February 23, 2021
6 min read
Identifying and treating psoriasis in skin of color present a unique set of challenges for practitioners, leading to a call for advanced education.
Disparities have been shown in how the disease is identified due to its presentation in non-white skin types, while treatment disparities and mental health impacts in individuals with skin of color have also been identified.
Diagnosing psoriasis often leads with identifying erythema. The red, scaly patches common to the condition are generally easy to spot on lighter skin, but in skin of color, erythema presents much differently.
“There are many features of psoriasis that present similarly across skin types. For example, the symmetrical distribution of psoriasis on the body and well-circumscribed nature of psoriasis plaques. An important difference that clinicians need to keep in mind is that the pink-to-red color that is typically seen with psoriasis on light skin often appears more purple or brown in darker skin types,” Junko Takeshita, MD, PhD, MSCE, assistant professor of dermatology and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, said. “Sometimes the scale that accompanies psoriasis is so thick that it is difficult to appreciate that underlying color of the plaque itself.”
Erythema is influenced by background pigmentation, meaning the ability to identify erythema is also affected by that pigmentation, according to Andrew F. Alexis, MD, MPH, FAAD, chair of the department of dermatology at Mount Sinai West and Mount Sinai Morningside, professor of dermatology at Icahn School of Medicine at Mount Sinai and director of the Skin of Color Center.
“Depending on one’s experience, one may have some degree of challenge in assessing accurately the erythema associated with psoriasis lesions,” he said. “This could impact the diagnosis, but it could also impact the scoring of psoriasis severity in the context of clinical trials where erythema is a key component to the scoring and severity scales that are used.”
Therefore, the definition of erythema, which is most commonly described as “redness” in light skin, should be broadened to include the full spectrum of how it can look on more darkly pigmented skin.
In addition, clinicians should look beyond plaque coloration to identify psoriasis.
“Really assess the thickness of the lesions. Look at the quality of the scale, look at the sharpness of the border, look at the distribution of the lesions,” Alexis said. “These other clues can very much help in terms of making the right diagnosis of psoriasis as well as severity.”
Treatment disparities and challenges
Once a diagnosis of psoriasis is made, gaining access to treatment can also be different for racial and ethnic minority patients.
A 2015 study found Black patients, regardless of socioeconomic and other demographic factors, were less likely to receive biologic therapies for their psoriasis compared with white patients. As a follow-up to this study, Takeshita and her research team interviewed white and Black patients with psoriasis to understand their perceptions of biologics.
“We found that Black patients with psoriasis generally reported less familiarity with biologics than white patients,” Takeshita said. “To me, this means that Black patients with psoriasis have less exposure to and/or are less likely to recognize biologics as therapeutic options for them.”
Researchers then looked at how psoriasis treatments, specifically biologics, are marketed and found direct-to-consumer advertising included few people of minority race/ethnicity. In fact, among televised psoriasis treatment ads, 92.6% of the main characters were white, while only 6.2% were Black actors and 1.2% were Asian actors.
“Therefore, Black and other racial/ethnic minority individuals with psoriasis are very unlikely to see themselves represented in ads for psoriasis treatments and, thus, may not recognize these treatments as something that is for them,” Takeshita said.
Once identified, treating psoriasis in skin of color has its own challenges because the condition can leave behind patches of hyperpigmentation or present other issues.
“The treatment options that we would use in a lighter skin type patient may not always be ideal for a psoriasis patient with a darker skin tone,” Seemal R. Desai, MD, FAAD, president and medical director at Innovative Dermatology in Dallas, Texas, clinical assistant professor of dermatology at the University of Texas Southwestern and immediate past president of the Skin of Color Society, said. “Phototherapy is a prime example. Phototherapy is not something we use in our darker skin type patients without having the discussion that it can potentially cause their skin to become darker in other areas of the body.”
While phototherapy can be useful in treating psoriasis lesions, a conversation with the patient must happen to discuss if it is worth the effects, he said.
Hyperpigmentation can be left on skin of color after psoriasis treatments. Treating these hyperpigmented areas can also lead to problems with access to care as insurance companies often will not pay for these treatments.
“Many insurance providers will refuse to cover treatment for hyperpigmentation, saying that it is simply a cosmetic problem that does not warrant coverage,” Shadi Kourosh, MD, MPH, assistant professor of dermatology at Harvard Medical School, director of community health and director of the Pigmentary Disorder and Multi-Ethnic Skin Clinic, said. “This is unfair, inadequate care for patients. Their hyperpigmentation is a result of their psoriatic disease and a result of their psoriatic illness.”
The American Academy of Dermatology is working to increase education, awareness and advocacy on this topic.
“We need to work to raise awareness and provide coverage because it disproportionately affects our psoriatic patients with darker skin types,” Kourosh said.
Developing a treatment plan
Being aware of these disparities and open communication with patients are important when developing a plan of action to treat psoriasis in skin of color. Many patients of color do not seek treatment as early as those with lighter skin, adding to the challenge.
“With my psoriasis patients with skin of color, often by the time I see them for diagnosis, they’re much further along in their disease process,” Desai said. “Had I had an opportunity to treat the patient sooner, they probably wouldn’t have extensive hyperpigmentation and discoloration that we now have to tackle in addition to trying to control their psoriasis.”
Being mindful of the effects certain treatments will have on darker skin is necessary before beginning treatment. In addition to phototherapy, topical steroids can also affect the skin tone.
Many darker-skin individuals with psoriasis will experience lesions of the head and scalp, which practitioners should be cognizant of and respectful of how treatments can affect that area, specifically in women of African ancestry, according to Alexis.
“Coming up with a regimen that is compatible with that woman’s hairstyle, hair type and cultural practices is necessary,” he said. “When it comes to prescribing medications for scalp psoriasis, one has to take into account these differences.”
Quality of life impact
While all patients with psoriasis experience itch and scales that can be disfiguring, the quality of life for patients of color has been shown to be disproportionately affected negatively.
“For patients with darker skin types, because of hyperpigmentation and damage due to psoriasis inflammation, the disfigurement can be more profound and longer lasting,” Kourosh said.
A 2011 study of 2,511 subjects found quality of life impact to be worse among African American and Asian American patients compared with white Americans despite white patients having the longest disease duration. Another study, conducted by the National Psoriasis Foundation, found 72% of African American subjects believed their psoriasis interfered with their ability to enjoy life compared with 54% of Caucasian subjects.
“From these data, there appears to be a greater quality of life impact of psoriasis in patients of color,” Alexis said.
Education to reduce disparity
Outcomes data related to psoriasis in skin of color are severely lacking, as is clear prevalence data, according to Desai.
One way to reduce disparities in the identification and treatment of psoriasis in darker-skinned populations would be to increase the number of patients with skin of color who are enrolled in clinical trials and studies.
“Finding clinical investigators who have patients of color in their practices so they can enroll those patients in studies is huge,” Desai said. “This is a massive unmet need and something we need to work toward. Until we get more patients of color in clinical trials, we’re not going to have as much data on how these treatments really work and if they work differently in patients of color.”
Continuing education for residents and board-certified dermatologists is also imperative.
The AAD has a task force gathering data and developing an official skin color curriculum.
“We are working to create a larger curriculum to teach diagnosis and management of skin diseases in darker skin types and also working to make sure curriculum is culturally competent,” Kourosh, who chairs the task force’s cultural competency, anti-racism and policy section, said. “We hope this will help to train the dermatology workforce to do a better job of taking care of darker-skinned patients and provide a resource to the larger medical community.”
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For more information:
Andrew F. Alexis, MD, MPH, FAAD, can be reached at Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029; email: [email protected].
Seemal R. Desai, MD, FAAD, can be reached at Innovative Dermatology, 5425 W. Spring Creek Parkway, Suite 265, Plano, TX 75024; email: [email protected].
Shadi Kourosh, MD, MPH, can be reached at Massachusetts General Hospital, 50 Staniford St., Boston, MA 02114; email: [email protected].
Junko Takeshita, MD, PhD, MSCE, can be reached at Penn Dermatology Perelman Center for Advanced Medicine, 7th floor, South Tower, 3400 Civic Center Blvd., Philadelphia, PA 19104; email: [email protected].