In this podcast, Ginette Okoye, MD, discusses important treatment considerations dermatologists should keep in mind when treating psoriasis in patients with skin of color.
Dr Okoye is the chair of the department of dermatology at Howard University in Washington, DC.
Melissa: Hello. Welcome to another podcast with the dermatologist. Today I’ll be speaking with Dr Ginette Okoye, chair of the department of dermatology at Howard University.
Today we’ll be discussing the diagnosis and management of psoriasis in patients with skin of color, and important treatment considerations dermatologists should keep in mind when treating patients with darker phototypes. Thank you for joining us today, Dr Okoye.
Dr Ginette Okoye: It’s my pleasure to be here.
Melissa: Patients with skin of color face a lot of barriers for access to care. Would you mind discussing some of these barriers that you particularly see among your psoriasis patients?
Dr Okoye: Sure. One of the main barriers I see in my patients with psoriasis and skin of color is just access to dermatologists. For patients who are uninsured, undocumented, or even those who are insured with public insurance, it may be difficult or impossible to see a dermatologist. Many of them have been managed either by their internist or just using home remedies.
Another barrier is when they do see a dermatologist, I find that skin of color patients with psoriasis are more likely to be misdiagnosed. As we know, psoriasis does not always present with the classic findings we learn in residency. The bright red plaques with micaceous scale that we’re taught to look for, aren’t always as evident in our patients with skin of color.
Erythema can be tricky to ascertain, and the lesions can look violaceous. They can be brown or hyperpigmented. In my experience, the scale can also be really variable in terms of its appearance. Additionally, in our dermatology training, so our textbooks, our Kodachromes, our lectures, the vast majority of the psoriasis photos we see are in white patients.
We are in a sense trained to miss this disorder in skin of color. There are also barriers to treatment, especially for our skin of color patients from lower socioeconomic backgrounds. For example, coming to the office three times a week for phototherapy, may not be feasible for patients who have a less flexible work schedule or patients who have less autonomy at work.
The cost of medications for psoriasis and even phototherapy copays can be prohibitive for this group as well. For some of my patients on public insurance, we’re actually limited to sometimes one very specific biologic for their psoriasis, even though a newer biologic might have been shown to be more effective than the one that’s on their formulary.
I’ve even encountered patients whose insurance mandates that we use a biologic with a more concerning side effect profile. That’s just some of the barriers I think these patients face.
Melissa: What clinical presentations of psoriasis are often missed by either primary care providers or even dermatologists in patients with darker phototypes?
Dr Okoye: The first issue is the fact that erythema in skin of color can be tricky to pick up. I think the first thing that’s often missed is the fact that patients with skin of color and psoriasis may have these violaceous or hyperpigmented plaques, as I mentioned before.
Additionally, in my experience, the accompanying post-inflammatory discormia, be it hypo or hyperpigmentation, is really a significant concern for our patients with skin of color. It’s worth addressing and acknowledging that at the outset, and reassuring the patient that you’re keeping that in mind, and that you have some ideas about how to treat the discormia, once the psoriasis has improved.
Also, a recent study done out in California compared the clinical presentation of psoriasis in Caucasian, Asian, and Latino patients. They actually found that Asian and Latino patients were more likely to have pustular psoriasis and that Asian patients were more likely to have erythrodermic psoriasis. These both are severe subtypes of psoriasis.
That I think is interesting, and we should keep that in mind. Interestingly, they didn’t find a difference in the distribution of psoriasis lesions by race. Extensor areas, scalp, palms, and soles were all the common locations in all the different racial groups. In my experience, scalp psoriasis can be a little bit more severe in particularly African American patients, and particularly African American women.
Part of that is the decreased frequency of hair washing in this group, allows the scale of the psoriasis to accumulate a little bit more, so it’s a little bit more obvious.
Melissa: Going off of the last point you made about scalp psoriasis, are there any other important cultural or patient factors dermatologists should keep in mind when treating patients from certain minority groups?
Dr Okoye: The cultural factors is probably one of the most important things that we have to keep in mind when we see patients who are different from us. This is a great question. The first thing is psoriasis is just not as common in skin of color populations.
It’s really important that we, as providers, take the time to educate the patients about the disease, give them handouts so they can read, they can take it to their families, and connect them to support groups and advocacy groups so that the patient can find a community where they can feel a bit more empowered about this disease. They just may not have been exposed to psoriasis before.
Secondly, when prescribing topicals for patients with psoriasis, it’s really important for you to ask the patient which vehicle they prefer, and then describe the different vehicles, the differences between an ointment and a cream versus a lotion, etc.
This is really important when you’re prescribing products for the scalp for people with curly hair, who may have specific preferences upon what they want to apply to their scalp. Just the time you take to engage patients on this question will improve adherence.
Another thing I think it’s important for us to consider is the cost of our treatments. It’s really important that we try to use our patients’ formulary and use generic drugs when we can. If the patient can’t afford what you prescribed, then obviously they’re not going to use it and they’re not going to get better.
Probably the most important point, from my perspective, is it’s worth spending the time to get to know your patients and to build rapport. It fosters trust, and that trust will improve adherence to your treatments, which will improve patient outcomes. Finally, it’s OK to tell your skin of color patients about your familiarity or lack thereof with skin of color.
Patients want to know. Tell them about that course that you took, or the podcast that you listened to, or the experiences that you had in residency because you trained in a place where you saw a lot of patients with skin of color. Again, this transparency builds trust, and trust improves adherence, adherence improves outcomes.
Melissa: Do you have any other pearls you would like to share with dermatologists for treating patients of skin of color with psoriasis?
Dr Okoye: Sure. We take it for granted that our patients know about biologics. We’ve all seen the commercials on TV, but just don’t take anything for granted. Discuss all of the options with your patient, including the systemic medications like the biologics and clinical trials, and build that rapport and trust, and you’ll be well on your way to making a big difference.
Melissa: For clinical trials, what is needed to improve patient’s ability to just have access to be enrolling in clinical trials, and also understanding psoriasis in skin of color, and the efficacy and safety of treatment among patients with skin of color?
Dr Okoye: This is such an important question. In the 24 phase III pivotal trials of biologics for psoriasis, only four included enough African Americans to even be numbered in the study. None included Hispanic patients. Obviously, in order to improve our understanding of psoriasis in patients with skin of color, we need to ensure that they’re included in clinical trials and in research in general.
One way to do this is to include more researchers or PIs from different racial groups. These providers will likely have a more diverse patient population from which to recruit research participants. Another strategy, in my opinion, is similar to what I mentioned before, just taking the time to build rapport with patients, and especially in race discordant interactions.
It’s the trust that’s engendered, that increases a person’s likelihood of participating in research. For my colleagues, I would say, if you’ve heard of a trial for your patients’ disease, in question psoriasis, for example, mention that trial to every patient with that disease. Don’t assume that the patient won’t be interested in participating because of their race.
I think that there’s some larger issues at play here that hopefully can be discussed at the highest levels of the pharmaceutical industry. For example, some of the exclusion criteria and even the frequency and link of study visits can actually exclude certain populations from enrolling in studies in the first place.
For example, in my patient population, which is primarily African American, if you exclude patients with diabetes, that shrinks my pool of potential patients considerably. For my lower-income patients who work 9:00 to 5:00 jobs with very little flexibility, taking time off for the study visits could actually jeopardize their job, and they’re less likely to participate.
There’s a lot of work to be done on this issue, and those are just some of my ideas, my suggestions.
Melissa: Do you have any other key takeaways or thoughts you would like to add?
Dr Okoye: Yeah. Just one final thought is, we’ve been told that patients with skin of color in psoriasis, black patients, in particular, have a lower prevalence of psoriatic arthritis. I really encourage my colleagues not to hang their hats on this idea. In my experience, patients of color are less likely to be referred to a rheumatologist for evaluation, even if they’ve complained of joint pain.
They may have the same access issues with rheumatology that they do with dermatology. Please screen all of your psoriasis patients for joint pain at every visit, and refer them to a rheumatologist for evaluation, and let the rheumatologist decide whether or not they have psoriatic arthritis.
At Howard University, we collaborate closely with all rheumatologists. We share many psoriasis and psoriatic arthritis patients with skin of color, whose outcomes would be better if their psoriatic arthritis was diagnosed and treated sooner.
Melissa: Thank you so much for taking the time to do this today.
Dr Okoye: My pleasure.
Melissa: Thank you for listening. If you enjoyed this podcast or you have any questions or comments, please submit them in the feedback box below. Thank you.