1. It’s not uncommon.
We know that more than eight million Americans have psoriasis, but what do the numbers look like when you break it down by race? And how important is it that we do take race into account in the first place? According to Pooja Sodha, M.D., director of the Center for Laser and Cosmetic Dermatology at George Washington University in Washington, D.C., the answer to the latter question is very important.
“Prevalence data tells us what population is more affected with a skin condition, and it helps a great deal when it comes to guiding disease research,” she says. “Amongst those 20 years and older, psoriasis affects about 3 percent of the U.S. population, and by race, Caucasians have the highest prevalence at 2.5 percent to 3.6 percent, followed by African Americans at 1.3 percent to 1.9 percent, and Hispanics at less than 1.6 percent.”
According to Robert Finney, M.D., clinical instructor of dermatology at NYU Langone Health in New York City, we don’t yet know why the stats are what they are. What we do know, however, is that “racial composition, genetics, and environmental conditions likely all play a role,” he says.
Dr. Sodha agrees, explaining that psoriasis is mediated by both genetic and environmental factors. For instance, given the mixed ancestry of African Americans, this may explain the intermediate rate of psoriasis seen amongst this group, she says.
2. It often goes undiagnosed.
Psoriasis is likely to be under- or misdiagnosed in African Americans and people with skin of colour. For instance, according to Dr. Sodha, these patients are 52% less likely to report having been given a psoriasis diagnosis by a physician. There are a few reasons for this, like the fact that people of colour are 40% less likely than whites to report having seen a dermatologist for care. “They also report three million fewer overall out-patient visits for psoriasis,” Dr. Sodha notes. “And population studies of psoriasis patients show that African Americans tend to report lower income and fewer years of education, which likely affects access and utilization of healthcare, thereby delaying diagnosis, leading to disease progression and delayed initiation of treatment.”
Experts—and patients—agree that this is where education and normalizing conversations about skin conditions within diverse communities will help. “My hope is that dermatologists are exposed to a diverse range of skin tones when they’re trained and educated, as well as in residency," says patient advocate Reena Ruparelia of @psoriasis_thoughts. “This will ensure that patients get the best care and the peace that comes with a formal diagnosis.”
3. Symptoms are the same but can look different.
“Symptoms of psoriasis do not vary by skin tone,” says Dr. Finney. And yet, despite having the same symptoms (i.e. scaly, thick patches of skin, itching, etc.) psoriasis can look somewhat different on deeper skin tones. “On dark skin, the plaques may appear purple or grayish and thicker compared to the pink-red scaly plaques that appear on Caucasian skin,” explains Dr. Finney. “And once healed, psoriasis may leave behind dark or light skin patches, which are more apparent in people of colour.”
Additionally, Dr. Sodha says that redness is typically less apparent in those with darker skin, though you’ll still see thickened, scaly patches of skin just like anyone else with plaque psoriasis. “Patients with darker skin types are frequently troubled by light and dark discoloration [a.k.a. hyperpigmentation] of the skin after treatment that can take months to resolve or, in some cases, be permanent,” adds Dr. Finney.
4. Psoriasis cases tend to be more severe.
For people with psoriasis, research shows that the condition impacts nearly every aspect of their life—what medicines they take, what they eat…even what they wear. Dr. Sodha says that people with skin of colour appear to have more “extensive psoriasis at the time of diagnosis, with more surface area involvement.” To this point: A study in the Journal of the American Academy of Dermatology (JAAD) found that Asians and Hispanics are both more likely to have more severe psoriasis than Caucasian counterparts.
The same study says that Asians have reported having greater body surface area involvement compared to Caucasians with psoriasis, though the reason for this is still unknown. But one theory is that disparities in access to health care, as well as ethnic differences in utilization of dermatology services, could contribute to differences in severity. Ultimately, we need more diverse studies done in order to determine why and how psoriasis outcomes are so different across skin colours.
5. Treatments are equally effective.
Treatment for psoriasis is typically the same across the board for all races, however, there are certain factors, like hair type, that may affect a physician’s suggested treatment plan for a patient with say, scalp psoriasis. “Hair care practices in African American patients are very different than those in Caucasian patients, so this can influence how we treat scalp psoriasis,” says Joshua Zeichner M.D., who serves as the director of Cosmetic & Clinical Research in Dermatology at Mount Sinai Hospital in New York City. “It’s important to tailor a prescription regimen to the personal needs and preferences of the patient—for instance, if someone is only washing their hair once per week or every other week, we can't necessarily use the same [scalp psoriasis] treatments as we would if they were washing daily, as over-washing can lead to increased dryness and damage to the hair itself.”
As for skin tone, Dr. Sodha says there are no off-limit treatments. “We follow the same algorithm of treatment using topical therapies for less severe disease, followed by light therapy and systemic treatments for patients needing a more aggressive approach.” Dr. Finney agrees: “Treatments in psoriasis are the same across all ethnic groups—the only minor difference is that when light treatment is chosen, higher doses may be required in darker skin tones due to the increased amount of melanin present in the skin,” he says.
6. Scarring is more prevalent in dark skin.
As previously mentioned, psoriasis patients with darker skin tones are more susceptible to post-inflammatory hyperpigmentation or scarring than their Caucasian counterparts. This simply means that when a person with darker skin has a flare-up of psoriasis, it will leave behind discoloration on the skin even after the rash itself has healed. Unfortunately, the best way to avoid scarring is to avoid flare-ups altogether, though we know that’s not always realistic. A few things you can do to prevent scarring include not scratching, moisturizing often, and protecting your skin from the sun, as we know sun damage is a surefire way to make scarring worse.
https://www.healthcentral.com/article/psoriasis-dark-skin-of-color
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