Anyone can get psoriasis, but people of color are more often undertreated for the chronic autoimmune disorder, with its inflammation and scaly, itchy, or burning patches of skin. This may be because psoriasis happens more often in White people and is easier to see on fair skin. It can look different on other skin tones. People of color may find themselves in a rut of topical therapies that don’t effectively treat their psoriasis, or they may not be treated at all.
“In general, Black patients are more likely to present with more advanced disease,” says Ginette Okoye, MD, a professor and chair of dermatology at Howard University College of Medicine. “One, because of access to dermatologists, but also because sometimes it’s just harder to diagnose, and it could have been misdiagnosed.”
Although Okoye treats a lot of people of color with psoriasis, “I still can’t always pin it down,” she says.
How Psoriasis Appears on Various Skin Tones
“Psoriasis is characterized by a kind of sharply demarcated erythema – meaning red and silver scaly plaques – often on the scalp, elbows, and knees, but virtually any site can be involved,” says Lisa Akintilo, MD, a dermatologist with NYC Health + Hospitals/Bellevue.
“In patients with more pigment in their skin, that inflammation can be a little more subtle in appearance,” she says. “For example, instead of being pink or red, it might be more purple. It could be grayish or dark brown.”
Other ways psoriasis can appear differently in people of color are:
- More areas of the skin can be affected.
- Plaques may be thicker and have more scaling.
- Skin hyperpigmentation, or dark spots, can mask areas with active lesions.
Social Factors Play a Role
Health care disparities (or differences) can mean less access to specialists and new treatment options for people of color. Fewer than half of the patients of color with psoriasis are referred to a dermatologist for treatment. And they may wait up to 3 years longer than White people for the right diagnosis.
“The prevalence of psoriasis is in fact lower in African Americans, and I think because it’s less common in our community, we don’t talk about it as much,” Okoye says. Nonwhite patients may not have a family member or anyone they know with the condition. “These patients start off with a baseline unfamiliarity that some of my White patients don’t have,” she says. The goal, she says, is more education about what psoriasis is, what causes it, and to “dispel fears that psoriasis might be contagious or that there’s something they did to cause it.”
Black, Latino, and Asian people are more likely to have serious psoriasis symptoms, with Black patients reporting that the condition affected anywhere from 3% to 10% of their skin area, as opposed to White patients who reported skin coverage of 1% to 2%. Other studies found that worse outcomes for psoriasis patients increased their likelihood of having complications from unchecked inflammation, including heart problems and diabetes or hospitalization. Despite these issues, researchers found that patients of color are 40% less likely to visit a doctor to treat their psoriasis than White people.
Doctor Training Plays a Role
Dermatologists diagnose and treat diseases of the hair, nails, and skin, the body’s largest organ. Together, Black and Latino people make up more than a third of the U.S. population, but fewer than 8% of practicing dermatologists are Black or Latino.
The skin is unique because, unlike the body’s interior organs, your skin’s pigmentation (color) can play an important role in diagnosing and treating disease. But nonwhite skin tones are not well-represented in dermatology textbooks and manuals doctors use to study and diagnose disease. It’s not surprising, then, that some doctors might not know a lot about how diseases like psoriasis look different on nonwhite skin. These days, many dermatology residency programs rotate doctors in training through hospitals or clinics that serve people of color so they have experience treating darker skin types.
In clinical trials, where new drug and treatment therapies are tested, studies have found those focusing on psoriasis to have the smallest number of nonwhite participants. Researchers noted that in the phase III clinical trials testing biologics against existing treatments, two-thirds to close to 95% of the people being studied were White, with very few Black and Latino patients involved.
Pursuing Treatment Options
People of any skin tone can be effectively treated for psoriasis with all current therapies. “In general, a lot of psoriasis patients are not aware of the many treatment options available to them,” Akintilo says. They usually visit a primary care doctor first, who might prescribe topical steroids and topical vitamin D as first-line therapy.
But, people of color – and particularly Black people – may have scaling that’s considerably thicker. The plaques can take longer to heal and require stronger medicines to treat.
What’s more, Akintilo says, people “with more melanin in their skin are often affected by post-inflammatory hyperpigmentation, meaning that when lesions go away, they're left with a dark stain on their skin that takes a good deal of time to go away.” This hyperpigmentation can also mask active psoriasis lesions.
People of color may also be left with hypopigmentation, or light spots, on their skin. Depending on where they are on the skin, these dark and light patches may take as long as a year to clear. For some, these post-inflammatory changes in pigmentation can be more of a worry than the psoriasis itself. A National Psoriasis Foundation study found that 72% of people of color said that psoriasis impacted their “quality of life,” and the condition left them feeling self-conscious, frustrated, embarrassed, and helpless.
Biologics
“At this point, the best treatments we have are biologics that actually change the immune system on a molecular level,” Akintilo says. But one study found that Black Medicare patients were 70% less likely to be treated with biologics than White people with the same insurance, economic status, and seriousness of disease.
Black people were less familiar with biologic medicines for psoriasis, another study found, no matter their income or education. Research shows that early and effective treatment of psoriasis may lower your chances of getting psoriatic arthritis (PsA), a complication that about a third of psoriasis patients get.
Akintilo believes biologics are a good first-line treatment if psoriasis plaques cover a large area of your body or affect your daily activities and quality of life, since it’s not practical to put topicals everywhere.
For some, getting biologics prescriptions filled can be difficult, Okoye says. “Depending on the type of insurance they have, and their insurance company’s preference for biologics, the process can be quite time-consuming, lengthy, and confusing for patients. It sometimes takes us weeks, sometimes a month, to get the medicine into their hands.”
Phototherapy
Phototherapy, which uses ultraviolet light, is a useful treatment for psoriasis. Phototherapy may cause increased pigmentation, or tanning, on darker skin. A higher dose of phototherapy may be needed, which many doctors may not feel comfortable providing. Still, it’s considered safe and effective for skin of color.
Akintilo recommends it, saying, “There’s testing done at the initiation period where we make sure we start at the right dose so patients don't get any burns of the skin. And then it's kind of a tightly regimented protocol for adjusting the duration of treatment, but it's a great treatment option for a lot of patients.”
Also, patients with darker-toned skin “have an advantage with phototherapy because they are less likely to get a sunburn from the procedure,” Okoye says. “The melanin in the skin is protective. It’s almost like your own natural SPF, which is why we need higher doses of phototherapy.”
New treatment guidelines from the American Academy of Dermatology include recommendations for using phototherapy on more melanated skin.
Tyrosine kinase 2 inhibitor
Deucravacitinib (Sotyktu) is a newer oral medicine that selectively reduces tyrosine kinase 2 (TYK2), a protein in the Janus kinase (JAK) family. The protein normally causes inflammation in the body. So blocking the protein can help ease psoriasis.
It’s for people who have moderate to severe psoriasis, but who don’t have other conditions. Deucravacitinib weakens your immune system, so it raises your risk of infection.
Some people with psoriasis like it more than biologics, because you take a pill once a day, instead of getting shots.
Very few people of color took part in clinical trials for deucravacitinib. But, researchers say, for those who did, the medicine was just as effective and safe as for other people in the trials.
Be Your Own Best Advocate
It’s estimated that by mid-century, more than 50% of the U.S. population will be people of color. “In dermatology, we are trying to recruit more diverse patient populations, especially when it comes to skin color and skin type,” Akintilo says. “A lot of studies have been done exclusively on lighter skin types without awareness of the fact that a lot of these diseases are present in all skin types, and we need to study them as such.”
Psoriasis is more than a skin disease, Okoye says. “It represents systemic inflammation. So these patients are ill. Yes, they’re walking and talking and sometimes leading normal lives, but they are at a very high risk for cardiovascular disease. They are more likely to have diabetes and high blood pressure. Psoriasis affects your quality of life and your sense of self. They can’t sleep because sometimes they’re really itchy. It’s a really impactful disease.” The longer you wait to see a doctor, or the longer your diagnosis is delayed, the more psoriasis may impact your life.
Don’t let the lack of people of color featured in advertisements about psoriasis treatments keep you from getting more guidance about your condition. Psoriasis can affect anyone, regardless of race or ethnicity. Resources such as the National Psoriasis Foundation’s Skin of Color Resource Center and the Skin of Color Society provide information to patients and doctors about special considerations when treating psoriasis in skin of color.
Remember, getting an early handle on managing your psoriasis can help ease your symptoms and prevent complications. You don’t have to have a dermatologist who’s a person of color, but it does help to find one who has cultural competency. That’s the ability to see the social, cultural, and community influences on health care actions and include that information when planning patient care. The doctor should also have an understanding of how to treat all types of skin. Tell your health care provider your concerns, Akintilo says. “Report your symptoms or say if it’s affecting your quality of life.”
Show Sources
Photo Credit: Moment/Getty Images
SOURCES:
Lisa Akintilo, MD, MPH, FAAD, assistant professor of dermatology and laser and cosmetic dermatologic surgeon, Department of Dermatology, NYC Health + Hospitals/Bellevue
Ginette Okoye, MD, professor and chair of dermatology, Howard University College of Medicine.
Archives of Dermatological Research: “Racial disparities in dermatology.”
Arthritis Foundation: “Psoriasis Is Misdiagnosed and Undertreated in Nonwhite Patients.”
Dermatology and Therapy: “Unmet Need in People with Psoriasis and Skin of Color in Canada and the United States.”
Journal of Clinical and Aesthetic Dermatology: “Psoriasis in Skin of Color: Epidemiology, Genetics, Clinical Presentation, and Treatment Nuances,” “Disparities in Dermatology: A Reflection.”
Journal of the American Academy of Dermatology: “Cultural competence for the 21st century dermatologist practicing in the United States.”
Journal of Investigative Dermatology: “Racial Differences in Perceptions of Psoriasis Therapies: Implications for Racial Disparities in Psoriasis Treatment.”
National Psoriasis Foundation: “Psoriasis and Skin of Color,” “Phototherapy,” “FDA Approves Sotyktu for Psoriasis,” “Treating Skin of Color,” “About Psoriasis,” “Skin of Color Resource Center.”
Penn Medicine News: “Racial Minorities Less Likely to See a Doctor for Psoriasis.”
Skin of Color Society.
The Skin Care Network: “Psoriasis on Dark Skin.”
StatPearls: “Anatomy, Skin (Integument), Epidermis.”
Dermatology Times: “Deucravacitinib: A Year in Review.”
