Q&A: Recognize Racial Bias and Inequalities in Psoriatic Disease Care

A social movement is underway in the United States, sparked by the deaths of George Floyd in Minneapolis and Breonna Taylor in Louisville, Kentucky, both at the hands of police officers.

Protests have occurred in cities around the world, and public discussions are taking place regarding how race plays a part in police brutality and American history.

Healio Psoriatic Disease spoke with Lynn McKinley-Grant, MD, FAAD, associate professor of dermatology and director of curriculum innovation and development, department of dermatology, at Howard University College of Medicine and president of the Skin of Color Society, about how the Black Lives Matter movement relates to the psoriatic disease field and how physicians can work to equalize care for people with skin of color.

Q: How can practitioners work to address racial inequalities within their practices or institutions?

Answer: Martin Luther King Jr. said, “Of all forms of inequality, injustice in health care is the most shocking and inhumane.” One of the reasons we have inequalities in the distribution of care is because often dermatologists and rheumatologists are not in areas where black and brown people live. There is a shortage of doctors in general, but dermatologists especially are not in areas where black and brown people are, so there is less access to care. Location is important.

Q: What types of disparities do people of color face when seeking care, and how can practitioners mitigate these problems?

A: Inequalities and health disparities come about in terms of misdiagnosis and not recognizing health and disease in skin of color or recognizing the epidemiology of conditions that are going to occur in skin of color. In psoriasis and other inflammatory diseases in the skin, it is vital to the physical exam to visualize erythema in dark skin. Many doctors will say it does not exist, but it does. Melanin, oxygen, hemoglobin and other pigments in the blood determine the erythema’s shades of red in darker skin types.

One of the significant inequalities is being able to detect erythema early. Erythema can be a sign of life-threatening disease: psoriasis, lupus, meningococcemia infections, cellulitis.

The shade of red in psoriasis is diagnostic according to the skin type. We use patterns of recognition to make diagnoses. Psoriasis is always symmetrical, and we also use color and topography of the lesions. So, in darker skin types, psoriasis is a deeper red or even purple.

Q: How can physicians be more prepared to treat skin of color?

A: More education for medical students, residents and physicians is necessary. So many people have not trained around people of color, but now you can get online training. While nothing beats in-person training, online training can at least show how some diseases look in skin of color.

There is a real shortage of physicians coming up, but there is really a shortage of black and Latinx physicians. Training more of these physicians is important, and that starts in making sure they get into medical school. From there, if we can get them into the specialties of dermatology and rheumatology, that would be great because those are two areas that have a great need for physicians of color.

Patients with the same background as the physician will listen more to what their doctor says and better follow instructions. However, when the doctor is knowledgeable in dealing with different skin tones, patients will still listen confidently to professional advice.

Doctors must recognize and appreciate that there are differences. We are all different colors, and that is OK. It can be hard with young doctors who are afraid of being politically incorrect, but we all have different color skin, and the skin reacts differently to certain conditions depending on its color.

Skin color should be a vital sign. It reflects the health of a person, even with “pale.” What does pale look like in brown skin? Visualized in the video of George Floyd, his skin went from a dark brown to a dark gray man as he was dying with the lack of oxygen. Skin color matters and is a vital sign in health and disease.

Q: How can people of color more easily find safe, effective, affordable care?

A: Patients who are concerned and want to find someone who has experience in darker skin types can ask for that information when they call for an appointment. Has the doctor been trained to work with darker skin types? Do they get CME? Do they go to the American Academy of Dermatology meetings or attend Skin of Color Society symposiums? Are they board-certified in dermatology or rheumatology?

Searching for health care providers who accept specific insurance is complicated, and patients should use their insurance services to help them find providers. Institutions can help by accepting all types of insurance, including Obamacare and Medicaid. Doctors can also volunteer at a free clinic that has black and brown patients. Academic institutions that train physicians are now seeking more black and brown doctors to help improve the health disparities gap. Patients can seek care at these institutions.

Q: Do you have any final thoughts to add?

A: In summary, we need in the medical school curriculum and residency training programs education in epidemiology and the pattern of recognition of the disease in all skin types and culture to decrease morbidity and mortality and close the gap in health disparities in Black and Brown people.

Health care providers and patients should recognize that we all have biases. We have to become aware of bias and change our behavior to eliminate health disparities and inequalities. – by Rebecca L. Forand

For more information:

Lynn McKinley-Grant, MD, FAAD, can be reached at The Dermatology Center, 2041 Georgia Ave., Washington, DC 20060; email: SOCSleaders@gmail.com; website: www.skinofcolorsociety.org.