Here's What People of Color Should Know About Psoriasis

Ⓒ Provided by Self

By Adele Jackson-Gibson, Self

Psoriasis is a fairly common skin condition, but if you only relied on what you see in the media, you’d probably have no idea it affects more than just white people. A quick “psoriasis” image search will show you mostly photos of people with light skin. TV is no better. In 2020, a group of researchers who analyzed television ads for psoriasis treatment over the course of two weeks discovered that nearly 93% of the main characters were white.

Even dermatology textbooks are lacking, Lynn McKinley-Grant, MD, FAAD, an associate professor of dermatology at Howard University and the president of the Skin of Color Society, tells SELF. “A lot of what dermatologists learn is to see psoriasis inflammation in white skin,” she explains, but they aren’t always trained to see the possible symptoms in darker skin, which can delay a diagnosis.

The truth is, psoriasis affects more than 7.5 million people in the US, which includes people of varying ethnicities and skin colors: A 2014 study concluded that about 3.6% of white Americans have psoriasis, while 1.6% of Hispanic Americans and 1.9% of Black Americans have this often painful, itchy, and frustrating condition.

Unfortunately, studies show that undertreatment of psoriasis is common, regardless of skin color. But the lack of Black and Brown representation in the media, dermatology education, and research has left many people of color feeling especially misunderstood, discouraged, and alone when it comes to finding the care they need and deserve, according to the National Psoriasis Foundation.

The good news: Many dermatologists of color are working hard to educate others on how psoriasis affects people with darker skin. SELF spoke with some of these experts about what people of color need to know about psoriasis, and where they can get support.

Read More: 7 Things Dermatologists Want You to Know About Guttate Psoriasis

1. Psoriasis inflammation often looks more purple than red on deeper skin tones.

Psoriasis is generally considered to be an autoimmune skin disease, according to the Centers for Disease Control and Prevention (CDC). This means the condition begins as a malfunction of the immune system, which triggers skin cells to grow too quickly and pile up on the body’s surface, often resulting in an uncomfortable rash or a raised lesion.

There are different types of psoriasis, but the most common is plaque psoriasis, according to the American Academy of Dermatology (AAD). This type causes thick, scaly, and often itchy or burning patches of skin to form, typically on the knees, elbows, lower back, and scalp. Across all skin types, these patches “tend to appear in a similar pattern on both sides of the body and have well-defined borders,” Junko Takeshita, MD, PhD, MSCE, assistant professor of dermatology and epidemiology at the University of Pennsylvania, tells SELF.

The nuances, however, start with the color of the rash, as it often shows up as a different shade in people of color than most doctors are trained to see, Caroline Robinson MD, FAAD, a board-certified dermatologist and founder of Tone Dermatology, tells SELF. “Psoriasis is often described as salmon-colored in dermatology textbooks,” she says. “However, in those with darker skin tones, it can appear more bruise-like, purple, or even dark brown.”

Not recognizing this shade difference may be why some doctors confuse psoriasis with everyday skin irritation, eczema, a drug reaction, or even an infection in people of color, says Dr. Robinson. But there are other clues that may point to psoriasis.

For example, “you can touch the patient and feel that the inflamed area is usually warm,” says Dr. McKinley-Grant. A thorough dermatologist will ask about your family history since the condition can (but not always) have genetic roots, she adds. In case your doc is uncertain, they might also take a small biopsy (a skin sample) and examine it to be sure of the diagnosis and rule out any other skin conditions.

2. Rare types of psoriasis tend to be more common in people of color.

While plaque psoriasis is the most prevalent form of the condition, “there are also rare subtypes that appear more frequently in certain racial and ethnic groups,” Dr. Robinson says. For example, researchers have found that pustular psoriasis—which appears as inflamed, scaly, pus-filled bumps—is more common among Asian and Hispanic communities.

Asian people are also more likely to have erythrodermic psoriasis,5 which covers the body in a red, burn-like rash and can be fatal if it’s not treated quickly. What’s more, Asian and Black people tend to be more vulnerable to scalp psoriasis, in which plaques pop up around the scalp, hairline, forehead, back of the neck, and on the skin around the ears.

This is important to know because getting an accurate diagnosis can be complicated if you’re dealing with a form of psoriasis that’s rarer in white people, according to Dr. Robinson, especially if you’re seeing a doctor who’s not experienced in treating darker skin. (You can check out our resources below to help you find a doctor who is well-versed in treating darker skin tones.)

3. Certain treatments may not be ideal for your skin color and hair type.

While there is still no cure for psoriasis, there are plenty of treatment options to help keep the symptoms at bay, no matter how much melanin is in your skin. These include prescription-strength creams and ointments, phototherapy, oral and injectable medications, and scalp oils and shampoos, among others.

However, special considerations need to be made for a few treatments. One, for example, is phototherapy, which involves exposing the skin to a controlled amount of ultraviolet light. “People with darker skin tones require higher doses of phototherapy in order for it to be effective,” Dr. Takeshita says. However, phototherapy can tan the skin and make any unwanted dark spots you have darker, which people of color are especially susceptible to, according to the AAD. If that’s the case for you, standing in a lightbox a couple of times a week may not be the best way to go.

For scalp psoriasis, you also need to think about your natural hair texture, how often you prefer to wash it, and how you like to style it, says Dr. Robinson. Frequent shampooing with medicated formulas, which may be recommended in combination with oral medication, can help to remove the scales, but if you have dry hair or washing often doesn’t align with your hair care routine, there are other options out there to help keep your hair as happy as possible.

For example, medicated oils tend to work better for natural hair, “as they are more moisturizing than liquid or foam formulations,” Dr. Takeshita says. On top of that, very tight styles like braids and chemical relaxers can cause scalp psoriasis symptoms to flare, per the AAD, so it’s important to discuss this with your dermatologist and stylist.

4. Biologics, although super effective, are often not prescribed to people of color.

Studies have shown that biologic medications—a type of treatment given by injection or infusion that targets certain parts of the immune system—are incredibly effective at taming psoriasis symptoms for many people. A 2020 review of research published in the International Journal of Molecular Sciences revealed that more than 80% of patients who received these injections over the course of 52 weeks experienced a reduced appearance of symptoms by 90%.

Yet, many people of color miss out on these treatments. In a 2015 study, Dr. Takeshita and her team discovered that Black people with psoriasis are less likely than white people to receive biologics. “We also found that Black adults with moderate-to-severe psoriasis were less aware of biologics than white adults,” she adds.

Why? Part of the reason, she suggests, is how these medications are typically marketed. Since TV ads for psoriasis treatments have very few non-white characters featured in them, this may create the assumption that psoriasis only occurs in white people or that the treatments are not for people of color. There’s also some mistrust about the safety of biologics among Black communities, according to Dr. Robinson. (Understandable, given the long history of racial discrimination and mistreatment in the US health care system.)

Biologics are not the easiest treatment to access either, says Dr. McKinley-Grant. They can be expensive and often require pre-authorization from insurance companies for doctors to even prescribe them, she says. That’s why, for people in marginalized communities who have limited access to insurance, specialized doctors, and support for health care questions, starting on biologics can be especially challenging. For these reasons and more, people of color also “are less likely than white individuals to see a dermatologist for their psoriasis,” says Dr. Takeshita.

The potential consequences of all this can be serious. When psoriasis is not treated effectively, it can get worse, creating more discomfort and pain while increasing the risk of infection and skin discoloration, according to Dr. McKinely-Grant. The systemic inflammation can also cause other health problems beyond just the skin, increasing the risk of eye inflammation, nail issues, and even heart disease. Untreated psoriatic arthritis, an inflammatory arthritis that affects an estimated 30% of people with psoriasis, can be particularly debilitating and potentially cause permanent damage to the joints if left undiagnosed and untreated, per the National Psoriasis Foundation. Overall, it’s important to consult with a dermatologist ASAP to figure out the best treatment for you.

5. Hyper- and hypo- pigmentation can be just as frustrating as psoriasis itself.

Even when you do find the right treatment and the rash or plaques start to disappear, you might be left with dark spots on the skin that don’t just go away—at least, not for some time.

When psoriasis symptoms clear, people of color often find light patches (hypopigmentation) or dark patches (hyperpigmentation) where the plaques once were. According to the AAD, these are not scars but discoloration that typically disappears after three to 12 months (sometimes even longer). Still, seeing unwanted spots in the mirror can be really bothersome for people of color, as they can be really noticeable, says Dr. Robinson.

The best way to reduce the amount of skin lightening or darkening is to treat psoriasis as early as possible, says Dr. McKinley-Grant. It’s also important to tell your doctor your level of concern with skin discoloration in the first place. “I think sometimes doctors don’t understand the stress you’re feeling about the pigment changes,” she says. An empathetic doctor should be willing to listen and shouldn’t dismiss your concerns.

Once psoriasis has cleared, there are strategies you can use to get clearer skin such as using lightening creams and limiting sun exposure, depending on how your skin responds to tanning, says Dr. McKinley-Grant. Your derm can help you figure out the safest, most effective treatment plan for your situation.

Read More: 4 Proven Ways to Treat Psoriasis

6. There are resources out there to support people of color living with psoriasis.

Psoriasis is distressing, and it can have a significant impact on a person’s physical and mental health, as well as their quality of life. This is particularly true for people of color who may not be receiving the most effective treatments.

If you or someone you know is struggling to find a doctor who understands psoriasis in darker skin tones, these resources are great places to start:

• The National Psoriasis Foundation. This organization has articles about treating psoriasis in people of color, a dermatologist directory, as well as a list of opportunities to participate in cutting-edge research. “I encourage people to participate in clinical trials, if they feel safe, because there’s still so much we don’t know about psoriasis and how it affects people of color,” says Dr. McKinley-Grant.
• Skin of Color Society. This group of professionals is working to promote awareness of skin health and dermatologic issues in people of color, and has a national database of dermatologists who specialize in treating skin of color throughout the US.
• @BrownSkinMatters. This Instagram account shares images of how skin conditions appear on dark skin, with descriptions of the condition. Anyone can view this account, and it can help doctors and people of color identify how things like psoriasis may look on different skin tones.
• Twill Care (Talk Psoriasis). To find community as well as resources, tips, and strategies to manage your condition, this app seems to have it all. Here you can connect with other people who are navigating the same challenges, connect with board-certified experts, and track symptoms.
• The Psoriasis and Psoriatic Arthritis Alliance. This org has tons of resources, forums, and a large collection of personal stories from people living with various types of psoriasis. This org also keeps tabs on the latest research and treatments.

Yes, the medical world still has a long way to go in recognizing and treating people of color living with psoriasis. Even if you are able to find a dermatologist who specializes in skin of color, actually getting (and paying for) an appointment can be challenging. Ultimately, finding the right doctor may be frustrating, particularly for marginalized people; you might need to be persistent and see a few to find the best one for you. Of course, it’s crucial to remember that finding the support you need should not be dependent on your determination as an individual, and there are deeper, systemic issues the dermatologic community needs to address to improve care for people of color.

Despite these barriers, there is a positive shift taking place. “There is a great push in dermatology to strengthen the core of skin-of-color training in residency programs and beyond,” says Dr. Robinson, which will hopefully bolster better outcomes for people with darker skin, from diagnosis to treatment.

See more at Self