Why Is Psoriasis Often Misdiagnosed in Skin of Color?

“This question biases the count toward people who have already received a diagnosis,” Dr. Takeshita says. It does not account for those who may have the disease but who have not yet seen a provider or those who have not yet been diagnosed.

Maybe psoriasis is less common in some racial and ethnic groups, she says, but it is not rare. And among those who have it, the impact of the disease may be greater. Dr. Takeshita points to a recent study in which she and her colleagues looked at the impact of psoriasis on quality of life by race and ethnicity. They found that people with psoriasis who are Black, Hispanic/Latino, or Asian reported a greater impact from psoriasis on quality of life than did white patients with psoriasis. It did not matter how severe the psoriasis was or whether patients received treatment. [7]

Differences in severity of psoriasis at the time of first visit to a health care provider have also been observed. [13] In a study looking at adults with psoriasis, Black individuals reported a greater extent of disease than white individuals. [14] In addition, a survey of 29 experts in psoriasis found that more than half (66%) reported differences in how psoriasis presented among their African American patients compared with their white patients. These providers noted thicker plaques, more dyspigmentation (discoloring of the skin), and less redness. [15] Among other factors, these variations in presentation can affect an individual’s diagnosis and treatment. [16]

“There are certainly health care access issues that contribute to missed or delayed diagnoses, but another major factor is the absence of images of psoriasis on darker skin both in medical education and among the public,” Dr. Takeshita says.

Barriers to Timely Diagnosis and Treatment

In general, the typical distribution of psoriasis – how it mirrors itself on both sides of the body with well-defined plaques and thick scales – is common across skin tones, says Dr. Takeshita.

The main difference comes from how inflammation is recognized, typically described as redness on lighter skin. On darker skin, inflammation may look more purple or just darker than a person’s normal skin color.

Another issue has arisen with the classic technical description of psoriasis being “salmon-colored” and having “red, scaly plaques.” These are descriptions and presentations relevant to lighter skin, and they do not necessarily fit the way in which psoriasis presents or might be described on darker skin tones.

This variation in presentation may make some health care providers uncertain about a diagnosis. Researchers examined this by presenting individual dermatologists with the headshot of either a Black patient or a white patient, photos of the individual’s skin disease, and a summary of patient characteristics that was identical for both the Black and white patients. The survey found the dermatologists were less confident in their diagnosis of the Black patient, and this uncertainty was associated with a lower likelihood of recommending appropriate treatment. [16]

“From a medical education standpoint, health care professionals are not being taught to diagnose these skin conditions in darker skin types. I think that’s a main cause of misdiagnosis,” says Dr. Takeshita. But she adds that “in the last couple of years, there has been a major shift, and there are now many more images of skin disorders on darker skin tones included in a variety of medical resources such as textbooks and online image collections.”

While clinical education may be improving, public images of psoriasis from reliable sources remain lacking, impacting the ability of people with darker skin tones who experience psoriasis to find health-related information with which they can identify.

“A Google search of psoriasis still mostly reveals psoriasis on lighter skin,” Dr. Takeshita says. “So people with darker skin who may have it can’t find pictures of it on their skin tone. How is a person with darker skin supposed to find information that is relevant to them?”

Similarly, representation of people with psoriasis in television advertisements appears to be limited primarily to white adults, according to a study by Dr. Takeshita and her colleagues. [17] Noting that direct-to-consumer advertising is a potentially important source of information for patients, with the potential to reduce underdiagnosis and undertreatment of disease, the research found low representation of racial and ethnic minorities among individuals portrayed as having psoriasis.

In addition, the placement of ads was not ideal for reaching a diverse group of patients. One network included in the study carried two of the top three primetime programs among Black viewers at the time, but researchers found no advertisements on that network. This lack of exposure may factor into findings from other studies that identify gaps in awareness or understanding of available treatments for psoriasis. [8] [9]

What Can Be Done?

Medical education and training aimed at improving the diagnosis of psoriasis in people of color, as well as improved representation of racial and ethnic minorities with psoriasis through advertising, public images, and health information, are important components of addressing the disparities in psoriatic disease diagnosis and treatment.

Dr. Takeshita recommends seeking reputable sources for information about skin disease, such as the National Psoriasis Foundation (NPF), and learning as much as possible about psoriasis. She also encourages getting a second opinion if you do not feel you are getting appropriate care.

“If a patient feels uneasy about their provider in any way, or they feel like the provider they’re seeing is not comfortable with treating their particular skin type, I would encourage a patient to seek other opinions if they are able to do so,” Dr. Takeshita says.