In honor of Public Health Thank You Day on Nov. 20, we chatted with dermatologist Junko Takeshita, M.D., Ph.D., who is also an assistant professor of dermatology and epidemiology at the University of Pennsylvania Perelman Medical School. She is the recipient of multiple NPF Dermatology Fellowships and an NPF Outstanding New Investigator Award. Here’s what she had to say about tackling health disparities with regard to psoriasis.
Joe Doolen: How are low-income individuals disproportionally affected by psoriatic disease compared with those with higher incomes?
Junko Takeshita: There are a lot of effective new treatments for severe psoriasis, particularly biologics, and they are expensive. As a result, lower-income individuals have more difficulty affording treatment. There are a few exceptions to this. For example, we performed a study of Medicare beneficiaries to identify factors associated with whether or not someone received biologic therapy. People who had Part D Low-income Subsidy (also called “Extra Help”), which allows for low out-of-pocket payments for biologics, were more likely to get biologics than those who did not qualify for the subsidy.
I think the largest problem with access is that being financially disadvantaged is correlated with poor insurance coverage. In terms of psoriatic disease, more work needs to be done to discover the impact socioeconomic status has on disease activity itself. A couple of studies have looked at socioeconomic factors and psoriasis, and results indicate that socioeconomic status has an effect on the levels of undiagnosed psoriasis. This may be related to poor access to health care as well.
JD: How is access to care different between socioeconomic groups? Besides income, are awareness and culture also factors?
JT: There needs to be more research into this, but anecdotally I could share experiences I have had. First of all, in terms of disease awareness, psoriasis is more prevalent in people of a European background. While still a common skin disease among minorities, psoriasis is much less prevalent among these groups, in comparison. So psoriasis is much more well-known among white communities.
Certainly in textbooks and commercials, we mostly see white people with psoriasis. I have heard from patients, “Oh, I didn’t know that psoriasis could occur in non-white people,” so I suspect there is an awareness issue. This may relate to the findings we see where minorities tend to have more severe psoriasis (as a proportion of total cases). That may be biologically driven, but could also be due to under-diagnosis. But there is not a lot of data to robustly support this.
JD: Lives of individuals with psoriatic disease are markedly better today than in generations past. Are some members of our society being left behind when it comes to the improvements we have seen in overall quality of life?
JT: We have more targeted therapies out there now that are just working better. Socioeconomics and insurance coverage can be huge access barriers. In our study, we tried to control for socioeconomic status, and the beauty of Medicare data is that everybody had some level of medical coverage, so we minimized those issues somewhat.
Independent of those, we did find race to be a factor in whether or not you receive a biologic; African-Americans in the study were less likely, for unknown reasons, to receive biologic treatment for severe psoriasis. Also (not in the study), geographically, access to dermatologists and psoriasis specialists can be more difficult in rural areas.
JD: Are there diseases associated with psoriasis that are also more prevalent among poorer populations? What about factors like environment and behavior?
JT: In terms of environmental and behavioral risk factors, the most well-established ones for psoriasis are obesity and smoking, which are more prevalent among the more socioeconomically disadvantaged. Also, psoriasis comorbidities like heart disease are also higher in these groups. So socioeconomic status can have an effect on psoriasis itself, conditions associated with psoriasis and risk factors that can trigger the disease.
JD: How can psoriatic disease researchers and advocates alleviate disparities in care?
JT: First, as researchers, we need to better identify and understand what disparities in care exist. Once we do this, we can start to develop methods to reduce those disparities. If we take financial and resource barriers to accessing medications as an example, I think NPF is doing an excellent job advocating for patients. NPF’s Patient Navigation Center provides assistance of all sorts to patients with psoriatic disease, including tips on how to navigate the health care system to access treatments. Increasing awareness of disparities in care is critically important, and alleviating disparities requires more efforts like those of NPF.
Are you living with psoriasis or psoriatic arthritis? NPF’s Patient Navigation Center can provide personalized support and answer questions about receiving better care and treatments. Call 800-723-9166, option 1 or visit psoriasis.org/navigationcenter.
Answers have been edited for length and clarity.
Driving Discovery, Creating Community
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