Expanding education ‘paramount’ to improve psoriasis care for patients with skin of color
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Although psoriasis therapies continue to expand and improve, patients with skin of color still face barriers in access to care and diagnosis, especially if physicians are not adequately trained to identify the condition in all skin types.
“It comes down to education across all specialties and across all levels of trainees,” Daniel Gutierrez, MD, assistant professor in the Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine, NYU Langone Health, told Healio. “Incorporating diverse images of psoriasis, and other skin conditions, in people of all skin colors is going to be absolutely paramount so we can make change and decrease the health disparities that we observe on a routine basis.”
Healio spoke with Gutierrez about existing challenges in diagnosing psoriasis in patients with skin of color, barriers in access to health care and the importance of including diverse populations within clinical trials.
Challenges in diagnosis
One of the challenges in diagnosing psoriasis in people of color is the lesser rate of prevalence in minority populations. However, according to Gutierrez, that may not be the whole picture.
“Traditional research that they've done on psoriasis in non-Caucasian populations, although limited, overall suggests a lower prevalence compared with Caucasians,” Gutierrez said. “However, there is some question about this because many of these epidemiologic studies rely on patients presenting for evaluation by a physician, and we know that for a lot of minority populations there are barriers to accessing health care. Therefore, it might be due less to a lesser prevalence, and more to a lack of presentation to physicians so that we can make diagnoses.”
Gutierrez also points to the impact structural racism and personal bias may have in educational materials used to identify skin conditions.
“It ties into how textbooks, from which physicians are reading and learning about these skin conditions, present these diseases. The majority of these skin conditions are highlighted on people with lighter skin color. When you look at textbooks, you see a lot more of these very bright red lesions with psoriasis, and there's less representation of people with much more richly pigmented skin. Granted, there have been many experts in the field who do try to rectify this disparity and have pushed for including resources, or even creating atlases, of how skin diseases present in patients of color,” Gutierrez said.
When identifying psoriasis in patients with richly pigmented skin, Gutierrez noted that there are important differences and nuances that should be taken into account.
“Psoriasis will present in less pigmented skin as bright red, thick plaques — so elevated, thick lesions on the skin with quite a bit of scale — and when people have much more richly pigmented skin, that basal melanin can change the hue of these skin rashes. They might be more of a violaceous color or a deep purple color, and sometimes that can be confused with other kinds of skin diseases, such as eczema, atopic dermatitis or lichen planus, for example,” Gutierrez said.
“Further, when people do have much more richly pigmented skin, there may be inflammation that can cause some darkening of the skin, which is post-inflammatory hyperpigmentation,” Gutierrez continued. “Post-inflammatory hyperpigmentation, because it presents and persists for much longer than the inflammatory areas of the psoriasis, can be very debilitating and impact the quality of life for patients since that might be more visible and more noticeable.”
Hyperpigmentation from a rash can obscure a recurring rash, according to Gutierrez, which can be challenging for those without robust training in evaluating psoriasis in patients with skin of color to notice the subtle changes.
“Because of lack of representation in a lot of educational material, I do think that that does impact the diagnosis of psoriasis in patients, and oftentimes it can lead to a delay,” he noted.
Access to care
When considering a patient’s access to care, it is important to factor in their socioeconomic status and insurance, according to Gutierrez.
“I work at Bellevue Hospital Center, which is a city hospital, and the majority of patients that we see are patients of color. These patients may be underinsured or uninsured. In patients that have either no insurance or are underinsured, it can be a little bit more difficult to be able to get some of these medications used to treat more severe psoriasis,” Gutierrez said.
“However, I will say that many hospitals, specifically for patients that do not have insurance, have patient assistance programs where we can get medications from the [pharmaceutical] company to provide these very necessary treatments.”
The COVID-19 pandemic has also further complicated the ways in which minoritized populations are able to access health care, according to Gutierrez.
“In many of our minority populations, they may not have the same access that people who have a higher socioeconomic status have,” Gutierrez said.
“Some people may not even have the access to telehealth communication or telehealth visits, so that in and of itself presents a barrier and can also present reasons for why these diagnoses are done much later,” he continued. “It's seen in literature that patients of color often have a much later diagnosis of these chronic skin conditions, and they might be more severe at presentation.”
A lack of proper technology and high-resolution devices in underserved settings can also make it more difficult to get accurate visualization of specific spots of concern in patients, which leads into health equity as well, said Gutierrez.
Addressing disparities
Although disparities exist in both diagnosis and access to care for psoriasis patients with skin of color, there are innovative disruptors working to change that.
One such disruptor is Nada Elbuluk, MD, MSc, FAAD, associate professor of clinical dermatology at the Keck School of Medicine of USC, founder and director of the USC skin of color and pigmentary disorders program and of the USC dermatology diversity and inclusion program, and director of clinical impact at VisualDx. At VisualDx, Elbuluk works as the leader for Project IMPACT (Improving Medicine’s Power to Address Care and Treatment), a program dedicated to the improvement of health equity and educational training through improved skin of color education.
Pharmaceutical companies are also working to address these disparities. Earlier this year, the Janssen Pharmaceutical Companies of Johnson & Johnson announced the launch of VISIBLE, a double-blind, randomized, placebo-controlled study with a focus on plaque and scalp psoriasis in people of color specifically.
Gutierrez also notes the importance of including diverse populations within clinical trials.
“For clinical trials, we need to be able to have broad populations studied so that we can then expand these results and translate them into clinical practice that is going to be reflective of the populations that we see. There may be nuances as to why certain patients of different geographic areas and backgrounds may or may not respond as well as other groups to certain therapies. Providing education on the importance of having diverse populations represented within the recruitment status, and taking that extra step to make sure these trials have a reflective population, is important for results that can be more easily generalizable to the population as a whole,” Gutierrez said.
“As we know, by 2050, the majority of the population in the United States will be people of color, and in light of this, we should be very cognizant of including people from different backgrounds,” he concluded.
References:
Janssen initiates first-of-its-kind clinical study to bridge critical gaps in care for people of color with moderate to severe plaque psoriasis. https://www.jnj.com/janssen-initiates-first-of-its-kind-clinical-study-to-bridge-critical-gaps-in-care-for-people-of-color-with-moderate-to-severe-plaque-psoriasis. Published March 22, 2022. Accessed Aug. 22, 2022.
Meet Nada Elbuluk, MD, MSc, VisualDx Director of Clinical Impact. https://www.visualdx.com/blog/meet-nada-elbuluk-md/. Published Oct. 27, 2020. Accessed Aug. 22, 2022.