Unmasking Psoriasis in Skin of Color: Clinical Clues and Care Strategies

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You’re listening to DermConsult on ReachMD. On this episode, we’ll hear from Dr. Amy McMichael, who’s a Professor of Dermatology at Wake Forest University School of Medicine in Winston-Salem, North Carolina. She’ll be discussing the nuances of treating psoriasis in patients with skin of color. Here’s Dr. McMichael now.

Dr. McMichael:
In patients with skin of color, psoriasis is often missed early on because the pigmentation in the skin actually masks the erythema that we typically think about seeing in psoriasis. In fair-skinned patients, the erythema is brilliant—it’s red or pink. But in patients of color, sometimes there’s very little to suggest even a red color. Sometimes it’s violaceous. Sometimes there’s a brown or hyperpigmented look, and it makes things look as if they are not inflammatory or perhaps that the patient has already been treated and there may be healing.

The only hint might be that in a lot of patients of color, their psoriasis might actually be more hypertrophic—the skin is thickened beyond what we might expect for an average psoriasis plaque, for instance, so you might see more of a verrucous kind of psoriasis, which has been seen primarily in patients with skin of color.

So it’s really important to take a minute when you see a patient with skin of color who has very well-demarcated plaques—or maybe even not well-demarcated plaques—and at least allow the idea of psoriasis to run through your mind as a possible diagnosis if there is hyperkeratosis bilateral plaques in areas that you would typically think about psoriasis or scalp involvement, intergluteal cleft involvement, or nail involvement. All of those things will be hints because the redness won’t be there. 

When we’re talking about psoriasis patients, I don’t think there’s a huge difference between getting a good regimen for patients of color versus those who we would typically think of as Caucasian because, really, every regimen has to be personalized. It has to be personalized for your lifestyle, the level of health and the ability to get these drugs covered by your insurance or pay for them outright. So when we talk about treatment, it has to be focused on what that patient can do.

And then after that, we might have to jump more quickly in some patients of color to a systemic agent simply because, as I discussed, sometimes we see these thicker lesions, and they’re not going to improve with topical steroids or non-steroidal topical agents. So you want to give yourself a chance to do what you normally do—so first-line treatments—but maybe jump to a systemic agent more quickly because these patients will be suffering for longer if we don’t think about doing that sooner. 

So in terms of key takeaways, what we just want to think about is the fact that we might miss the redness, the intense pink, and erythematous plaques in those patients who are with skin of color. So that means that you need to think about psoriasis and things that don’t typically look like psoriasis sometimes or reach for your biopsy more quickly so that if you do have a patient who is suffering, you can at least determine that they have psoriasis much earlier. So I think biopsying earlier, particularly in children, where people are hesitant to give systemic agents despite very widespread rashes, is really important.

I think the other key takeaway is to use your systemic agents in an appropriate fashion and use them in patients who have extensive psoriasis earlier because they’re not going to respond to topical treatment. They’re just going to suffer more. Now we have these agents that are safe and efficacious, and we need to use them in all of our population of patients with psoriasis. 

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That was Dr. Amy McMichael talking about key considerations for treating psoriasis in skin of color. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!