Recognizing Psoriasis in Skin of Color

Research has shown that psoriasis may impact the quality of life of minority patients more negatively¹ and be more severe than that in White patients.² Further, there is evidence that Black patients experience disparities in care, particularly when it comes to treatment with biologics.^3-5 Dermatology has a critical need to include patients of color in clinical trials and research as well as expand its education and literature to better train physicians to identify dermatologic diseases such as psoriasis in darker Fitzpatrick phototypes.

Dr Lynn McKinley-Grant is associate professor, department of dermatology at Howard University College of Medicine in Washington, DC; former Vice Chair for Diversity and Community Engagement at Duke University School of Medicine in Durham, NC; and serves as the president of the Skin of Color Society. She shared several pearls on diagnosing and treating psoriasis in SOC in an interview with The Dermatologist.

Q. What do we need to remember about identifying dermatologic diseases such as psoriasis in SOC?
A. There has been quite a bit of research and discussion recently about how diseases may present differently in SOC. If we train on one skin color, then only that presentation is how we will learn diseases. Training or practicing in a geographical area with a diverse population can help you learn to recognize diseases in all skin types.  

Diseases will present in different stages and patterns, but these patterns and stages can be the same in any skin type. It is the redness and inflammation, or erythema, that is different depending on the background. The color of erythema in a lesion is determined by Fitzpatrick phototype, hemoglobin and oxygen levels, other pigments in the blood and the pathological location of the inflammation. Erythema in Fitzpatrick IV-VI is brown-purple, and anemia and hypoxemia are diffusely grey over the brown pigment.

With psoriasis, no matter what the skin tone is, specific anatomical locations—the elbows, knees, scalp, lower back, and nails—are involved. Also, in all skin types, psoriasis has the same kind of geometric shapes, ie, the specific annular shape of guttae psoriasis. One very remarkable thing I find with psoriasis is that it is very symmetrical, presenting on almost the same spot on the other thigh, elbow, arm. We need to recognize the pattern of psoriasis that occurs in all the Fitzpatrick phototypes. On biopsy, these external patterns also have the same pathology. The difference comes in color, whether from the melanin, anemia, oxygen status, or other illnesses that may produce pigments.

Consider an otherwise healthy person with Fitzpatrick IV-VI skin presenting with these symmetrical plaques that are very diagnostic of psoriasis. The color of these plaques will be a deeper purple. In addition, Fitzpatrick phototypes IV-VI tend to be more hyperactive, so psoriasis maybe even a little more hypertrophic or raised, but generally, the plaques will be in the same shapes. There will be pits in the nails, scaling of the scalp. It comes down to learning first the pattern and then applying the color to it for recognizing psoriasis in SOC.

Q. Are there any special considerations to treatment of psoriasis in SOC?
A. One of the most critical things with psoriasis in all people is to make the diagnosis accurately. We understand how negatively psoriasis can impact the quality of life, and starting biologic agents can make a world of difference for patients with severe psoriasis. Severe hyperpigmentation can occur in darker skin types. Asymptomatic hyperpigmentation is a better quality of life than active psoriasis. The earlier psoriasis is treated, the less postinflammatory hyperpigmentation or hypopigmentation occurs. 

Scalp psoriasis treatments complicate hairstyling for patients of color who do not regularly wash their scalp once a day, as it is an arduous, time-consuming process to comb, dry, and style the hair. Generally, people do not mind using keratolytic and oils along with steroids to help alleviate itching and scaling, and with COVID-19, many patients are wearing a natural style which is more amenable to washing the hair every day as prescribed.  

Phototherapy is an effective and safe method of psoriasis treatment for people of color. The main issue is the time for travel and brief visits for the two to three appointments per week, particularly for working people. Maintaining that schedule is not easy, and it can be an economic strain on many people. Home phototherapy is an option if housing accommodations are large enough to have a home phototherapy unit. All of these factors must be considered, including insurance coverage, when considering phototherapy. 

Q. Can you share a few pearls for diagnosing psoriasis in SOC?
A. Listen to the patient’s history and description of their symptoms, close observation for the presenting eruption pattern, and do not accept the diagnosis of psoriasis from any source unless the patient has biopsy-proven psoriasis, and remember that psoriasis has many patterns, stages, and presentations. All too often, we see dry skin and do not appreciate the erythema, thinking, “it is just dry skin, they are using antibacterial soaps and scrubbing and doing things that dry out the skin.” I think the pearl here is to ask the patient what is different about their skin. While I recommend following appropriate recommendations and personal protective equipment guidelines for in-person appointments, it helps to touch the skin to see if it is warm. Psoriasis is usually a little bit warmer than normal skin. Touching can also help to feel the scale and appreciate that it is the fish-like psoriatic scale we learned about in medical school. Touch is also healing, and the patient who is touched is comforted that it is not a contagious disease.

It is also so helpful to listen and find out about the patient’s history. They may not know their parents had psoriasis, but they may say something like, “oh, well, my parent just had dry skin all the time. I guess they had something like me, but we just thought it was dry skin.” So, listening to the patient and relying on what you, as the physician, know about psoriasis can help with an accurate diagnosis. 

Also, recognize that other people may have misdiagnosed a patient before the appointment. A nondermatologist may have told them they have dandruff of the scalp when it is psoriasis on closer examination. It is important to ask patients for more details to help make an accurate diagnosis to start treatment sooner. If in doubt, it does not hurt to biopsy to confirm the diagnosis.

Q. What broad impact can psoriasis have on patients with SOC?
A. Psoriasis is a very traumatic disease to have in all people. Some uninformed people thought that patients with psoriasis had AIDS. Even in the art world, many older paintings show people with leprosy. When you look closely at the painting, the subjects have classical patterns of psoriasis. Now that we have improved treatments, though, there is optimism. Patients can get better and can live in everyday life.

 Having a skin disease causes a more stressful psychosocial burden on the lives of a patient of color with psoriasis.

The most powerful impact on treating a psoriasis patient is making the most accurate diagnosis. Patients, both children, and adults will do well if we make the right diagnosis and start the appropriate treatments.

References
1. Shah SK, Arthur A, Yang YC, Stevens S, Alexis AF. A retrospective study to investigate racial and ethnic variations in the treatment of psoriasis with etanercept.
J Drugs Dermatol. 2011;10(8):866-872. 

2. Gelfand JM, Stern RS, Nijsten T, et al. The prevalence of psoriasis in African Americans: results from a population-based study. J Am Acad Dermatol. 2005;52(1):23-26. doi:10.1016/j.jaad.2004.07.045

3. Takeshita J, Eriksen WT, Raziano VT, et al. Racial differences in perceptions of psoriasis therapies: implications for racial disparities in psoriasis treatment. J Invest Dermatol. 2019;139(8):1672-1679.e1. doi:10.1016/j.jid.2018.12.032

4. Takeshita J, Gelfand JM, Li P, et al. Psoriasis in the US Medicare population: prevalence, treatment, and factors associated with biologic use. J Invest Dermatol. 2015;135(12):2955-2963. doi:10.1038/jid.2015.296

5. Kerr GS, Qaiyumi S, Richards J, et al. Psoriasis and psoriatic arthritis in African-American patients—the need to measure disease burden. Clin Rheumatol. 2015;34(10):1753-1759. doi:10.1007/s10067-014-2763-3