Psoriasis underdiagnosed, undertreated

With psoriasis posing special challenges in skin of color, dermatologists should be aggressive regarding diagnosis, treatments and outreach, according to an expert who spoke at the 75th annual American Academy of Dermatology (AAD) meeting.

"Psoriasis is an underappreciated condition in skin of color, particularly because the inflammation and classic bright red skin that we're used to seeing in skin types 1 through 3 often are not seen in skin types 4 through 6. In a darker-skinned individual, you'll probably see more purple or even brownish-blue, darker discoloration," says Seemal R. Desai, M.D. He is founder and medical director of Innovative Dermatology, P.A., in Plano, Texas, clinical assistant professor of dermatology at the University of Texas Southwestern Medical Center, president of the Skin of Color Society and chair of the AAD Leadership Development Steering Committee.

Moreover, in skin of color, "The differential diagnosis of psoriasis is larger. For example, conditions like sarcoidosis, lichen planus, lupus, inflammatory fungal infections and medication reactions all can mimic psoriasis. Dermatologists should not be afraid to do a biopsy." It's often the key to a proper diagnosis, he says. "The pathology is exactly the same, no matter the skin tone. But clinically, to the eye, psoriasis may be misdiagnosed."

Skin of color also requires caution regarding phototherapy, Dr. Desai says.

"It can be done in a darker-skinned individual. But be careful because UV light can make the entire skin tone darker," he says.

Treatment may clear the psoriasis, he added, but patients may be left with large dark brown to black patches of postinflammatory hyperpigmentation (PIH). "Cosmetically, that may be more distressing the purple appearance of the psoriasis."

Access to care also can pose challenges for patients of color, Dr. Desai says. As with skin cancer, "It's very important to increase awareness that psoriasis can happen in darker-skinned individuals." Underserved populations sometimes have more urgent need for dermatology or specialty care because they lack access to healthcare generally, he said. "It's important that these patients are educated to seek out care, and not wait until their skin condition becomes unmanageable."

Presently, "We are looking at doing studies to show whether biologics work better in one skin type than another. So far the data show that's not the case." To learn more about outcomes and treatments, he says, dermatologists must conduct more studies in this population.

"The take-home message is: treat your patients with darker skin types early and aggressively to avoid PIH and other long-term sequelae. Make sure they understand that psoriasis can happen to them. And the same treatments you offer your lighter-skinned patients should be effective in darker skin types."

Disclosures: Dr. Desai reports no relevant financial interests with relation to his talk.