Psoriatic arthritis (PsA) is a heterogeneous, immune-mediated inflammatory disease characterised by multidomain clinical involvement, including peripheral arthritis, enthesitis, axial disease, dactylitis, and skin and nail manifestations, alongside a substantial burden of comorbidity. Over the recent decades, therapeutic options for PsA have expanded, with the introduction of multiple biologic and targeted compounds targeting tumour necrosis factor, the IL-23/IL-17 axis, and Janus kinase signalling. These advances have improved outcomes for many patients; however, incomplete responses, domain-specific refractory disease, treatment intolerance, and loss of efficacy remain common. In addition, current treatment strategies are largely reactive, reflecting limited ability to predict treatment response or align immune mechanism with clinical phenotype. This review summarises the current PsA treatment landscape and its limitations, and examines emerging therapeutic directions that aim to address disease heterogeneity and unmet need. These include combinatorial and sequential treatment strategies, next-generation biologics and oral agents, immunometabolic modulation, selective targeting of pathogenic immune cell populations and upstream inflammatory, immune tolerance-based approaches. It is with hope that these developments highlight a shift from incremental therapeutic expansion towards a integrated, targeted and ultimately, more informed treatment approach.