Psoriasis often has a greater impact on quality of life in patients with skin of color as the condition and its treatment can result in long-lasting pigmentary changes. Dermatologists should keep this in mind when managing the disease in this population to ultimately ensure that patients are fully aware of the risk of pigmentary changes and how they can be minimized, says Andrew Alexis, M.D., M.P.H., chairman of the department of dermatology and director of the Skin of Color Center at Mount Sinai St. Luke’s and Mount Sinai West in New York.
When assessing patients with skin of color for psoriasis, physicians should also be aware that clinical features can differ depending on the individual’s skin pigmentation, warns Dr. Alexis. In particular, erythema will be more difficult to perceive on darker Fitzpatrick V and VI skin tones.
TIPS FOR DIAGNOSIS
“The eye needs to be calibrated, so to speak, for the skin type of the patient because the redness of the lesions will be potentially masked by background melanin pigment in the epidermis,” he explains. So rather than a red or pink hue, erythema may appear violaceous, grey or red brown, depending on the background skin color.
Failing to appreciate the different appearance of erythema in skin of color raises the risk of confusing psoriasis with lichen planus, sarcoidosis or discoid lupus, especially the hypertrophic variant.
As well as the risk of misdiagnosis, he adds, “under-appreciation or under detection of the erythema component can lead to incorrect assumptions about the severity of the lesions.” This is important not only for the management of the condition in a patient but also for clinical trials where erythema is formally measured as an EASI score or SCORAD to assess treatment efficacy.
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