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Pearls in Psoriasis: Treating Patients With Skin of Color

In this episode, Larry Green, MD, interviews Seemal Desai, MD, about identifying and treating psoriasis in patients with skin of color, as well as what the field of dermatology can do to improve patient care and access for this patient population.



Dr Larry Green: Hi, everyone. Welcome to another podcast. My name is Larry Green. I am section editor of The Dermatologist's Psoriasis Center of Excellence, and Clinical Professor of Dermatology at George Washington University School of Medicine in Washington, DC.

We're fortunate to have with us on the podcast today Dr. Seemal Desai, who is president and medical director for Innovative Dermatology, PA in Plano, TX, as well as clinical assistant professor of dermatology at the University of Texas, Southwestern. Dr. Desai served as the Skin of Color Society president from 2017 to 2019.

Today, we'll be discussing a very hot topic, which are the presentations and treatment of psoriasis among patients with skin of color. Thanks, Seemal. Thanks for joining us, and thanks for being here and explaining all this.

Dr Seemal Desai: Thanks for having me, Larry. I'm excited to be with you.

Dr Green: Let's get right into it. Patients with skin of color in the United States definitely face barriers to care. Could you discuss some of these barriers that dermatologists should keep in mind?

Dr Desai: Absolutely. Patients who have psoriasis in general are continuing to increase in numbers in terms of the numbers of patients seeking the care of a board‑certified dermatologist.

The problem is, in my practice, which predominantly focuses on skin of color, revolves around the fact that many of my patients who have plaque psoriasis end up coming to see me much later in their disease course, by which time they're either suffering from post‑inflammatory hyperpigmentation, extensive disfiguring of the skin including lichenification, and then even long‑term manifestations of the disease that could have been prevented had we treated it earlier on, such as psoriatic arthritis and even nail involvement.

I think for me and our patients with psoriasis and skin of color more broadly, we need to educate patients and the healthcare community that patients of color who deal with psoriasis need to be identified, and addressed, and treated earlier in their disease course to have better treatment outcomes.

Dr Green: What do you think is part of the reason why these patients are coming to us later on? Is the barrier part of us? What are we doing to prevent them from accessing our care?

Dr Desai: I think that's a really important point, Larry, and I think there's multiple layers to that. Obviously, doing even a podcast like this with you is a great step in increasing the awareness of the board‑certified dermatologists physician community to make sure that we're treating these patients earlier and aggressively.

I think some of the nuances of treating our patients with skin of color with psoriasis in particular, and also actually with atopic dermatitis and even other skin diseases, is the fact that many of these patients come from underrepresented minority backgrounds and may not have the same access to healthcare in general. They may not have access to a primary care physician who knows when to refer to a board‑certified dermatologist.

They may not even know that they have a chronic skin disease that can be treated. I've had many patients with skin of color come in, who have psoriasis and were just told it's dry skin or it's ashy skin. It's eczema. It's just itchy, it'll go away. Just put moisturizer on it. This has been going on for years.

The patient actually comes in eventually having been...They're so used to having the skin disease that they're not even worried about that anymore. What they're more worried about is the dispigmentation and how to make their skin just look better. Then when we have the dialogue that no, you actually have an inflammatory skin disease that has systemic comorbidities. Let's talk through those.

I will say that also in my patients with skin of color, I see higher rates of those systemic comorbidities such as diabetes and metabolic syndrome. I know that many of my patients who come to me also tend to have poor health outcomes, because we need to treat that patient holistically and more broadly.

Those are just some of the nuances, but I think educating the public about what we as board‑certified dermatologists do in skin disease is number one. Helping reduce health disparities is a second. Increasing awareness for primary care physicians and knowing when to refer, and then making sure we're looking at these patients holistically.

Dr Green: I think it's a very good point, Seemal, especially when it comes to looking at potential comorbidities in our patients with skin of color who have modern to severe psoriasis. That's something, as dermatologists, we don't think about all the time or when we should be thinking about it. Not everybody we should think, but especially in patients with skin of color.

Dr Desai: Completely agree with you, Larry. I think whatever we can do to continue to increase our dialogue, interaction, and education with each other on this, both in the derm community and then more broadly, is really important.

Dr Green: Let me delve a little more into treating patients with skin of color who have psoriasis. Studies have shown that black patients with psoriasis are less likely to receive biologics or know about biologics compared with white patients, even after adjusting for insurance. Why is that happening, do you think, and what can we do to change this?

Dr Desai: Again, I think to your point, it's multifactorial. I think psoriasis, what we're focusing on today, is just one, getting disease prototype, but a lot of what we're talking about, as you know in clinical research, transcends many different inflammatory diseases, atopic dermatitis, vitiligo, alopecia, all of these skin diseases. I think the more outcomes data we can have, the better we can advocate to payers and insurance companies to make sure we have the treatments.

The critical part of this in my opinion is that we really need to ensure that we also enroll more patients with skin of colors in the clinical trials and have clinical sites where they are doing research, like your practice and my practice, making sure investigators are looking for these patients so that you get them in the studies. If you get them in the studies, then you have the data to then go to the FDA and the payers and say, "listen, this is why this patient needs this more than maybe someone else."

Dr Green: It's interesting you mention that. It goes all the way back to clinical trials and getting the amount of skin of color patients in the studies, enough to get it large enough and to get data to the FDA so the FDA can say. The FDA is not going to say that it's been safe to use a patient with skin of color if they don't have the evidence.

Dr Desai: Exactly.

Dr Green: Right. That's something I know was a huge push but has to continue and really continue in clinical trials like you and I do, to make sure we get the outcomes that we have. That's happening now and it's topically in the COVID vaccine trial. We want to make sure the same thing, we have enough skin‑of‑color patients, patients of all ages, all types, to know the vaccine is safe for everybody. You don't want to have anything left to chance.

Dr Desai: I agree. I will mention, Larry, that the FDA, to their credit, has been much more demanding on companies and sponsors and industry to include patients of color into clinical trial. Having that clinical trials data, in fact they just recently released some guidance on helping to further recruit minority populations broadly in clinical studies in all of medicine. I hope this continues and we can be part of that too in dermatology.

Dr Green: Do you think there's anything else we're missing in clinical trials that can improve our understanding of psoriasis and treatment? Anything else besides what the FDA is doing?

Dr Desai: Yes. One thing that I'll say, and this may be a little controversial, but I think you'll know where I'm coming from this, especially for those of us who've lived in the trials world. I think that we also need to be much more demanding and selective on our CROs, and picking CROs that then know how to vet appropriate investigators and sites that have patients with skin of color.

If you're going to keep doing clinical trials in one part of the country where there is really very little diversity in population, you're not just going to be able to enroll those patients. That's not the investigator's fault. That's a geographic and a practice setup concern and constraint. That's no one that we can point fingers at, but what we can say to the CRO is you all need to be looking for sites and investigators that you inherently know are interested in doing this.

I think the other part of this is as we continue our push with the Skin of Color Society and with the AAD to increase our workforce of dermatologists of different backgrounds, we need to also train more younger dermatologists to go into clinical trials, who are of a skin of color background or who are interested in skin of color so that they then know how to recruit those patients. I think there's really a lot of layers here that we can help to dive into.

Dr Green: Yeah. You bring up a really good point too in that the investigators themselves has to be trained. You're a board‑certified dermatologist, FAAD, Fellow of the American Academy of Dermatology, which fit that bill, but CROs don't always pick these people like us to be investigators.

If you're looking at selecting psoriasis and determining severity of psoriasis and other chronic inflammatory diseases besides psoriasis in skin of color, you have to have experience. You have to know how to do all that. That goes back to the CRO, just like you were saying.

If they aren't going to pick people who are correctly trained, because we know they don't always pick the board‑certified dermatologists, member of the American Academy of Dermatology‑type investigator who knows how to do all of this, who knows what psoriasis looks like in skin of color, looking at the severity of psoriasis in skin of color, and same thing too with atopic dermatitis. Very good point.

Dr Desai:   agree with you. To your point, for psoriasis in skin of color, it can look very different from psoriasis in lighter skin tones. You know this, and I see this every day, because this is what I do, but lots of my psoriasis skin‑of‑color patients, they don't have silvery scale. Their lesions are not as thick. They're not as erythematous. They tend to be more violaceous and purple.

Believe it or not, I see a lot of times, my patients with psoriasis skin of color, they actually look like lichen planus lesions many times.

Dr Desai: You've probably seen that too.

Dr Green: Yeah.

Dr Desai: Especially in the DC area, you see a lot of diverse patients.

Dr Green: Yes.

Dr Desai: Morphology and clinical picking up on those clues is really important. Obviously, the Skin of Color Society is working really hard at education on images and skin of color.

We just recently, by the way, completed a landmark series of webinars with The New England Journal of Medicine and VisualDX that just concluded a series of four educational webinars on skin disease in skin of color, but not just for dermatologists. It was for the whole healthcare community. We had close to 9,000 people register from around the world for this. Spreading this kind of messages, what we're doing today, I think is really important.

Dr Green: That's great. You talk about clinical presentations differing. Is there anything you want to say in terms of adding how psoriasis in skin‑of‑color patients can be different? Yes, I think it's very interesting you brought the lichenified look and the violaceous lichen planus and actually lichenified too sometimes look of psoriasis. Any other presentations you want to bring about that may be different or...?

Dr Desai: Yeah, absolutely. I think scalp psoriasis in our patients with skin of color, particularly African American descent patients and even Southeast Asian patients where the hair type and hair quality is different, scalp disease is very nuanced in many of these patients. I've seen patients who have psoriasis and they initially were just told they have seborrhea and dandruff, but if you really delve in there and you look through the hair and the scalp, it's actually psoriasis. Sometimes, you have to biopsy these patients. I don't hesitate to do biopsies on inflammatory skin disease in my skin‑of‑color patients, because a lot of times, I've been fooled, and I do this all day long and I'm an expert at it.

The other thing I'll mention is there's a rare variant of psoriasis called follicular psoriasis. I know you've heard of these in our psoriasis meetings before. Follicular psoriasis actually has almost a keratosis pilaris, a very lichen, very spiny papules. You biopsy one of those papules, you'll see classic histologic changes of psoriasis just at the follicles. That's been reported more in skin‑of‑color patients. A lot of case reports of that in the Middle East and in India.

Then also, we have patients who in skin of color tend to also have more of the sebopsoriasis presentation. Again, tying in to making sure you want to look at intertriginous areas for clues. Don't just look at elbows and knees. Look under the breasts. Look in the groin. Look in the gluteal creases.

Make sure you're looking for subtle findings. Not necessarily erythema, but looking for areas that either look itchy, excoriated, and maybe even macerated.

Dr Green: Thanks, Seemal. Let's wrap up. You've done a great job explaining everything. Is there anything else you want to add that you think I've missed help us in treating psoriasis patients with skin of color?

Dr Desai: I really appreciate the opportunity to talk about this. One of the things we need to work on is getting more outcomes data. I will mention that there is some interesting prevalence data out of Africa and Asia that talks about how different geographic communities even in the same part of the world have very highly different rates of prevalence.

If you compare Japan, and Hong Kong, and Singapore, vastly different rates of psoriasis in skin of color, even though you're dealing with a fairly homogeneous Asian type population. Why is that? We don't know. We need to figure out if that's genetic, if it's epidemiologic, what's going on? 

Even in Africa, by the way, where you have patients of a very homogeneous skin type V to VI population, in general, East Africa compared to West Africa, much different rates of psoriasis. Countries like Kenya, and Tanzania, and Uganda on the eastern side of Africa, much higher rates of psoriasis than Nigeria, and Ghana, and Togo on the western side. Why is that? Possibly some dietary things linked to linoleic acid has been postulated, which tends to be more protective as an anti‑inflammatory.

I think there's a lot more work we need to do, and having discussions like this, I think, really helps us whet our appetites to do that.

Dr Green: Yeah. Back to the bench, back to clinical trials for us.

Dr Desai: That's right.

Dr Green: Thank you very much. Thanks, Dr. Desai for going over all this, and appreciate all the insight you've given us.

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