At the 2024 Skin of Color Update conference, we had the privilege to learn about the approach to psoriasis in patients with skin of color from the pioneer in the field, Dr. Amy McMichael, professor in the Department of Dermatology at Wake Forest School of Medicine in Winston-Salem, NC. In her presentation, Dr. McMichael provided an in-depth exploration of the unique challenges and considerations in diagnosing and treating psoriasis in patients with darker skin tones, emphasizing the importance of early recognition, tailored treatment approaches, and addressing disparities in clinical research.
Current Epidemiology in Psoriasis
Current epidemiological data show that psoriasis affects 3.7% of the U.S. population, with the highest prevalence among white individuals, followed by Black and Hispanic populations.1 Notably, Black patients were found to be 69% less likely to receive biologic treatments compared to their white counterparts.2
Psoriasis Presentation in Patients of Color
In patients of color, psoriasis can present with distinct features, such as violaceous or hypertrophic plaques instead of the bright red scaly plaques typically seen in lighter skin tones. Some patients may exhibit hyperpigmented thin plaques without an overlying scale. In addition, guttate psoriasis, which manifests as scattered, raindrop like lesions, may also be present in patients with skin of color. To confirm the diagnosis, Dr. McMichael recommended performing a biopsy, particularly since the appearance of psoriasis can change as treatment progresses.
Treatment Approaches for Psoriasis in Skin of Color
Given the unique presentations of psoriasis in darker skin tones, particularly with regard to post-inflammatory hyperpigmentation (PIH) and the variable appearance of plaques, early intervention and a nuanced treatment regimen are critical for effective management.
Dr. McMichael advocated for an aggressive, early approach to treatment, starting with ultrapotent topical steroids. These steroids help to manage inflammation and reduce plaque buildup. For patients with milder disease or those concerned about side effects, non-steroidal options such as calcipotriene, roflumilast, or tapinarof can be used as alternatives or adjunct therapies. These treatments aim to reduce inflammation and scale while minimizing potential long-term side effects associated with prolonged steroid use.
For more severe or resistant cases, Dr. McMichael recommended early consideration of systemic therapies, including methotrexate and cyclosporine, both of which are traditional, effective anti-inflammatory medications. For hypertrophic lesions, acitretin, a systemic retinoid, can be particularly effective, especially for adults who may not want to use biologics. Another systemic option, apremilast, is an oral medication often used for moderate-to-severe psoriasis, although gastrointestinal side effects may be a concern for some patients.
The use of biologics in treating psoriasis has expanded in recent years, and these are often reserved for patients with more severe disease or for those who do not respond to traditional therapies. Biologics, which target specific cytokines such as TNF-alpha, IL-12, IL-23, and IL-17, have been shown to provide significant improvement in psoriatic skin and joints, particularly in cases where psoriatic arthritis is also present. Dr. McMichael noted that biologics have been proven effective across skin types, although much of the clinical trial data remains skewed toward white populations. This is one reason she emphasized the importance of conducting more inclusive clinical trials.
JAK inhibitors, another newer class of systemic drugs, were also mentioned as a treatment option, particularly for patients with refractory disease. For patients who may prefer non-drug options, UV phototherapy remains an effective treatment, especially in combination with topical or systemic medications. Phototherapy can be administered in clinical settings or via home units, making it accessible to a wider range of patients.
For patients with difficult-to-treat areas, such as the scalp, groin, or intertriginous regions, systemic therapy is often necessary due to the challenges in treating these areas topically. Dr. McMichael also highlighted that when treating the scalp, physicians must consider the patient’s hairstyle and hair care practices to ensure that the vehicle is compatible with the patient’s hair type. Non-steroidal treatments may be more suitable for patients with certain hair care regimens, particularly when treating the frontal scalp.
Additionally, PIH is a common issue in patients with skin of color, and many patients may be dissatisfied with the results of their psoriasis treatment due to persistent PIH. Dr. McMichael advised setting realistic expectations for patients and considering the concurrent use of non-steroidal topicals, such as retinoids or skin-lightening agents, alongside biologics to help reduce PIH. She stressed the importance of patient education on PIH, encouraging patients to understand that hyperpigmentation may take time to improve, even after psoriasis itself has been controlled.
Disparities in Clinical Trials for Psoriasis
Dr. McMichael emphasized that despite effective treatments for psoriasis, clinical trials have historically underrepresented people of color. A systematic review found that 84.3% of participants in psoriasis studies were white, raising concerns about the applicability of these treatments to non-white populations.3 However, the VISIBLE trial, which specifically enrolled a racially diverse cohort with moderate-to-severe plaque psoriasis, demonstrated that inclusive trials are possible. This trial serves as a model for how to address historical disparities in dermatology research.
Conclusion: The Importance of Early Diagnosis and Aggressive Treatment
In her conclusion, Dr. McMichael stressed the need for early diagnosis and aggressive treatment in patients of color, the importance of expanding clinical trials to diverse populations, and the necessity of increasing knowledge of treatment outcomes in patients of color. Properly managing patient expectations, especially concerning pigmentary changes, is also critical for successful long-term management.
References:
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- 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
- Takeshita J, Gelfand JM, Li P, et al. Psoriasis in the US Medicare Population: Prevalence, Treatment, and Factors Associated with Biologic Use. J Invest Dermatol. 2015;135(12):2955-2963. doi:10.1038/jid.2015.296
- Charrow A, Xia FD, Joyce C, Mostaghimi A. Diversity in Dermatology Clinical Trials: A Systematic Review. JAMA Dermatol. 2017;153(2):193-198. doi:10.1001/jamadermatol.2016.4129
This information was presented by Dr. Amy McMichael during the 2024 Skin of Color Update conference. The above session highlights were written and compiled by Dr. Nidhi Shah.
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