Rethinking Psoriasis

What It Is and Considerations for Treatment
By Caroline Robinson, MD, FAAD

According to the American Academy of Dermatology, approximately 7.5 million people in the United States have psoriasis – so if this is a condition you have been diagnosed with, know you are not alone. In this blog, Dr. Caroline Robinson, MD, FAAD, summarizes what we know about the condition and considerations for the diagnosis and treatment of psoriasis on skin of color.

What is psoriasis and what are some of the key symptoms associated with it?

Psoriasis is a common chronic inflammatory condition that usually appears as scaly plaques on the elbows, knees, and scalp and can affect all skin types and tones. There can often be redness associated with these scaly plaques, however, in those with darker skin tones this can appear more bruise-like, purple, or even dark brown instead of red. Psoriasis can impact the nails and rarely appear as pus-like bumps, widespread redness of the skin, or even affect the joints in a condition called psoriatic arthritis. These can be itchy and painful and have a significant effect on quality of life. If you are experiencing symptoms that you believe may be psoriasis, it is important to see a board-certified dermatologist who can help diagnose and treat this condition.

Diagnosing Psoriasis on Darker Skin

Psoriasis is often described as salmon-colored or red in dermatology textbooks and this, combined with the underrepresentation of images of the condition on Black and brown skin, makes it difficult for clinicians to accurately diagnose. This is related in part to the ability to recognize and appreciate inflammation on darker skin; we all need to recalibrate our eyes to be better at picking this up. While the scaly plaques of psoriasis are the most common appearance of the condition, there are also rare subtypes that appear more frequently in certain racial and ethnic groups, which adds to the complexity in arriving at the diagnosis. Data suggests that scalp psoriasis for example may be more common in Asian and Black patients and that Latinx and Asian patients are more likely to have more severe disease compared to other groups. Psoriasis in skin of color may look similar to other conditions such as atopic dermatitis, nummular eczema, lichen planus or drug rashes.

Treating Psoriasis on Darker Skin

One of the biggest considerations in patients with psoriasis and more melanin in their skin is that there can be post-inflammatory hyperpigmentation (or a dark scar or shadow on the skin) once the scaly plaques have cleared away. Some are more likely to develop hyperpigmentation than others due to family history and just by virtue of having more melanin in their skin. Patients of color are often just as bothered by the resulting post-inflammatory hyperpigmentation as the psoriasis itself. Addressing post-inflammatory hyperpigmentation while treating psoriasis is crucial.

The treatments for psoriasis are similar no matter your skin tone or type but there are some important barriers that racial and ethnic minorities face. Topical anti-inflammatory creams such as topical steroids, light therapy, retinoids, and injectable medications known as biologics are some of the more common treatments. There is a general unfamiliarity with injectable biologics for psoriasis in communities of color and some fear of these medications in part due to lack of representation in marketing and community education. Injectable biologics are a safe and effective treatment for moderate to severe psoriasis and your board-certified dermatologist can help you determine if you are a candidate. Phototherapy (or light therapy) is a treatment option for psoriasis as well, however, for someone with a tendency to develop hyperpigmentation it is important to know that the risk of darker areas developing may be higher.

For scalp psoriasis, hair texture is a consideration, and your dermatologist might recommend a different formulation of the same active ingredient to be more compatible with your lifestyle and how you prefer to wear your hair. Often times there will be a combination of treatments needed for scalp psoriasis including shampoos, oils or solutions, and sometimes oral medications, to gain control of symptoms.

The Future of Psoriasis Treatment and Management

It is very important to be as open with your dermatologist as possible when designing a treatment plan together. Talk about any concerns you have with incorporating treatments into your life and the impact that psoriasis is having on your quality of life. Sometimes one treatment may be a better option over another because of your specific cultural considerations or lifestyle. Provide feedback to your doctor and remember that you can be an advocate for your care.

If you’re in need of finding a board-certified dermatologist in your area, check out the Vaseline See My Skin dermatologist directory.

Caroline Robinson, MD, FAAD, is a board-certified dermatologist and founder of Tone Dermatology