Diversifying Psoriasis Research to Benefit the Population

Chronic plaque psoriasis in a patient with skin of color | © Image credit: DermNet

“It’s very difficult for us to understand what those genetic risk factors are. I don’t believe I’ve seen more than 1 or 2 studies that focus just on Latino populations,” Zelma Chiesa Fuxench, MD, MSCE, FAAD, assistant professor of dermatology at the University of Pennsylvania in Philadelphia, said in an exclusive interview with Dermatology Times. During the discussion, Chiesa Fuxench spoke about the lack of research into psoriasis in skin of color, absence of diversity in clinical trial populations, and where dermatology as a discipline can go from here.

The US Hispanic population, a group who represents a substantial portion of many patient bases, often remains underrepresented in psoriasis research and clinical trials. Chiesa Fuxench highlighted this pressing issue, noting that although psoriasis is a prevalent and debilitating condition across diverse ethnicities, there is a striking deficiency in research focused on its prevalence, pathophysiology, and treatment outcomes in Hispanic individuals. This not only impedes the ability to provide culturally and clinically relevant care but also underscores the need for targeted studies that explore how psoriasis uniquely affects Hispanic patients.

Psoriasis Prevalence and Ethnic Considerations

Although there have been studies and research articles discussing a possible lower prevalence of psoriasis within Hispanic populations, such as that published by Armstrong et al, Chiesa Fuxench noted that these studies do not always accurately represent the population.¹ Her 2 major considerations when addressing these data are: Is the sample population representative of a diverse patient population, and is their initial diagnosis correct?

Results from similar studies, such as that completed by Yan et al, found a higher prevalence of pustular psoriasis within the Hispanic population.² Chiesa Fuxench stated that the small scope of this study makes it difficult to confirm this frequency but noted that its findings highlighted the need for studying these subtypes further within specific populations.

Disease Presentation and Treatment Considerations

Chiesa Fuxench emphasized the importance of including diverse skin tones in clinical trials, noting that psoriasis can manifest in various ways—a consideration she prioritizes in her role in academic medicine. “We try to encourage our residents, as they’re learning and preparing to be the dermatologist of the future, to take their time assessing a patient who comes in with psoriasis,” she said. “Take a close and careful look at their skin to make sure that you’re not making the common mistake of confusing that erythema with postinflammatory hyperpigmentation, because that can have an impact in terms of treatment selection.”

As for location, Mona Shahriari, MD, FAAD, an assistant clinical professor of dermatology at Yale University and associate director of clinical trials at Central Connecticut Dermatology (CCD) Research, says some studies show specific manifestation areas are more prevalent within this population. "Studies show that Hispanic patients are more likely to have scalp involvement as part of their overall psoriasis picture in comparison to their Caucasian counterparts," Shahriari said. "And in those patients that have textured or tightly coiled hair, psoriasis of the scalp can be particularly challenging to treat."

Regarding treatment choices, Chiesa Fuxench highlighted the need to consider the whole patient, especially when it comes to individuals with skin of color. She pointed out that certain treatments can lead to hyperpigmentation, which, although it might appear minor in relation to the initial diagnosis, can significantly affect a patient’s quality of life. “It’s important to capture things like quality of life, because sometimes the results of those 2 instruments may not align. We might think we’re doing a great job because clinically, the patient is improving. But then we ask them all these other questions, and they’re saying, ‘No, I’m still suffering even though my disease looks better.’”

Shahriari noted that cultural considerations are also at play when it comes to treating a diverse patient base: "In Hispanic culture, many times patients think their disease is caused by an internal imbalance and may seek the help of a healer and try herbal medicine before agreeing to a systemic medication prescribed by an allopathic clinician. Cultural sensitivity is a key part of the treatment regimen to ensure trust between the clinician and patient forms and guides treatment decisions."

Awareness and Inclusion Campaigns

Despite the growing visibility of dermatology through social media, Chiesa Fuxench highlighted a persistent gap in awareness regarding dermatological conditions in skin of color. Whether it be on television commercials or in textbooks, she noted that media presenting psoriasis focus predominantly on lighter skin tones. “Let’s not talk about it, but let’s put those pictures in the books so that when everyone goes back and references, they can see differences,” Chiesa Fuxench said.

"Clearly, there is still work to be done to ensure all patients feel knowledgeable about their skin disease and feel empowered to ask their clinician about treatment options for their psoriasis," Shahriari added.

Chiesa Fuxench also stressed the importance of considering the diversity of skin tones in awareness campaigns aimed at Hispanic patients with psoriasis: “How do you develop an effective strategy to reach these patients and create awareness when they all look very different?” One campaign that Chiesa Fuxench was excited to see was the American Academy of Dermatology’s effort to improve their database of images used for learning and teaching differences in skin diseases across the spectrum. She said she hopes this effort will lead to younger generations of physicians gaining a better understanding of these differences.

Increasing Overall Diversity

Chiesa Fuxench underscored the critical need for greater diversity in clinical trials and the dermatology field as a whole. She highlighted that by not including a broad range of populations in these studies, we may miss important genetic risk factors and pathogenic genes specific to certain groups. “You have a big chunk of the population for which we need more data in terms of disease prevalence, risk factors, treatments, or effectiveness of treatments,” Chiesa Fuxench pointed out.

With the US population projected to be made up of nearly 50% of individuals with skin of color by 2060, including Hispanic individuals making up 27.5% of the population, this issue is becoming increasingly urgent.³ As of 2022, Sevagamoorthy et al found that 77.5% of clinical trial participants were White, with an even higher percentage in psoriasis trials (84.7%).^{4 "}We need clinical trials that capture the racial and ethnic diversity of the US population that we see in everyday clinical practice," Shahriari said. "This is the only way that we can take the results of a clinical trial and apply it to our real-world patients in clinical practice."

“I think we are making progress, which is good, so we have to keep this conversation going,” Chiesa Fuxench said. She concluded that this push for diversity could be orchestrated among dermatologists, researchers, and advocacy groups, such as the National Psoriasis Foundation, to build a better understanding for all patients.

References

1. Armstrong A, Young M, Seal MS, Higham RC, Greiling T. Treatment burden and the perspectives of patients with psoriasis using topical treatments: results from a national survey of adults with psoriasis in the United States. J Dermatolog Treat. 2024;35(1):2389174. doi:10.1080/09546634.2024.2389174

2. Yan D, Afifi L, Jeon C, Cordoro KM, Liao W. A cross-sectional study of the distribution of psoriasis subtypes in different ethno-racial groups. Dermatol Online J. 2018;24(7):13030/qt5z21q4k2.

3. Vespa J, Medina L, Armstrong DM. Demographic turning points for the United States: population projections for 2020 to 2060. US Census Bureau. March 2018. Updated February 2020. Accessed August 11, 2024. https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf

4. Sevagamoorthy A, Sockler P, Akoh C, Takeshita J. Racial and ethnic diversity of US participants in clinical trials for acne, atopic dermatitis, and psoriasis: a comprehensive review. J Dermatolog Treat. 2022;33(8):3086-3097. doi:10.1080/09546634.2022.2114783