Psoriasis in Skin of Color

Shiva: My name is Shiva Mozaffarian and joining me today for a discussion about recognizing and treating skin of color with psoriasis is Dr. Mona Shahriari, Assistant Clinical Professor of Dermatology at Yale University School of Medicine and partner at Central Connecticut Dermatology where she is also the Associate Director of Clinical Trials serving as principle investigator for numerous multi-center clinical studies. Additionally, she is the President of the Connecticut Society of Dermatology and Dermatologic Surgery and a senior editor for the Journal of Psoriasis and Psoriatic Arthritis. Dr. Shahriari’s clinical and research interests include inflammatory skin diseases such as psoriasis and the study of novel therapeutics for skin diseases.

Welcome Dr. Shahriari! It’s such an honor having you back on Psound Bytes™ today! So, we know psoriasis is a complex disease that affects many regardless of sex, socioeconomic status, ethnicity and skin color. Given our topic today is managing psoriasis in skin of color, would you say psoriasis is rare in people with skin of color?

Dr. Shahriari: Well, first of all, thank you so much for having me. I'm excited to be back and I would say psoriasis is not rare in skin of color. According to some of the current studies that we have about 125 million people worldwide have psoriasis. More than eight million Americans have psoriasis with similar prevalence between men and women. But there was a study from 2014 that reported the prevalence of psoriasis in Caucasians is 3.6%, but it is 1.9% in African Americans, and 1.6% in Hispanics.

Shiva: And does genetics play a role in the development of psoriasis in skin of color?

Dr. Shahriari: So yes, it does. The pathogenesis of psoriasis involves a complex interplay of environmental and genetic factors. And there is some heterogeneity in alleles that are implicated in the development of psoriasis, and these may explain some of the differences that we see in prevalence, clinical presentation and response to treatment. I'm going to get a little technical here, but HLA-CW6 was the first gene shown to be significantly associated with psoriasis susceptibility and the frequency of this particular allele can differ between various ethnic groups. However, there are some ethnic groups who have this allele, but they have a lower risk for psoriasis, which suggests that genetics plays a role, but it may not be the only factor. There are also some changes, or what we call polymorphisms, in IL-10, which is an important signaling molecule in our body that helps maintain homeostasis, and with those changes in that IL-10 molecule, those particular patients may be more susceptible to psoriasis. In particular, some of our Asian populations, like our Indian patients and our Korean. However, genetics, like I mentioned before, plays a role, but psoriasis is very heterogeneous and multifactorial, so genetics is just one piece of the equation.

Shiva: So Dr. Shahriari what other factors impact the development of psoriasis in skin of color?

Dr. Shahriari: Well, environmental triggers are actually a big player. Bacterial infections, in particular, strep have been known to jumpstart psoriasis in somebody who may have that underlying genetic predisposition. HIV is another virus and other viruses have actually been linked as well, which is why when someone asks me why did I get psoriasis? I often times asked if they were sick recently. That can give us some clues as to why it's happening when it's happening. Stress and trauma are other players. Cold weather and humidity can play a role as well, and smoking. All of these have been shown to contribute to the development of psoriasis. In people with skin of color, they may be more susceptible to some of these environmental factors just by virtue of where they live, where they work, and different individuals that they may come into contact with.

Shiva: Can you please describe how psoriasis typically presents in darker skin tones versus those with lighter skin?

Dr. Shahriari: So one classic hallmark of psoriasis is its color. In individuals with lighter skin tones, psoriasis tends to be more pink or red. However, in people who have more melanin rich skin, it can have other hues. It can be violaceous. It could be dark brown, it could be reddish brown or even gray. The other thing is psoriasis can have a texture to it or what we call induration. In lighter skin, it's very easy to see that elevation in the skin. However, in darker skin tone, sometimes it's tough to distinguish hyperpigmentation from an old spot and a true act of spot of psoriasis. So it's important to touch an area that we think is psoriasis and see if there's elevation there to be able to tell is this an active lesion of psoriasis or is this a nonactive area that's resolving.

Shiva: And given that description, is it possible that psoriasis is more likely to be misdiagnosed in individuals with darker skin and what steps can be taken to avoid being misdiagnosed? Should a skin biopsy be done?

Dr. Shahriari: Well, that's absolutely true. Part of the problem is there’s a lack of medical education that focuses on skin of color, in particular with all skin diseases. But psoriasis being the topic of discussion today. And if a lot of individuals don't know what psoriasis looks like in skin of color, they may have difficulty diagnosing it so they may misdiagnose it. Some things that psoriasis can look like on melanin rich skin is eczema, lichen planus, sarcoidosis. cutaneous T cell lymphoma, or even discoid lupus. So it's really important to look at the whole patient. When I'm examining my patient, I'm looking at where are the plaques? What color are they? What's the morphology? I'm looking inside people's mouth. I'm looking in the groin area. Whatever can clue me into what the diagnosis is. And if I see involvement of the nails, involvement of the scalp, involvement of the elbows or the knees, or the buttock area. I'm thinking of psoriasis. However, sometimes the diagnosis still isn't clear cut, so it's never wrong to do a biopsy to ensure that we have the correct diagnosis, so that then we can customize our treatment options appropriately.

Shiva: And is psoriasis usually more extensive or more severe in skin of color? Meaning it could take longer to treat due to thicker scales or lesions.

Dr. Shahriari: It is actually, and part of that reason is the delays in diagnosis as well as the lack of access to care. So let's talk about that in a little bit more detail. So there are some ethnic differences in terms of seeking care which can lead to a delayed diagnosis of psoriasis. Some individuals just don't necessarily go to the doctor because they're having an issue with their skin. For other people who want to go to the doctor, they may not have access to a healthcare provider, a dermatologist, or they may not be able to take time off work to go to an office visit. So they end up going to an emergency room. And in an emergency room, you don't always have access to a specialty dermatology care, and that psoriasis can go undiagnosed. So it's ultimately more severe when it is finally diagnosed. And for some of those people who do finally make it to a primary care doctor or dermatologist, there are still that provider educational barrier that can lead to delayed diagnosis, under diagnosis of the psoriasis, and sometimes the psoriasis can be misdiagnosed as post inflammatory hyperpigmentation because it has more of those brownish violaceous hues and to the untrained eye that can be mistaken for non-active disease. A lot of studies are showing us that patients with skin of color are more likely to be offered creams or no treatment at all for their psoriasis, and they're less likely to receive biologics, which are very effective targeted medications for psoriasis. So again, it's very important for our patients to be aware of what psoriasis is, but also for their providers to be aware of what psoriasis looks like so that we can avoid those delays in treatment that can ultimately lead to more severe disease at presentation.

Shiva: And how common are pigmentary changes such as post inflammatory hyperpigmentation or hypopigmentation in skin of color with psoriasis?

Dr. Shahriari: So those post inflammatory pigment alterations are extremely common in our skin of color patients, and they're disproportionately seen in those patients versus their Caucasian counterparts. However, when we're assessing the severity of the psoriasis, it's not something that we're capturing. But it can be very troubling for different people who have psoriasis, and from a psychosocial standpoint, quality of life standpoint, individuals with skin of color can definitely be impacted by this significantly. So a lot of times I counsel people on the development of the post-inflammatory pigment alterations, even after we treat the psoriasis because it's important for them to know that treating the psoriasis did not lead to those marks, and the treatment is not making their condition worse because we don't want them to feel anymore helpless and defeated because of the treatment. And then we go ahead and we treat those post-inflammatory alterations.

Shiva: And you mentioned treatments, what treatments are used to clear hyper or hypopigmentation and how long will it generally take to return skin color back to where it was originally?

Dr. Shahriari: I'm a firm believer that it's much easier to prevent than to treat once it happens. So I tend to be more aggressive in treating my skin of color patients in order to avoid the development of those pigmentary issues. However, that's not always possible. So when we do have those pigmentary issues that we're dealing with, I make sure I advise my patients that these marks will clear with time. But because your skin has a little bit of color to it, this will take longer. And in my patient population, I start with topical retinoids. These are products that cannot only treat the psoriasis, but also can treat the pigmentary changes. And if this doesn't work, I've also had good results with compounded triple creams that contain hydroquinone, a bleaching agent, a retinoid, as well as a low potency corticosteroid. But I do take more of an active approach in treating these pigmentary changes because it does have such a profound impact on individuals with skin of color who have psoriasis.

Shiva: And other than hyper or hypopigmentation, what other factors need to be considered when treating psoriasis in someone with skin of color?

Dr. Shahriari: So there are a lot of additional considerations to keep in mind. One is that some individuals based on their race and beliefs, they may believe that skin diseases are directly linked to a blood or an organ disease and will request additional testing like blood work, imaging, before they accept the diagnosis of psoriasis and agree to a treatment regimen. Other individuals may have different perceptions of the safety of medications like biologics and may even have some mistrust towards healthcare providers as a whole. As a result, they may be less likely to opt for a biologic to treat their psoriasis. One other important consideration is when you're treating scalp psoriasis, which is a common manifestation of psoriasis in skin of color, you have to take into account the texture of the hair, the differences in hair care practices in our skin of color patients because the topical therapies or the daily shampoos that we use for our other patients may not necessarily apply to individuals with skin of color. A lot of my patients with skin of color do prefer oils and lotions to creams and solutions. So really my job as the physician is to have cultural awareness and be sensitive to these different nuances, gain the trust of my patients, and then properly educate them on the risks and benefits of appropriate treatment for their psoriasis. I also talk to my patients about the downsides of not treating psoriasis because this is a systemic disease with systemic inflammation, and the sequela of not treating can be just as problematic as some of the adverse effects of treatment itself.

Shiva: Thank you Dr. Shahriari for helpful information about treatment options. If you’re listening today stay with us for more information about treating scalp psoriasis after this short announcement from CeraVe.

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Shiva: Welcome back! So Dr. Shahriari before the break you mentioned caring for hair. How difficult is it to treat scalp psoriasis and what treatments do you recommend for people with skin of color?

Dr. Shahriari: So as I mentioned earlier, scalp psoriasis is very common in psoriasis in general, but in my skin of color patients, it definitely does pose a treatment challenge. So I generally have a lower threshold to consider systemic treatment in my skin of color patients with scalp psoriasis because the topicals are so challenging to use. But when I'm treating scalp disease, I take into account the hair texture, the styling practices, the lower hair washing frequency, and then any shampoos that require daily use that cause hair dryness or may interfere with usual hairstyling are a nonstarter. Because ultimately my patients are not going to like the product. They'll be dissatisfied with their treatment, and they may lose faith in the overall treatment regimen. I also prefer to use oils, lotions, or foams because I find these formulations are more compatible with a variety of hair textures and hairstyles. I also ask my patients about traditional therapies or ethnic products that they may have gotten from an ethnic store that they may be using on their scalp to help treat their psoriasis, because often times these products can have ingredients in them that can worsen the scalp disease.

Shiva: And are there any treatments or medications where differences in effectiveness or caution should be considered, such as in the use of phototherapy?

Dr. Shahriari: There are. So topicals are actually cornerstone for the treatment of psoriasis. However, they can cause lightening of the skin. So I generally talk to my skin of color patients about minimizing the use of these medicines and only using it when they need it. And I educate them on how to effectively use it, but not overuse these products. Another treatment that's very common for psoriasis is phototherapy. It's very safe and very effective for skin of color, however, because of the high doses that my patients with the melanin rich skin need, they can have tanning of the skin which for some individuals can be unacceptable. So it's really important to have that conversation about tanning of the skin, darkening of the skin before starting phototherapy, and finally, there is some data that shows certain genetic polymorphisms that are more common in skin of color can make my patients more susceptible to adverse effects of pills that are used for psoriasis. Some polymorphisms can actually predict response to the treatments that I'm giving them. However, none of this is ready for prime time yet, so we do need more studies to identify if there are any unique molecular targets for psoriasis medications in individuals with skin of color.

Shiva: So a number of articles indicate psoriasis is often undiagnosed and undertreated in people of color. Why do you feel this is the case and what actions can be done to address such health disparity issues?

Dr. Shahriari: This is unfortunately absolutely true. For starters, lack of access to a dermatologist that can correctly diagnose and treat psoriasis in skin of color can lead to misdiagnosis and incorrect treatments. Insurance and socioeconomic challenges in individuals with skin of color can make it more difficult to obtain prior authorizations for some of the best medications that we have. And for some smaller offices in remote locations of the country, obtaining these prior authorizations maybe a hard stop in terms of individuals getting the medications that they need. And many of our individuals with skin of color get their care through an ER, which doesn't necessarily give them appropriate access to specialty dermatology care. And as a result, their psoriasis can go undiagnosed or undertreated for years. So as a provider, there are many ways to improve health equity. One of those is just improving access for individuals with skin of color by connecting them with the right specialists that are equipped to diagnose and treat their skin disease. Also, if you look at advertising campaigns and direct to consumer marketing from various industry partners, we really don't see skin of color patients well represented. So individuals with skin of color may not know one that they have psoriasis, and two that those treatments that are being advertised are actually viable options for them. So improving diversity in our advertising campaigns whether it's in the media, social media, or any sort of direct-to-consumer marketing is really important. Patients should be able to see the various faces of psoriasis. And as mentioned earlier, some individuals, by virtue of their race, their beliefs, they may have different perceptions of the safety of medications like biologics. And so it's important as the physician to have cultural awareness be sensitive to these nuances and really gain the trust of our patients and properly educate them so that they understand the risks and benefits of these treatments and they can make an educated decision.

Shiva: And Dr. Shahriari Is telehealth a viable option to help address some of the access issues that you mentioned previously?

Dr. Shahriari: So telehealth, I would say is a double-edged sword because we've talked about how difficult it is to diagnose psoriasis in skin of color in person. So in a telehealth scenario, you can only imagine how much more challenging it is to be able to diagnose the condition. I know during COVID I did a lot of telehealth and seeing the skin, appreciating the texture, the different hues and colors was very, very challenging. However, telehealth can be a good adjunct. If we can have our individuals with skin of color seen for that first visit in the office, but then the continuation of care can be done via televisit so that our patients don't have to take time off of work, they don't have to struggle to come into the office for every single visit, then yes, I think it can definitely allow for that continuation of care and it can allow for our patients to follow up with their treatment regimens.

Shiva: And as you know, there are risks associated with being undiagnosed and undertreated. Can you address what those risks are, and how can someone access health care to obtain treatment if access is limited?

Dr. Shahriari: So it's really important to understand that psoriasis is a systemic condition that goes beyond the skin. That systemic inflammation really results in a multidimensional burden of disease, which is why not treating or under treating psoriasis can have its own set of risks. Now psoriasis is associated with that greater psychological impact and worse quality of life in individuals with skin of color in comparison to white individuals. With our black patients and our Hispanic patients having consistently lower scores with respect to quality of life. I also see similar trends in Indian individuals and Malaysians. And this higher impact of quality of life in our individuals with skin of color is likely the result of those post inflammatory pigment alterations that we talked about because it can have a much greater negative impact on individuals with skin of color than, say, their Caucasian counterparts. There's also some cultural variations in the perception of skin disorders and social stigma surrounding them, and if you come from a cultural background where skin disease is shunned, then it can really impact feelings of self-worth and contribute to embarrassment and anger and perpetuate these psychosocial impacts of the disease. Beyond the psychosocial impacts patients that have psoriasis are also an increased risk of diabetes, heart disease, stroke, fatty liver disease, arthritis and inflammatory bowel disease. So I generally encourage healthy behaviors like eating well and exercise and really ensure that individuals have a close relationship with their primary care doctor so they can get appropriate screening for the comorbidities that we discuss and appropriate referrals to specialists can be jumpstarted with when needed. But our individuals with skin of color are at a disproportionately higher risk of some of these comorbidities, like diabetes like heart disease, like stroke and fatty liver disease by virtue of their lifestyles because they're socioeconomic status may not be conducive to healthy eating habits or regular exercise. They may be working seven days a week. How are you going to fit in going to the gym amongst that busy schedule? I really do encourage individuals to take an active role in their health and educate themselves on psoriasis and its comorbidities. And if access to the right health care professional is limited, I encourage individuals to work with their primary care doctor and organizations like the National Psoriasis Foundation to obtain access to appropriate health care providers. Sometimes the resources are out there, but we just need to find the right person or group to guide us in accessing the resources.

Shiva: Thank you for your comments Dr. Shahriari and for providing such an informative podcast about skin of color and the management of psoriasis. Do you have any final comments you'd like to share with our listeners today?

Dr. Shahriari: I think just the take home point is that diagnosing and managing psoriasis in skin of color is hard and comes with unique challenges. It's through education of healthcare providers on the nuances of diagnosis as well as treatment, as well as being aware of the social determinants of health that impact individuals with skin of color. And really having cultural sensitivity towards individuals that come from these diverse ethnic backgrounds that we can do right by individuals that have that skin of color and allow for them to receive that high quality health care that they deserve. And have an inclusive society that recognizes them for their own unique selves. I also encourage anyone with skin of color to be their own advocate. Do the research and take an active role in their care to ensure that they do get that high quality care that they deserve.

Shiva: Well said Dr. Shahriari! An inclusive society that recognizes all is so important. Thank you again for such an amazing podcast today! For more information about managing psoriasis in all skin colors, tips for developing an effective skin-care routine, and details on over-the-counter products with the NPF Seal of Recognition program like the CeraVe products mentioned earlier, order our free Skin Care E-kit by calling our Patient Navigation Center at (800) 723-9166 or by emailing education@psoriasis.org. And finally, this Psound Bytes® episode is supported by unrestricted educational grants from Amgen, Bristol Myers Squibb, CeraVe, Janssen, and UCB.

Psoriasis in Skin of Color

Psound Bytes™ Transcript: Episode 187

Release date: February 7, 2023

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