While previously thought to be a rare diagnosis in non-white racial ethnic groups, more recent data has shown that psoriasis in patients with skin of color is much more common than was once thought. Dr. Andrew Alexis spoke during the Skin of Color Seminar Series (now Skin of Color Update) in New York City on May 5th, 2018 on this condition and on the important differences in clinical characteristics, diagnosis, and treatment of psoriasis in skin of color.
Beginning with the diagnosis of psoriasis in skin of color, it is important to be aware that the classic red plaque typically seen in Caucasian skin may appear more violaceous or even red-brown in our skin of color patients. This can be confusing with the similar appearing, but histologically unique entity, lichen planus. Pay close attention to the distribution of the plaques—extensor surfaces and asymptomatic will favor psoriasis whereas flexural and pruritic may favor lichen planus. Other conditions that may be more common in our skin of color patients such as sarcoidosis or hypertrophic discoid lupus also need to be considered.
Once a diagnosis of psoriasis is established, it is important to understand the intricacies of treating the psoriasis in skin of color patients. For example, when treating psoriasis of the scalp, it is important to select practices and treatments that are compatible with the patients’ hair care regimen and hair texture. It is critical to determine how frequently patients are washing their hair and how feasible it is for patients to use a daily solution or medication on the scalp. One potential option shown to have clinical benefit is a mixture of calcipotriene and betamethasone dipropionate in a castor oil vehicle.
Another complication in our skin of color patients is the post inflammatory pigmentary alterations that affect many of our patients once the psoriasis has cleared. Research has shown that the same biological molecules modulating psoriasis– TNF-alpha and Interleukin-17– can also alter pigmentary change. Keep a low threshold to consider changing your patients to non-topical treatments. Currently, apremilast and brodalumab research is showing no difference with regard to efficacy and safety of the medications when used in skin of color patients. It is prudent to keep up on the literature as other biologic medications are likely going to have similar ethnic comparison outcome studies in the near future that may alter your treatment choice.
Finally, it is important to address the psychosocial impact that psoriasis has on our skin of color patients. A survey performed by the Psoriasis Foundation as well as multiple other studies have shown that psoriasis has a greater impact on the quality of life in our African American patients when compared to the Caucasian population. This may be related to the significant hyperpigmentation that can remain even when the psoriasis is fully treated. Thus, this gives us even more reason to be astute in our diagnosis and aggressive in our treatment to obtain the best possible medical and cosmetic outcomes for our patients.
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