An example of nuanced treatment is when psoriasis affects the scalp of women of African ancestry.
“One has to take into account the differences in haircare practices in this cohort and differences in hair structure that can affect the optimal topical therapies,” Dr. Alexis says.
Therefore, before prescribing, the patient’s hair-washing frequency needs to be determined, as well as what is involved in her hairstyle and preferred vehicle or formulation, whether it is a water-based solution, a lotion, an oil-based product or a foam.
“You need to have some discussion about these issues to integrate the treatment recommendation into their existing or preferred haircare practices,” Dr. Alexis says.
For example, if a woman straightens her hair using heat, “any exposure to water will revert the hair from straight to curly again,” Dr. Alexis says. “Hence, recommending daily washing with a medicated shampoo would not be compatible with that person’s usual haircare practices and could potentially lead to hair breakage and dryness.”
Instead, Dr. Alexis recommends a once-weekly washing with a medicated shampoo.
“To compromise for that less frequent shampooing, there are topical products that the patient can leave on [her] scalp that are effective for psoriasis,” he says.
One such daily product is a two-compound scalp formulation containing calcipotriene and betamethasone diproprionate (Taclonex, Leo Pharma).
“This topical suspension also has castor oil in its vehicle, which is very well suited for this hair type and is widely accepted by patients in this population,” Dr. Alexis says. “It was also specifically used in studies in black and Latino patients with scalp psoriasis.”
In addition to the scaling, redness and thickness of psoriasis plaque that is found in all patient populations, darker skin types face the added burden of pigmentary alteration.
“Once the psoriasis resolves, it tends to leave postinflammatory hyperpigmentation or postinflammatory hypopigmentation,” Dr. Alexis says. “This lasts for many months after the psoriasis is cleared, thus delaying the total clearance of the skin during treatment by three months to six months, depending on the overall severity.”
Quality of life
Such a bleak outlook “very likely contributes to the more adverse quality-of-life impact that has been observed in this population,” Dr. Alexis says.
“Thankfully, we now have a much larger range of treatment options for all of our psoriasis patients,” Dr. Alexis says. “But one should avoid undertreatment of psoriasis in darker skin types, given the risk of pigmentary sequelae that can last many weeks after a psoriasis plaque heals.”
Patients also need to be informed of a realistic timeline for pigmentation to resolve.
“There are instances where we may need to use a skin-lightening agent like hydroquinone to treat the residential hyperpigmentation that is left behind after a psoriasis plaque resolves,” Dr. Alexis says.
Early and effective treatment, including use of systemic and biologic agents to adequately control the inflammatory disease, “will not only help to address the scaling and the elevation and redness of the plaques, but also will likely reduce the severity and extent of pigmentary abnormalities that these patients face,” Dr. Alexis says.
A larger healthcare landscape issue, however, is that non-white racial ethnic minorities in the United States are less likely to visit a specialist for skin conditions, including psoriasis, according to some studies.3
“These heath disparities that do exist contribute to delays in diagnosis of psoriasis,” Dr. Alexis says.
Disclosure: Dr. Alexis has served as an investigator for Dermira and Novartis.
1. Shah SK, Arthur A, Yang YC, Stevens S, Alexis AF. A retrospective study to investigate racial and ethnic variations in the treatment of psoriasis with etanercept. J Drugs Dermatol. 2011;10(8):866-72.
2. McMichael A, Alexis A. Efficacy and Safety of Brodalumab in Patients with Moderate-to-Severe Plaque Psoriasis and Skin of Color. Poster Presentation at the 2017 Skin of Color Seminar Series, New York, NY
3. Kurd SK, Gelfand JM. The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: results from NHANES 2003-2004. J Am Acad Dermatol. 2009;60:218-224.