Psoriasis and Skin of Color

Psoriasis is a common skin condition in patients presenting to dermatology clinics but estimates of how prevalent it is among different racial and ethnic groups vary. By some estimates in the United States, psoriasis is less frequently seen in Black patients (1.3% to 1.9%) when compared with White patients (2.5% to 3.6%).¹ However, these estimates may be limited by underreporting and disparities in access to care. To better understand the issues that patients with skin of color (SoC) face when undergoing diagnosis and treatment of their skin disease, the National Psoriasis Foundation (NPF) spoke to E. James Song, MD, FAAD, a dermatologist and clinical researcher in Washington state.

Diagnosis and Presentation to Care

“By and large, patients with SoC who have psoriasis seem to have a disproportionate effect on their quality of life,” Song says. Studies have shown that patients with SoC present to dermatologic care with higher reported impact on their quality of life.² The reasons for this are multifold. Patients with SoC are less likely to see outpatient dermatologists compared with White patients,³ which may lead to conditions such as psoriasis being underdiagnosed in patients with SoC. In addition, erythema, which is critical in diagnosing inflammatory skin disorders like psoriasis, can be particularly hard to appreciate in darker skin types. Therefore, diagnoses may not be as clear cut, especially when dermatologists are trying to distinguish psoriasis from other skin conditions, such as lichen planus or lupus, which may look similar in darker skin. “Diagnostic uncertainty leads to diagnostic delay and subsequently to treatment delay,” Song notes. Patients may present to the clinic with more severe disease, including larger areas of disease, thicker plaques, and hyperkeratotic disease.

Social and cultural stigmas also exist in certain populations, in which psoriasis is seen as being a sign of internal illness. Where Song has practiced, Hispanic and Asian populations in particular see psoriasis as a sign of being unwell, even after patients’ skin has cleared. Studies have shown that the stigmatization and isolation patients face may influence their perception of their skin disease, and, therefore, their quality of life.⁴

Treatment Challenges

Treating patients with SoC presents unique challenges for providers. Postinflammatory hyperpigmentation or hypopigmentation can be particularly difficult when treating patients with SoC. Song indicates that the best way to manage this is to prevent hyperpigmentation by treating psoriasis aggressively early on. “[My patients] are often surprised by how aggressive I am in my approach to treating their condition,” Song remarks. He typically escalates treatment beyond topical therapies for his patients with SoC because erythema, which can be used as a marker of psoriasis severity, may be difficult to appreciate in patients with SoC, which can lead to an underestimation of their disease severity. However, in the broader population, Black patients are less likely to receive newer biologic therapies, in part potentially due to lack of access to care, unfamiliarity with biologics, or apprehension about systemic therapy.^5,6 Song suggests that attention must be paid to the needs of patients with SoC. For instance, light therapy dosages should be modified to decrease the risk of hyperpigmentation. Treatment methods may also be different. For example, managing scalp psoriasis in patients with SoC requires choosing topicals compatible with their hair care and cultural practices, including accounting for the frequency with which patients wash their hair, styling methods, and hair texture. Prescription shampoos to be applied and washed daily may not be suitable for some Black women because frequent hair washing can cause dryness and hair breakage.¹ Products such as foams or oils that contain topical steroids are available that may be more compatible with some hair care routines. In summary, Song sees the path forward to overcoming these challenges by primarily addressing patients’ concerns. Increased awareness among physicians regarding diagnostic suspicion and being cognizant about the postinflammatory pigmentary changes and unique needs for treatment in patients with SoC will help improve patient satisfaction.

Improving Training and Research on Skin of Color

Much has changed already since Song’s medical school and residency experience in Southern California, where he mostly saw patients in Asian and White populations and his practical experience with patients with darker skin was limited. The pictures of skin conditions in patients with SoC that he did see in dermatology textbooks perpetuated prejudices regarding certain health inequities, such as the disproportionate rates of syphilis, lupus, and sarcoidosis in patients with SoC. “We are very intentional about getting residents more exposure to SoC,” Song mentions, now working as a clinical instructor in the residency training program at the University of Washington. More studies have also been published regarding the importance of educating medical students and residents in managing treatment for patients with SoC,^7,8 and increased awareness has led to the creation of online training tools.

As a clinical investigator, Song comments that it is challenging to ensure clinical trials enroll enough patients with SoC to extrapolate conclusions to those patients. There are many reasons for the underrepresentation of people with SoC in clinical trials,⁹ including historic medical mistrust of Western health systems seen in some racial minority groups, and awareness of clinical trials may be low due to diff erent media channels. Song’s group has worked through some of these challenges by contacting church communities and online social networks frequented by local communities or speaking with trusted local community leaders to help spread awareness of clinical trials. Furthermore, he states that it is incumbent on the sponsors who pick clinical trial sites to ensure diversity in their patient populations and to make these studies more generalizable to patients with SoC. In the future, the hope is that increased awareness of the nuances of diagnosing and treating patients with SoC will continue to improve training and research and help inform management. To learn more, the NPF recently conducted a webinar with Dr Song about the challenges in diagnosing and treating psoriasis in patients with SoC. Visit https://www.psoriasis.org/cme-library/skin-of-color-webinar to access the webinar.

Sonia Wang is a year-out medical student at the University of Pennsylvania in Philadelphia, PA, and a volunteer with the NPF.

References:

1. Alexis AF, Blackcloud P. Psoriasis in skin of color: epidemiology, genetics, clinical presentation, and treatment nuances. J Clin Aesthet Dermatol. 2014;7(11):16-24.
2. 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.
3. Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of demographic and socioeconomic characteristics with differences in use of outpatient dermatology services in the United States. JAMA Dermatol. 2018;154(11):1286-1291. doi:10.1001/jamadermatol.2018.3114
4. Dimitrov D, Szepietowski JC. Stigmatization in dermatology with a special focus on psoriatic patients. Postepy Hig Med Dosw (Online). 2017;71(0):1115-1122. doi:10.5604/01.3001.0010.6879.
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7. Adelekun A, Onyekaba G, Lipoff JB. Skin color in dermatology textbooks: an updated evaluation and analysis. J Am Acad Derm. 2021;84(1):194-196. doi:10.1016/j.jaad.2020.04.084
8. Jones VA, Clark KA, Shobajo MT, Cordova A, Tsoukas MM. Skin of color representation in medical education: an analysis of popular preparatory materials used for United States Medical Licensing Examinations. J Am Acad Derm. 2021;85(3):773-775. doi:10.1016/j.jaad.2020.07.112
9. Price KN, Krase JM, Loh TY, Hsiao JL, Shi VY. Racial and ethnic disparities in global atopic dermatitis clinical trials. Br J Dermatol. 2020;183(2):378-380. doi:10.1111/bjd.18938