Psoriasis in Patients With Skin of Color

Historically, psoriasis(PsO) was assumed to be rare among people other than White individ­uals; however, more recent research documents that this association is untrue. Epidemiologic studies within the past 15 years have determined a considerable prevalence of PsO among people with skin of color.^1,2 A cross-sectional study using National Health and Nutrition Examination Survey data from 2011-2014 demonstrated the prevalence of PsO to be 3.6% in White individuals, 2.5% in Asian people, 1.9% in Hispanic or Latino persons, and 1.5% in Black or African American people. PsO was also frequent among non-Hispanic and multiracial individuals (3.1%). Until recently, clinical trials in dermatology underrepresented patients of different races and ethnicities.³ Fortunately, this is changing, and the addi­tional unmet needs of these individuals are coming to the forefront.

Challenges in the Diagnosis and Treatment of Psoriasis

Patients with skin of color often experience underdiagnosis, delayed diagnosis, and barriers to care. One of the primary contributions to delays in diagnosis is variability among health care providers in accurately analyzing erythema and other clinical features of PsO among the spectrum of skin colors. Although the word erythema suggests redness, it is a clinical sign of inflammation that presents differently across skin complexions and that can appear in hues of reds and pinks to browns, violets, and grays.

There are a few conditions that can mimic PsO; therefore, a biopsy may be necessary to identify the definitive cause. This is especially true when the effects of background melanin on ery­thema and other clinical features may complicate identification of the squamous disorder. Differential diagnoses in PsO include sarcoidosis and cutaneous T-cell lymphoma.

Changes in Pigmentation and Impact on Quality of Life

Dyspigmentation, hypopigmentation, and skin changes with the clearing of disease are important considerations for patients of different racial and ethnic backgrounds. Scalp PsO can have a tremendous impact on a patient’s quality of life (QOL). This is particularly true for patients with very textured hair and Black women who have specific hair care regimens and practices. These factors must be considered when selecting topical agents. The stigma of scaly visible plaques that extend to the front hairline, forehead, and temples can be substantial for patients. Similarly, patients with darker skin tones who have scalp PsO may experi­ence hypopigmentation, especially on the forehead or face, which can be very devastating and contribute to self-consciousness.

The Psoriasis Longitudinal Assessment and Registry (PSOLAR; NCT00508547) was a prospective, international study designed to assess the QOL burden of PsO in patients of different racial/ ethnic backgrounds who had moderate to severe disease and who were receiving or eligible to receive systemic therapy.⁴ This cross-sectional analysis involved 10,107 North American participants (White, 82.5%; Hispanic/Latino, 6.6%; Asian, 4.3%; Black, 4.0%; other racial/ethnic background, 2.6%).⁴ The mean total Dermatology Life Quality Index scores were significantly different among the racial or ethnic groups.⁴ Mean (SD) scores, when compared with those for White patients (5.6 [6.1]), were higher among Black (8.3 [7.6]), Hispanic or Latino (8.0 [7.6]), and Asian (7.9 [7.4]) patients (P < .001 across groups), indicating a more detrimental impact of PsO on health-related QOL.⁴

Patients with skin of color may not seek care until their PsO is severe, which would likely have a greater impact on their QOL. Additionally, these patients may not be offered treatments until their disease is severe.

Clearing of Disease Versus Dyspigmentation and Hypopigmentation

In patients with skin of color, the visible effects of active PsO are just as troubling as the lingering dyspigmentation that occurs during clearing of the disease. These patients often view the dyspigmentation as part of the disease; until it resolves, they do not consider treatment to be successful. Patients may avoid wearing specific clothing (eg, skirts) and consider these skin alterations disfiguring. Measurements of disease severity do not account for these postinflammatory changes in pigmentation.

The process of dyspigmentation and hypopigmentation that emerges following skin-clearing therapy is not well understood. However, the pigment alterations that persist after inflammation improves should resolve over time to support the ultimate goal of clear skin. Hypopigmentation in the face tends to respond more rapidly to treatment than it does in other areas of the body. Improvement is generally noted within 12 weeks. It is important to make use of highly efficacious agents that offer the ability to heal the PsO plaques and their sequelae.

In patients with skin of color, it is important to start treatment early, and perhaps aggressively, to prevent some of the severe dyspigmentation and to control the PsO quickly.

Faculty presenter: Andrew Alexis, MD. This article was reviewed, edited, and approved by Dr Alexis and Dr Stein Gold.

References

1. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CEM. Psoriasis prevalence in adults in the United States. JAMA Dermatol. 2021;157(8):940-946. doi:10.1001/jamadermatol.2021.2007
2. Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70(3):512-516. doi:10.1016/j.jaad.2013.11.013
3. Yadav G, Yeung J, Miller-Monthrope Y, et al Unmet need in people with psoriasis and skin of color in Canada and the United States. Dermatol Ther (Heidelb). 2022;12(11):2401-2413. doi:10.1007/s13555-022-00811-0
4. Takeshita J, Augustin M, de Jong EMGJ, et al. Health-related QOL differs by race/ethnicity in North American patients with psoriasis: results from PSOLAR. J Invest Dermatol. 2022;142(9):2528-2531.e3. doi:10.1016/j.jid.2022.02.013