Psoriasis and Skin of Color

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. [5]

“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 [6] and that dermatologists are less confident in diagnosing psoriasis among Black patients/darker skin types compared to white patients/light skin types. [7] 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. [4]

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. [8] 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.” [9]

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.”