Psoriasis often overlooked, misdiagnosed in people with skin of color
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The burden of psoriasis in people with skin of color is significant and there are many challenges in this patient population that need to be addressed.
According to a cross-sectional analysis of data from the National Health and Nutrition Examination Survey from 2009 through 2010, the prevalence of psoriasis is highest among white patients (3.7%) but is closely followed by Black patients (2%) and other individuals with skin of color (1.6%).
“The data is showing us that estimates are a lot higher than what was previously thought, but it is important to mention that this data is from 2014, so it could be even higher,” Amy J. McMichael, MD, FAAD, professor in the department of dermatology at Wake Forest School of Medicine, told Healio. “We are homing in on more reasonable and appropriate numbers in our estimates, but we will never catch everybody because not every database is catching every person of color with psoriasis.
“There are many things that are not being addressed in this patient population but need to be addressed more aggressively in terms of earlier diagnosis and offering biologics sooner,” McMichael continued. “Once we get over some of these hurdles, we can start working on getting these patients into clinical trials and work on following cohorts of patients with skin of color long-term.”
Diagnosis
The diagnosis of psoriasis is often overlooked in people with skin of color.
“We have data that show that Black patients have a lot more and worse psoriasis than we thought,” McMichael said. “They tend to have a higher palm count and it tends to present in a more hyperkeratotic fashion, which is very common in skin of color patients. Here we have this population of patients with this devastating disease that is much worse in terms of the amount of it and in terms of the thickness of it, and because of this, it is harder to treat.”
The presentation of psoriasis in patients with skin of color differs significantly from that in white patients.
“When looking at a typical textbook photograph of psoriasis, the person often has fair/light skin and they have very pink, red coloration and lots of scaling. It will be well demarcated,” McMichael said. “But, in brown people, we do not see the redness because the erythema is blunted due to pigmentation in the skin of the darker individual. As a result, there is less redness and sometimes even a purplish color. At times, it looks like the skin is just hyperpigmented. Dermatologists are taught to think about how lesions look by textbooks and can bypass lesions in people with skin of color because of that.”
Another reason why psoriasis is often overlooked in people with skin of color is that brown people use moisturizers more regularly, according to McMichael.
“People with skin of color exfoliate the scale and moisturize it and then the dermatologist will say that it cannot be psoriasis because there is no scale. Instead, they think the patient maybe has eczema, which is also quite common in people with skin of color,” she said.
Education
To improve care for these patients, better education is needed.
“We need to educate up-and-coming dermatologists as well as current dermatologists on how to better care for these patients,” McMichael said. “I biopsy my patients when I’m fairly certain that they have psoriasis and are ready to move in the direction of treatment. This needs to be established in the patient’s chart, because if it is not established in their chart, then the next thing that happens is it goes to a different physician that says that they don’t have psoriasis because the patient is already partially treated and so it doesn’t look like typical psoriasis. I have had this happen with patients.”
People with skin of color are also much less likely to receive biologics, according to McMichael.
“We have a lot of work to do at every point in medical care for these patients, including entry into the medical system, once they get into the system and once they get a treatment plan,” she said. “We have to train our up-and-coming dermatologists on all of these so that they have suspicions of psoriasis, because if they don’t have suspicion in their head, then they will never biopsy the individual and take care of them like they need to.”
There is also a need for more dermatologists to practice in underrepresented minority population areas, McMichael added.
“We need more dermatologists to go where these patients live,” she said. “We know that patients who are in certain geographical areas do not have access to dermatologists, so we need more dermatologists who will go back to these communities to practice. Once they’re there, then we need to arm them with the ability to conduct the clinical trials that are needed so that patients don’t have to go out of their neighborhoods and travel across the country to participate in a clinical trial.”
McMichael said the challenges of the COVID-19 pandemic also brought to light the inequities in dermatology care for people with skin of color and that dermatologists should be aware of those inequities as well.
“Just as it did for most medical specialties, the pandemic relegated people with skin of color in dermatology to forgoing medical care,” she said. “We have to think about the social determinants of health because what we know now about medicine in general is that it’s not just about the treatment that you give patients but really the social determinants that are going to determine how well patients do — whether they will be able to come in to see the doctor in the first place, how well they will be able to follow up with treatment that we prescribe and how well they’re going to be able to come back in to change treatment if the initial treatments don’t work.”
Looking ahead
Looking ahead, it will take the changemakers, innovators and disruptors in the field of psoriasis to address these barriers facing this patient population.
“The disappointing aspect of this is that there aren’t a lot of people who are talking about psoriasis in people with skin of color from a study standpoint and that’s why it’s so important to get dermatologists interested in this field to become experts and to move the field forward,” McMichael said.
“Joel M. Gelfand, MD, MSCE, is a changemaker. He is not a dermatologist of color but he has done more research in this area than most and is examining the use of phototherapy as another treatment option in patients with skin of color,” she continued. “He is committed to getting out into the community and measuring what’s happening and recommending things that would make it easier for people with skin of color to receive treatment earlier on.”
Another changemaker, Andrew F. Alexis, MD, MPH, is someone who trained in psoriasis clinical trials many years ago and is thought of as an expert in psoriasis, not just in this country, but also in Africa, McMichael added.
“Dr. Alexis has conducted review research that incorporates data from Western and Eastern Africa. He has examined the differences between the populations when it comes to the prevalence of psoriasis and how it compares to the population here in the United States,” she said. “We also need more people to discuss psoriasis in skin of color at medical meetings. Jenna Lester, MD, has done a wonderful job at pointing out the importance of representing skin of color patients in our lectures at meetings, and in the materials that we use to teach dermatology. All of this work is important to move the dermatology field forward for our patients with skin of color.”
Reference:
- Rachakonda TD, et al. J Am Acad Dermatol. 2014;70:512–516.
For more information:
Amy J. McMichael, MD, FAAD, can be reached at amcmicha@wakehealth.edu.
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