In recent years, the concept of axial psoriatic arthritis (PsA) as a distinct phenotype of psoriatic arthritis with implications for management has emerged. This article highlights advancements and controversies in the understanding of its epidemiology, pathophysiology, diagnosis, and treatment. Key challenges, including diagnostic uncertainty in patients with axial symptoms on the background of psoriasis, the lack of standardized classification criteria, and the absence of validated outcome measures specific to axial PsA, are discussed. Additionally, current evidence supporting the use of advanced therapies, including interleukin (IL)-17, Janus kinase, and IL-23 inhibitors, is presented.