Until recently, studies focusing on plaque psoriasis in diverse populations that included people of color were lacking, explains Andrew Alexis, MD, MPH. “Given variations in epidemiology, clinical presentation, and impact on QOL, it is important to better understand special considerations and distinct features of plaque psoriasis in patients with skin of color,” he says. “Educational and research gaps when treating psoriasis in patients with darker skin can lead to delays in diagnosis and treatment.” Dr. Alexis and colleague, Mona Shahriari, MD, presented their findings on “The Many Shades of Plaque Psoriasis: Considerations for Treating Skin of Color” at the 2023 Fall Clinic Dermatology Conference held recently in Las Vegas.
Hyper- and Hypopigmentation May Persist for Weeks to Months
The clinical presentation of psoriasis in patients with darker skin can have distinct features, such as variations in erythema (skin redness) and a tendency to develop post-inflammatory pigment alteration, Dr. Alexis notes. “Hyperand hypopigmentation can persist for weeks to months after a psoriasis lesion resolves, so this adds another dimension to the patient’s clinical and therapeutic ‘journey’ and certainly contributes to the impact of psoriasis among people of color,” he says. “The pigmentary sequelae might at least partially explain why in a recent study, Black, Asian, and Hispanic/ Latino patients reported a greater impact of psoriasis on their HRQOL compared with White patients.”
In melanin-rich skin, the plaques of psoriasis may appear violet to purple, red-brown, or gray in color, Dr. Alexis explains. As active psoriasis resolved, they give way to light or dark patches (post-inflammatory pigment alteration) that can last weeks to months. “Additionally, due to differences in hair care practices and cultural factors, the impact of scalp psoriasis among Black women tends to be particularly pronounced,” he says.
People of Color Greatly Under-Represented in Clinical Trials
For reasons that might include barriers to early diagnosis and treatment, psoriasis can often present with greater severity in populations with melatonin-rich skin, Dr. Alexis notes. “Furthermore, people of color are greatly underrepresented in clinical trials for psoriasis,” he says. “A recent study, VISIBLE, aims to provide valuable data on the treatment of moderate to severe psoriasis in patients with skin of color and is the first large-scale study to focus on this patient population.” The impact of psoriasis on HRQOL, as measured by the Dermatology Life Quality Index, was greater in self-identified Black/African American, Asian, and Hispanic/Latino patients, when compared with White patients. However, the study also revealed high rates of skin clearance and positive impact on QOL using biologic medication versus placebo.
Dr. Alexis encourages dermatologists and other healthcare professionals to consider “broadening our color palate” when it comes to treating persons of color. “If dermatologists are treating patients of color for a skin condition and are looking for ‘shades of bright red and pink’ in a person with richly pigmented skin, they may either overlook the condition or underestimate its severity,” he says. “Continued research into clinical variations, treatment responses, and the impact of psoriasis on QOL for patients with skin of color, including the sequelae of post-inflammatory pigment alteration, will help clinicians provide better outcomes for our patients.”
