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Addressing Plaque Psoriasis in Patients With Skin of Color


Mona Shahriari, MD, comments on plaque psoriasis in skin of color populations, as well as the importance of shared decision-making between patient and dermatologist.

Alexandra K. Golant, MD: To your point as well. We are in inflammatory skin disease in general at the tip of the iceberg in terms of how we understand the sheer heterogeneity of this disease. Not only from a cytokine standpoint but also from a disease presentation standpoint. And he brought up an interesting. And I would say what is a hot topic in dermatology is increasingly recognizing all of these different patterns. In the many different ways, this can present in patients that vary by a whole host of factors. But in one way…is how this disease presents in patients that aren’t Caucasian skin, which is how we all learn dermatology in textbooks in our skin of color population. What are some of the differences that you see in some of our skin color patients when they come into the office with this disease?

Mona Shahriari, MD: Seeing patients with skin color is a passion of mine, as you know. And I do see a lot of patients with psoriasis who are of skin of color and have that melanin-rich aspect to their skin. And 1 thing I find is they do tend to have more nontraditional presentations. Pustular psoriasis being more common, or erythrodermic psoriasis being more common. Interestingly, these patients are always more severe when they present to me. And it makes me wonder, there’s some genetic factors that play, there’s some environmental factors of play, but also the social determinants of health play a role in that presentation. Sometimes these patients don’t have access to a specialist, so maybe they’re not getting diagnosed correctly. Or they go to a dermatologist and the dermatologist is not well versed in diagnosing psoriasis and skin of color. So you end up with somebody who’s either been and undertreated or incorrectly treated. So these factors definitely come into play for a lot of our skin of color patients. And also, there’s other special considerations like scalp psoriasis is huge in our skin color population. And the reality is some of the traditional topicals that we use for psoriasis don’t work as well on the scalp, in particular, in our patients who have different [hair] textures… . They have different styling practices, they may have infrequent hair washing. So when I’m thinking of what topical, for example, am I going to give my skin a color patient with scalp psoriasis? The formulation matters. I’m thinking of lotions, oils, foams, and creams are solutions may not be ideal. And we got to keep that in mind. Because if I give my patient a regimen and expect them to wash their hair every day and use a formulation, it’s going to dry out their scalp. Let’s face it. They’re not going to use it. Have you noticed something similar?

Alexandra K. Golant, MD: Yes. You took the words right out of my mouth. And that is key into what shared decision-making has turned into in the office conversations. Whether you’re talking about topical treatments, systemic treatment, whether you’re talking about psoriasis or other inflammatory skin diseases, is trying to understand what life is like for your patient. Because if you’re talking to a patient [who] washes his or her hair once a week, sometimes once a month, it’s a very different conversation than someone who washes his or her hair every day or every other day. And that is critical too, you can recommend or select a treatment that might have great efficacy. But if it’s not practical to that person’s lifestyle, it’s not going to be used. And we know that [adherence] is a huge barrier to care, especially for topical treatment. To your point in terms of skin color, and I think about this too, when I focus on or think about how we educate our residents and the textbooks that we all learn from traditionally, our dermatology atlases in large part have Caucasian, European, American patients. So the way that erythema looks in a fair-skinned patient, that bright red smacks you in the face, is different than how erythema can present in a skin [of] color patient. It can be much more subtle, it can be much more violaceous. And again, this conversation, traverses inflammatory skin disease in general. But what that often leads to is an underappreciation of disease severity. From a social determinant of health perspective, we see less referrals of those patients [who] come in to emergency departments, urgent care settings, primary care settings, a less quick referral to specialists like board-certified dermatologist who can help guide these patients into appropriate therapy. So I wonder, do we see more severe disease because they are more severe, or because there’s so many pivot points of delayed diagnosis of getting them into the right providers’ offices?

Mona Shahriari, MD: And it’s interesting because when you look at the statistics, they see the prevalence of psoriasis in our [Caucasian patients], about 3.6% of the population. And in [African American patients], it’s about 1.5%. I wonder to your point is this underreported because we aren’t properly diagnosing this condition. It’s something that we definitely need to be aware of, especially in this day and age when people have many different skin tones. And we want to be able to offer that inclusive care for all of our patients.

Alexandra K. Golant, MD: Particularly at a time where the United States and every area of the country and the globe is turning more into a mixed melting pot. And we’re only going to increase that in the next 20, 30, 40 years. We all collectively have to do a better job of inclusivity in recognizing this disease and doing a better job of getting all our patients to treatment goal.

Mona Shahriari, MD: And to build upon that, to make sure we keep those patient goals in mind. Sure, decision-making is a huge part of our practice, I’m sure for you as well. And that’s why it’s so important for us to sit down with our patients and make sure our treatment goals and their treatment goals align. Because for each patient, those treatment goals are going to be different, their tolerance of certain safety signals is going to be extremely varied. And what they consider reasonable for their lifestyle in terms of a treatment may not be the same for the next patient that walks through the door. And I’ve always been a fan of including the patient in that decision-making process. Because I feel if they feel they have a voice that’s being heard, they are more invested in the process, and they’re more likely to [adhere to] the regimen.

Transcript edited for clarity.

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