The identification and management of psoriasis may differ in patients with skin of color, with this population having observed disparities in diagnosis and quality-of-life (QOL) impact. This important topic was discussed by Mona Shahriari, MD, and Andrew F. Alexis, MD, MPH, in a symposium presented at the 2023 Fall Clinical Dermatology Conference.

Following this presentation, featured expert Boni E. Elewski, MD, was interviewed by Conference Reporter Medical Writer Rick Davis. Dr Elewski’s clinical perspectives on this lecture are presented here.

In their session at the 2023 Fall Clinical Dermatology Conference, Dr Shahriari and Dr Alexis provided insights into the many factors that dermatologists should take into consideration when treating patients with skin of color who are diagnosed with plaque psoriasis. Social determinants of health, such as geographic location, transportation barriers, and economic limitations, can all lead to an underdiagnosis of psoriasis in this patient population. Gaps in medical education for health care providers (eg, an underrepresentation of skin of color in textbooks and limited training on the nuances of both diagnosing and treating this condition) can also be a factor.

One challenge with diagnosing psoriasis in patients with skin of color is that it may not present the same way that it does in patients with lighter skin. Although white patients are more likely to have psoriasis overall, African American patients often present with more severe and atypical disease, and they can also experience complications that we may not see in other populations. Upon examination, we may see hypo- and hyperpigmentation. The plaques may be less scaly than what is typically seen with psoriasis, so the psoriasis may look more like eczema. There can be a gray, black, or purple tone that looks like lichen planus. Misdiagnosis is common, and a biopsy may be needed to make a definitive diagnosis.

In my practice, I begin by looking at the patient’s fingernails for indications of psoriasis. If I see tiny nail pits, onycholysis with red borders, or oils spots, then the diagnosis of psoriasis may be confirmed, especially in the setting of generally pruritic, scaly, red, hypo- or hyperpigmented plaques. It is important to make an accurate diagnosis and choose appropriate treatment. Systemic steroids that may be used to treat a patient with severe lichen planus could flare a patient with psoriasis.

When managing scalp psoriasis in individuals with skin of color—especially those of African ancestry—efforts should be made to select a topical treatment regimen that is compatible with the patient’s hair care practices and cultural preferences. This involves taking into consideration hair texture, styling, and washing frequency. If a topical agent is needed, patients may prefer to use an ointment, which is more soothing, over a solution, which may be alcohol based. I have had African American patients tell me that the first thing their stylist does when they are getting their hair done at the salon is use a comb to try to uplift the scale(s). In discussion with other colleagues, this could be a cultural norm. It is important to explain to patients not to scratch or pick out the scale(s) on their scalp or other body areas because that could make the condition worse. When I treat an African American patient who has scalp psoriasis, after a discussion with the patient, I may consider relying more on a systemic agent to help manage their condition. If they only have scalp psoriasis, apremilast could be considered because it appears to work relatively well in the scalp. Alternatively, they may need treatment with a systemic biologic agent.

There are cultural perceptions of skin disorders that may impact a patient’s QOL, and the psychosocial impact of psoriasis in those with skin of color may be worse. These patients may be more likely to have feelings of embarrassment and hopelessness, especially because they are more likely to have more severe disease if they have been misdiagnosed for a long time.

Understanding the clinical variations in presentation and the therapeutic nuances when discussing treatment options in patients with skin of color who have psoriasis is important given the observed disparities in diagnosis and the impact that this may have on patient QOL and overall outcomes. Keeping these variables in mind when evaluating and treating patients will ultimately improve the overall care of all patients with psoriasis.