From blackdoctor.org
Scalp psoriasis poses unique challenges for people of colour, including misdiagnosis, treatment access barriers, and lack of representation in medical education. Dr. Mona Shahriari, the senior editor for the Journal of Psoriasis and Psoriatic Arthritis and the co-founder of Central Connecticut Dermatology and VISIBLE Steering Committee member, sat down with BlackDoctor.org to shed light on these issues and offer insights on how patients can advocate for themselves to receive the best care.
I think there are a lot of challenges that patients with skin of colour face, but one of the biggest ones is the social determinants of health. A lot of them cannot get to the right specialist that’s going to properly diagnose their disease, and there are many reasons for that. Sometimes from a geographic standpoint, you may not have access to your specialist, or you don’t have the luxury of taking time off between 8:00 to 5:00 when the doctor’s office is open. So they oftentimes get care in an ER setting where you don’t necessarily have access to a dermatologist who can properly diagnose your psoriasis.
But then to top it all off, some of these individuals actually do make it to a dermatologist’s office, but that dermatologist may or may not have proper training in the diagnosis and treatment of psoriasis in melanin-rich skin. So they may be misdiagnosed, there may be a delay in diagnosis, or they may be undertreated because the disease is being inaccurately graded from a severity standpoint. When you also look at a lot of the textbooks nowadays that are teaching the residents, that are teaching the healthcare professionals, we don’t have enough representation of melanin-rich skin.
Even when you do a quick Google search, if you put psoriasis into Google Images, you have to scroll down quite a ways to find one image with skin of colour. And in an era where a lot of patients are Googling their disease, if you don’t see it represented on that first page of Google, you probably don’t think that’s what you have and you’re not going to necessarily seek out care. So, I do think it’s a multifactorial issue, but the important thing is there’s a lot of attention to the nuances of diagnosing and treating psoriasis and skin colour, so hopefully, we’re going to make some progress for the future.
What are some common misconceptions or misdiagnoses people of colour face regarding scalp psoriasis?
A lot of times my patients with skin of colour come in thinking that they have just a fancy form of dandruff or they have a fungal infection of the scalp and they’ve been treated with multiple antifungal medications that haven’t made much progress. And also, eczema is another big one that I get because a very itchy scalp, especially in our patients with darker skin, can be very itchy for them. And typically, you think of eczema, not necessarily psoriasis.
But I think the most important reason why there are so many issues with the diagnosis is when we were taught about what psoriasis looks like, in medical school, it’s supposed to be this red plaque with a silvery scale. However, in melanin-rich skin, red is not the best adjective to use because sometimes that plaque can look violet, it can look dark brown, it can even have the shade of a post-inflammatory lesion. So it’s really important for us to broaden our colour palette and what we’re thinking of when we’re treating our patients with skin colour because things are not going to look the way we were traditionally taught, and that’s how you make a mistake. That’s how you come up with these other diagnoses that aren’t necessarily correct.
Could you discuss the recent study on scalp psoriasis in people of colour and its implications?
The Visible Skin of Colour study is the first of its kind, a dedicated study looking at psoriasis in individuals with skin of colour. And I really think that this was a great step toward diversity, equity, and inclusivity because what it comes down to is, nowadays, there’s a lot of challenges that our patients with skin of colour are going to face when they’re getting treatment for their plaque psoriasis, whether it’s on their scalp or their body. And this study not only was trying to figure out what is the effect of a drug like Tremfya on the plaques of psoriasis on the scalp, but also wanted us to understand what are the challenges that our patients with skin of colour face when it comes to just access to the system, getting these medications, are there any barriers that we’re unaware of that as clinicians, we need to keep in mind when we’re treating our patients with skin of colour.
And in this study, the results were quite amazing. And the majority of patients who had gotten to the primary endpoint, which was almost clear of their scalp psoriasis, the majority of them were actually 100 percent clear, which is reassuring for these patients because after three shots, you have a pretty darn good shot of having your psoriasis just melt away and you can live a healthy, normal life. We also saw a lot of quality of life impacts of the scalp psoriasis on these patients that after they were treated with the medication, that quality of life burden would decrease significantly.
What are some effective strategies for distinguishing between scalp psoriasis and other conditions like dandruff for people of colour?
It’s pretty challenging because even as clinicians, sometimes it’s difficult for me to know if it is scalp psoriasis or something else. There are a lot of over-the-counter shampoos that are available, but the problem is when you’re dealing with Afro-textured hair, for example, the shampoos over the counter, you need to use them every day for it to be effective. But when you have that tightly coiled hair, washing your hair every day is going to dry out your scalp, it’s going to potentially make things worse, it’s going to break your hair. So those are little nuances that I like patients to keep in mind.
I generally say it’s much better to just go see a dermatologist and have them diagnose it because there are nuances to treatment that maybe even over-the-counter stuff is not going to be able to address. But even for someone like me who sees a lot of skin of colour and scalp psoriasis, sometimes I have to biopsy because it can be challenging and I don’t want to give the patient the wrong medication. So we have a conversation and I sometimes tell them, “Hey, we could start with this treatment, if that doesn’t work, we can biopsy, or I’m on the fence, do you want a biopsy today?” And through shared decision-making, we kind of come up with the best option for each patient.
Are there differences in treatment approaches for scalp psoriasis in people of colour?
Definitely. So when it comes to individuals with Afro-textured hair, as I mentioned earlier, we don’t want to be giving them treatment regimens that require frequent hair washing because generally, medications are washing their hair once a week. So a regimen that’s going to be conducive to that usual hair care practice is going to be important because if I send them home with a regimen where they’re washing their hair every day, they’re not going to do it, they’re going to lose faith in me, and then they’re going to move on to the next expert and potentially have further delays in their treatment.
So I generally try to pick formulations that mesh well with an individual’s normal hair care routine. Oils are great for tightly coiled hair, foams, lotions, these are other favourites of mine. I try to avoid solutions and creams because these can be drying for the scalp and drying for the hair. I have a low threshold to consider systemic therapy because the reality is when you’re trying to get something into the scalp, topicals are just only going to do so much. And the multidimensional burden of plaque psoriasis goes beyond what we can see on the scalp. That itch that I talked about, the quality of life burden, you see all these flakes on your clothes. So I like to cool this down quickly and let my patients live their best lives. Going to a systemic agent early is another great option.
What advice do you have for people of colour living with scalp psoriasis to manage the condition in their daily lives?
Well, I think the important thing is to consider those formulations that match their regimen. They do have anti-inflammatory oils that they sell over the counter that would be a great option for individuals with Afro-textured hair. But if the dandruff is becoming too much, I do think it’s important for them to seek out care because there are limited options over the counter that would really help them nip this in the bud.
Are there any upcoming developments or advancements in the treatment of scalp psoriasis that you find particularly promising for people of colour?
Well, I think this study has been very revolutionary in terms of us not only understanding the response of patients with skin of colour to the medicine Tremfya, which was studied, but also really understanding the challenges and barriers that they go through when it comes to access to care, response to treatment, as well as their individual treatment goals. Cultural competency was another big issue that came out in the study because a lot of clinicians, if they themselves are not of colour, they may not know how to interact with the patient of colour to make them feel safe and have them get on board with any sort of regimen.
So I think those are the benefits that really go beyond what was specifically studied in the trial, but the scalp psoriasis piece I think was huge. We’re still analysing the data, there’s still so much more that we’re learning about individuals with skin of colour and their impact from scalp psoriasis. Across the entire dermatology landscape, there are new formulations of medications that are being developed, topical medications that are meant to really help bridge this gap because historically, we’ve just created lessons that work for the scalp, not really taking into account that many of our patients with plaque psoriasis of the scalp are patients with skin of colour. So now, I think pharma is doing a much better job of keeping in mind the formulation that’s going to work across all skin tones so each and every one of our patients can have access to the latest medications.
Historically, the problem we’ve had with clinical trials is we’ve had an underrepresentation of patients with skin of colour. And the problem with that is if you get the results from the study, you can’t necessarily apply it to your real-world patients because there is a disproportionate number of patients who are Caucasian included, and you don’t have enough patients with skin of colour to really help you know if this medication is going to work. So the movements toward including more diversity in our clinical trials and not just as a checkbox, but really putting in the effort to ensure patients with non-enriched skin are getting into these trials, we’re properly studying their response to treatment, I think we’re really going to help change the landscape so these newer drugs will be much better studied in these populations.
Is there anything else you would like people to know about scalp psoriasis?
I think we’ve covered the scalp psoriasis piece quite in detail. The only thing I would urge patients out there of skin of colour who are dealing with plaque psoriasis, whether it’s on the scalp or on their body, is really talk to your clinicians, make your expectations known, and be an advocate for yourself. Because I think there are a lot of clinicians out there who want to help, they just don’t have the right tools. And don’t be quick to just write someone off and say, “Well, they don’t know what they’re talking about.” Engage them, really let them know what your goals are because you’re just as important, and your needs and your goals should be at the forefront of every single discussion.
And if they give you a treatment regimen that doesn’t really mesh with your day-to-day, just let them know, “This is not gonna work for me, what other options do we have?” I think finding a culturally competent clinician can be challenging, but I also want patients to really advocate for themselves so that if somebody’s on the fence, they can get them to include that shared decision-making a little bit more at the forefront when they’re talking about treatment options.
https://blackdoctor.org/qa-dr-mona-shahriaris-tips-for-treating-scalp-psoriasis-in-black-skin/2/
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