About 2% of African American people and 1.6% of Hispanic people are diagnosed with the skin disease psoriasis. But patients with skin of color are often diagnosed with psoriasis at a later stage and have more severe disease, according to a presentation at the 2024 Fall Clinical Dermatology Conference. “Across the board, we see a delay in diagnosis and a delay in getting to specialists like dermatologists,” says Tina Bhutani-Jacques, MD, co-director of the Psoriasis and Skin Treatment Center at the University of California San Francisco and one of the conference panelists. This in turn may make it harder for people of color to get the psoriasis care that they need.
The Challenges of Diagnoses
The main reason patients with skin of color are missed? The doctors who treat them don’t recognize it. “Psoriasis looks different on skin of color,” Bhutani-Jacques says. “If you put a red plaque on a dark background, it looks purple, gray, or brown, none of which are the classic colors of psoriasis.” As a result, patients may go for months — or even years — undiagnosed.
That’s what happened to Mary Robinson, 37, a technological support coordinator in Jacksonville, Florida. About two years ago, she noticed white, pus-filled, scaly patches that quickly spread all over her body.
“I was nursing, so initially my gynecologist thought it was a fungal skin infection,” she recalls. When the antifungal creams didn’t work, she went to her primary care doctor. “Initially they thought it might be shingles, but shingles doesn’t usually spread all over your body,” says Robinson.
Finally, four dermatologists later, she found one who decided to do a skin biopsy, which came back positive for a form of psoriasis known as pustular psoriasis. “The dermatologist said that they had seen it before, but they’d never seen it on my shade of skin, so it threw them for a loop,” Robinson says.
Today, her psoriasis is well controlled with a prescription biologic. These drugs are often used to block reactions in the body that cause symptoms of psoriasis.
Psoriasis itself may also be worse in people of color since many patients are under chronic stressors from the effects of systemic oppression, points out Caroline Opene, MD, director of the Skin of Color Clinic at UCLA Health in Los Angeles. “Some patients also face barriers to care, such as lack of insurance or living in an area with few dermatologists,” she says. “They may end up seeking treatment in urgent care centers or emergency rooms, where they are seeing a resident who doesn’t have experience diagnosing skin diseases.”
Even if they do see a dermatologist, they can still get misdiagnosed, stresses Opene. “Psoriatic patches in people of color tend to be thicker, and more raised — they don’t look like the flat, pink, scaly lesions physicians are taught to look for in medical school,” she says.
Patients with skin of color are also about a third more likely to have psoriatic arthritis, says Mona Shahriari, MD, assistant clinical professor of dermatology at the Yale University School of Medicine in New Haven, Connecticut. People of color with psoriatic arthritis are also more likely to be younger, have more severe psoriasis, and have metabolic disease such as type 2 diabetes or high cholesterol.
The Challenges of Managing Psoriasis in Skin of Color
There are also specific challenges when it comes to psoriasis treatment in skin of color. “Most people with Asian or Black skin are impacted by scalp psoriasis, which is harder to treat,” Shahriari says. “If you only wash your hair a couple of times a week because of its style and texture, then a topical preparation like a daily shampoo isn’t going to be as helpful.” That’s why, she adds, it often makes sense to move to a stronger medication such as biologic.
But that’s often easier said than done, points out Opene. A 2019 study published in the Journal of Investigative Dermatology found that Black patients were less familiar with biologics than White patients were.
“Doctors often don’t bring up these medications because they think the patient’s psoriatic disease isn’t severe enough, even if they have scalp psoriasis that’s severely impacting their quality of life,” says Opene. Those that didn’t know about them were also more likely to want to avoid needles and to be concerned about side effects from treatment.
“Even if a patient is interested, some of the biologics often prescribed for psoriasis are insanely expensive, even with insurance,” adds Opene. “It can take a Herculean effort to make them accessible to people.”
Even when people of color get the right treatment, challenges linger. “Skin of color is more likely to develop post-inflammatory pigmentation after a psoriasis flare,” says Jacques. This is when your skin makes extra melanin after inflammation or injury. “It can be just as bothersome as having psoriasis,” she explains.
Prescription lightening creams that contain bleaching agents such as hydroquinone can help, but “there aren’t really a lot of great treatments out there,” notes Bhutani-Jacques. “The pigmentation does tend to get better over time, but it can impact a psoriasis patient’s quality of life.”
The Promise of Clinical Trials
People of color with psoriasis have historically been underrepresented in clinical trials for biologics, said Shahriari. But a new study, known as VIVIANCE, holds promise. It’s a first-of-a-kind study that measures the effectiveness and safety of the biologic guselkumab (Tremfya) in adults with skin of color who have moderate to severe plaque psoriasis. “It was intentionally designed to also collect information on post-inflammatory pigmentation,” says Shahriari.
While the study is still ongoing, the latest results were presented at the Clinical Dermatology Conference. The research found that guselkumab was effective to help clear both psoriasis plaques and post inflammatory pigmentation. Patients reported substantial, rapid improvements in both by week 16, after three doses, and those results held through week 48 with continued treatment.
“This research is important because psoriasis patients of color are often discouraged from moving to more advanced therapies, such as biologics, because their doctor doesn’t think their disease is severe enough,” says Shahriari, who was one of the investigators on the study. “But we know now that these drugs are safe and effective and improve patients’ quality of life.”
Results like these, says Opene, really highlight the importance of including psoriasis patients of color in clinical trials. “We know that people of color with psoriasis often don’t respond as well to first-line treatments like topicals,” she explains. “It highlights that health care providers may want to turn to biologics for these patients earlier, even with less severe disease.”
The study also included thousands of images of psoriasis plaques across different skin tones. These images will be available in a library accessible to doctors. “This is important because most medical school textbooks don’t have images of psoriasis on darker skin tones,” says Opene. “This way, dermatologists can look at photos of a variety of skin colors, if they’re unsure.”
What Patients Can Do
It’s important for people of color to be their own advocate, especially if they have persistent dark brown or purplish scaly spots on their skin, stresses Opene. “If you notice any sort of a skin condition, ask your primary care provider early and often for a referral to a dermatologist,” she says. If your skin doctor seems unsure, press for a biopsy, she adds.
If you do have psoriasis, Jacques recommends that you start a conversation with your provider early on about biologic medication. “The sooner you treat psoriasis, the less likely you are to develop hyperpigmentation,” she points out.
Robinson agrees. “As someone who lives with psoriasis, I am so glad that I kept pushing my doctors until I got the right answer,” she says. “I was able to get treatment early, which is why my psoriasis has been so well controlled these last couple of years. You are your own best advocate.”
Show Sources
Photo Credit: FG Trade/Getty Images
SOURCES:
Fall Clinical Dermatology Conference, Las Vegas, Nevada, October 24-27, 2024: “Shadows of Inflammation: Exploring Post-Inflammatory Pigment Changes in Psoriasis in VISIBLE, a Phase 3B Randomized Controlled Study of Guselkumab for Moderate-to-Severe Plaque Psoriasis Dedicated to People of Color.”
Tina Bhutani-Jacques, MD, co-director, Psoriasis and Skin Treatment Center, University of California San Francisco.
Mary Robinson, 37, psoriasis advocate, Jacksonville, Florida.
Mona Shahriari, MD, assistant clinical professor of dermatology, Yale University School of Medicine, New Haven, Connecticut.
Caroline Opene, MD, director, Skin of Color Clinic, UCLA Health, Los Angeles.
National Library of Medicine: “Postinflammatory Hyperpigmentation.”
Journal of Investigative Dermatology: “Racial Differences in Perceptions of Psoriasis Therapies: Implications for Racial Disparities in Psoriasis Treatment.”
American Academy of Dermatology: “Psoriasis Treatment: Biologics.”
National Psoriasis Foundation: “Psoriasis and Skin of Color.”
