Written by Sahithi Gangavarapu

In 2021, the American Academy of Dermatology (AAD) announced a 3-year initiative to improve diversity, equity, and inclusion in the field of dermatology. Racial health inequities have always been a consistent issue in dermatology; however, the AAD stated its initiatives were prompted by the social justice events of 2020 and the disproportionate impacts of COVID-19 on Black and Latino communities. Since then, there has been a stronger push for research studies examining health outcomes in underrepresented populations in dermatology which has uncovered new data on diagnoses and treatments in skin of color (SoC). One specific condition that has recently received more attention in dermatologic research is psoriasis.

Psoriasis is a skin disease that causes red, itchy, scaly patches of skin typically affecting the elbows, knees, scalp, and trunk, but can also affect any area of the body. The condition is a common, chronic disease with no cure, though medications exist to help manage symptoms. Psoriasis is linked with arthritis, depression, cardiovascular disease, and other comorbidities, and affects more than 7.5 million U.S. adults. It’s associated with a large economic burden, predominantly from indirect costs due to lost worker productivity, which is estimated to be around $35.4 billion. Although psoriasis is a universal condition that affects all skin types, people with SoC often face unique physical and psychological challenges while seeking care.

Differences in Physical Presentation

Psoriasis presents differently in different skin types. It’s important that both physicians and patients are aware of these variabilities to properly recognize and treat the condition. While redness and inflammation are common markers of psoriasis in White patients, people with SoC tend to present with less redness and noticeable inflammation. In darker skin types especially, inflammation appears more purple or brown. By relying on redness to indicate inflammation, dermatologists are more prone to misdiagnosing and under-treating psoriasis in darker skin tones. This highlights the need for more inclusive assessment tools that do not rely solely on erythema (redness) as a marker for inflammation and pathogenicity of psoriasis.

Disease Severity

Other studies have also found that patients with SoC, especially Latino and Asian patients, tend to have relatively greater psoriasis disease severity compared to White patients. Several factors could be contributing to this difference. Since patients with SoC are generally less likely to have access to a dermatologist, their psoriasis has potential to progress into greater severity until they decide to seek treatment. Stress, another factor that can trigger psoriasis, was also found to be a more prominent exacerbating factor for their psoriasis in Latino and Asian patients compared to White patients. However, research on this subject is still limited, and not many studies have addressed triggers of psoriasis specifically in patients with SoC. In addition to physical presentation, people with SoC may experience psoriasis differently from a psychological perspective. Studies have found that Black, Hispanic, and Asian patients with psoriasis report a greater impact on their quality of life from the condition, even when controlling for disease severity.

Access to Care

A common barrier to psoriasis treatment is cost of care. A research study based on a randomized online survey of people with psoriasis found that more than 70% of participants noted high cost of care as one of the largest barriers to seeking treatment for psoriasis. High cost of care was the most prominent reason to not seek treatment among all racial/ethnic groups compared to other barriers such as lack of available services, lack of understanding of treatment options, and not considering their symptoms significant enough. However, the concern of cost was greatest among Black and Latino populations, who were also the least likely to seek care.

Medication Hesitancy and Stigma

Cost of care is not the only factor impacting treatment choices in people with SoC. For patients with moderate-to-severe psoriasis, biologics are one of the most effective therapeutic options available for patients. Biologics are systemic medications that target specific parts of the immune system to reduce inflammation and usually come in the form of injectables. These medications can be especially costly for those who are uninsured, with a hefty price tag between $10,000 to $25,000 per year. However, patients with commercial insurance can usually get their medication more affordably as fully or partially covered. Biologics have been found to be used less frequently as a treatment option among SoC which may indicate undertreatment within this group. Cost could play a large role, but another important factor to consider is health literacy. One study showed that regardless of education or income levels, Black patients had less familiarity with self-injectable biologics as a treatment option compared to White patients. “Dislike needles” and “side effects” were reasons often given by Black patients for not pursuing the medication, despite the relatively safe side effect profile of many biologics. These hesitations may be a result of general distrust in healthcare, especially considering medicine’s long history of mistreatment and marginalization of Black patients. Further research on this subject can help providers understand the point of view of patients with SoC and special considerations that may be necessary when presenting treatment options to this demographic.

Moving Forward

AAD’s plan to improve diversity and inclusion in dermatology consists of four main goals: increasing diversity among the AAD organization itself, expanding research on SoC, advocating for issues impacting marginalized populations, and increasing the number of dermatologists from underrepresented minority backgrounds.

Although these are all necessary and progressive measures, an additional component the AAD needs to emphasize is the importance of cultural competence within dermatologists from non-marginalized backgrounds. Cultural competence is a popular term within healthcare referring to the ability to provide quality care to patients from diverse backgrounds with differing values, beliefs, and behaviors. This includes knowledge of social determinants of health such as education, housing quality, and access to healthy foods. Although having more physicians from marginalized groups is important, encouraging cultural competence within non-marginalized groups can be just as impactful.

Studies have shown that patients preferred to have dermatologists of the same race as them, however, it was not required to have a positive experience. In this study, satisfaction was instead related to a dermatologist’s knowledge about Black skin and hair. On the flip side, lack of cultural competence was identified as a key barrier in preventing people with SoC to seek treatment for psoriasis. This just shows that all dermatologists can and should play a part in improving psoriasis treatment in SoC. Increasing the number of dermatologists with SoC is valuable, but not the sole answer. The responsibility of improving health outcomes of patients with SoC lies within everyone, and all providers should work to further their understanding of SoC to develop more equitable treatment. 

Edited by Noor Naheed