthritis: Effects of Adalimumab Versus Placebo. PLoS ONE. 2010. DOI: 10.1371/journal.pone.0012556

[17] Evaluation of the novel ultrasound score for large joints in psoriatic arthritis and ankylosing spondylitis: six month experience in daily clinical practice. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-358

[18] Predictors of functional deterioration in Chinese patients with Psoriatic arthritis: a longitudinal study. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-284

[19] Adaptation of Chinese and English versions of the Psoriatic Arthritis Quality of Life (PsAQoL) scale for use in Singapore. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1292-4

[20] The GOLMePsA study protocol: an investigator-initiated, double-blind, parallel-group, randomised, controlled trial of GOLimumab and methotrexate versus methotrexate in early diagnosed psoriatic arthritis using clinical and whole body MRI outcomes. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1659-1

[21] Characterization of bone metabolism in hungarian psoriatic arthritis patients: a case–control study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-03952-z

[22] Changes of inflammation in patients with psoriatic arthritis after high intensity interval training assessed by ultrasound and MRI, a randomized controlled trial. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06871-3

[23] Imaging of psoriatic nail disease pre and post anti-TNF therapy shows persistent subclinical inflammation despite good clinical response. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-s1-a7

[24] Effect of psoriatic arthritis on the strength, proprioception, skill, coordination, and functional condition of the hand. International Journal of Rheumatic Diseases. 2021. DOI: 10.1111/1756-185x.14241

[25] Fatigue in psoriatic arthritis – a cross-sectional study of 246 patients from 13 countries. Joint Bone Spine. 2016. DOI: 10.1016/j.jbspin.2015.07.017

[27] Discovery of CLEC2B as a diagnostic biomarker and screening of celastrol as a candidate drug for psoriatic arthritis through bioinformatics analysis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03843-0

[28] Association between syndesmophyte and metabolic syndrome in patients with psoriatic arthritis or ankylosing spondylitis: a cross-sectional study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04222-8

[29] Treatment patterns and costs for anti-TNFα biologic therapy in patients with psoriatic arthritis. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1102-z

[30] VEGF, FGF1, FGF2 and EGF gene polymorphisms and psoriatic arthritis. BMC Musculoskeletal Disorders. 2007. DOI: 10.1186/1471-2474-8-1

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.