Worldwide, psoriasis affects 125 million people.  Despite this global reach, there is limited information about diagnosing and managing psoriasis in skin of color.
Diagnosing Psoriasis in Skin of Color
Psoriasis is found more frequently in white (3.6 percent) than in African American (1.9 percent) and Hispanic (1.6 percent) populations.  [Editor’s note: The National Psoriasis Foundation (NPF) understands that Hispanic is an ethnic designation; however, it is not possible to ascertain whether the publication meant Hispanic or Latinx.] However, these numbers may not paint the full picture, as psoriasis may be more readily identified in people with lighter skin and it is sometimes misidentified in people with darker skin tones. “Across skin types, many features present similarly, such as the symmetrical distribution of psoriasis on the body and well-circumscribed nature of psoriasis plaques,” shares Junko Takeshita, M.D., Ph.D., M.S.C.E., an assistant professor of dermatology and epidemiology at the University of Pennsylvania Perelman School of Medicine. Differences do exist and are important to recognize, such as “the red color or erythema that is typically seen with psoriasis on light skin often appears more purple or brown in darker skin types. Sometimes the scale that accompanies psoriasis is so thick that it is difficult to appreciate that underlying color of the plaque itself. Nevertheless, psoriasis remains a common condition across skin types and races/ethnicities,” continues Dr. Takeshita.
Is Psoriasis Undertreated?
It is not just differences in diagnosing psoriasis, though. Research shows that many patients with psoriasis are undertreated with only topical medications or receive no treatment at all. Racial/ethnic minority patients may be disproportionally affected by under treatment.  “While it’s not direct data on undertreatment, our research has shown that Black patients with psoriasis are less likely than White patients to get biologic treatment.  So, at least with biologic treatment, the evidence suggests that there is undertreatment among Black patients compared to white patients,” says Dr. Takeshita. In fact, a 2019 study showed that Black patients were less familiar with self-injectable biologics compared to white patients, despite these treatments being efficacious options for psoriasis. This study also showed that Black patients who were biologic-naïve were more likely to have a preference to avoid needles and have a greater concern about adverse effects of treatment. The authors of this study suggest that this poor familiarity may be a result of having less exposure to the treatments (for example, by their treatment provider or through advertising) or a lack of understanding of biologics as a treatment option. 
Interestingly, Dr. Takeshita further investigated the diversity of main characters in televised direct-to-consumer advertisements for psoriasis patients. These study findings demonstrated that over a two-week period, 92.6 percent of the main characters were white among televised psoriasis ads (only 6.2 percent were Black and 1.2 percent were Asian). These advertisements are a major source of health-related information for the general public, and this research concluded that Black and other racial/ethnic minority individuals with psoriasis are very unlikely to see themselves represented in ads for psoriasis treatments, meaning they may not recognize these treatments as an option for them. 
“There are multiple factors that drive undertreatment, including access (or lack thereof) to a dermatologist, diagnostic uncertainty on the part of the dermatologist, and socioeconomic or insurance status, among other factors, some of which we have yet to identify and understand,” shares Dr. Takeshita. Research she has been involved in has shown that racial minorities are less likely than white individuals to see a dermatologist for their psoriasis  and that dermatologists are less confident in diagnosing psoriasis among Black patients/darker skin types compared to white patients/light skin types.  Research findings have shown that patients without Medicare Part D low-income subsidies had 70 percent lower odds of receiving biologics for their psoriasis, compared with patients with low-income subsidies. More so, among Black individuals, the odds of having received biologics was 69 percent lower than that of white individuals. 
Special Considerations When Treating Skin of Color
Compared to white patients, African American patients may experience a higher degree of dyspigmentation but a lower amount of erythema, as well as more extensive disease involvement.  Dr. Takeshita thinks that addressing the post-inflammatory dyspigmentation that is more likely to occur among individuals with darker skin types is one of the biggest challenges in treating psoriasis in skin of color. “One approach should be prevention by ensuring appropriate and timely treatment of active psoriasis. It is important to also educate patients with darker skin types about the possibility of post-inflammatory dyspigmentation so they know that it is not active psoriasis (so they shouldn't keep treating it with topical steroids) and that it is not usually permanent,” says Dr. Takeshita. “The dyspigmentation, or ‘scarring’ as it is referred to by many patients, is something that is of particular concern among Black patients with psoriasis as we learned from our interview studies.” 
Phototherapy may be an effective treatment option, but it requires special considerations in darker skin colors. “Darker skin types need higher doses of phototherapy that clinicians and phototherapists may feel uncomfortable administering due to inexperience with treating individuals with darker skin types. Therefore, psoriasis patients with darker skin types may be underdosed when treated with phototherapy in this situation,” shares Dr. Takeshita. She adds that the current American Academy of Dermatology-NPF Psoriasis Treatment Guidelines have recommendations for proper phototherapy dosing for all skin types. Research, such as the LITE study, can help to further solidify the real-world effectiveness of phototherapy, including in darker skin types.
Scalp psoriasis is another area of special concern in patients with skin of color. Dr. Takeshita suggests providers ask about each patient’s hair care practices so that they can recommend a treatment plan that is compatible with the patient’s hairstyle, type of hair (e.g., fine vs course), and care regimen.
Quality of Life Concerns
Psoriasis has an impact on quality of life and is associated with significant comorbidities, including cardiovascular disease, diabetes, metabolic syndrome, mental health and psoriatic arthritis. However, Dr. Takeshita shares that compared to white patients, evidence shows that Black, Asian and Hispanic patients with psoriasis report greater quality of life impact, regardless of disease severity. [10, 11] However, the evidence is less clear with regards to the impact health care disparity has on comorbidities. “We have very little information about potential disparities in diagnosis or treatment of psoriatic arthritis, for example,” says Dr. Takeshita. “As for other comorbidities, such as cardiovascular comorbidities, we know that among the general population there are racial/ethnic disparities in the prevalence of cardiometabolic disease and their related outcomes. It is unclear if these disparities are compounded among psoriasis patients but, to date, we don’t have any evidence that they are.”
 National Psoriasis Foundation. Statistics. https://www.psoriasis.org/content/statistics. Accessed February 12, 2021.
 Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70(3):512-516. doi:10.1016/j.jaad.2013.11.013
 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
 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
 Holmes A, Williams C, Wang S, Barg FK, Takeshita J. Content analysis of psoriasis and eczema direct-to-consumer advertisements. Cutis. 2020;106(3):147-150. doi:10.12788/cutis.0070
 Fischer AH, Shin DB, Gelfand JM, Takeshita J. Health care utilization for psoriasis in the United States differs by race: An analysis of the 2001-2013 Medical Expenditure Panel Surveys. J Am Acad Dermatol. 2018;78(1):200-203. doi:10.1016/j.jaad.2017.07.052
 Sevagamoorthy A, Bazen A, Shin D, Barg FK, Takeshita J; Patient race affects dermatologists’ assessments and treatment of psoriasis. J Invest Dermatol. 2020;140(7S):S97.)
 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.
 Eriksen WT, Raziano VT, Bazen A, Gelfand JM, Barg F, Takeshita J. Concerns About Psoriasis Differ by Race: Implications for Patient-Centered Goal-Setting and Counseling. J Invest Dermatol. 2019; 139(5S, Supplement 1):S37.
 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.
 Takeshita J, Augustin M, de Jong E, Lafferty K, Langholff W, Langley R, Leonardi C, Menter A, Alexis A. Psoriasis-Related Quality-of-Life Differs by Race/Ethnicity. J Invest Dermatol. 2019; 139(5S, Supplement 1):S148.