Dermatology: how to manage psoriasis and recognize differences in pathophysiology and presentation in patients with skin of colour

Abstract

Psoriasis is a chronic inflammatory skin condition that affects diverse ethnic groups with a wide spectrum of skin colours. There are significant differences in how psoriasis presents and impacts the quality of life in non-White individuals. Genetic variations as well as cultural and socioeconomic factors all play a role in such differences and have important implications for the management of psoriasis in skin of colour. Despite these differences, the current psoriasis management is similar across different ethnic backgrounds and is mainly guided by factors such as disease severity, medical comorbidities and patient preferences. This is largely due to the lack of sufficient evidence for psoriasis treatment tailored for patients with skin of colour as most clinical trials are composed of mainly White individuals. Therefore, the focus of this article is to review the current evidence on how epidemiology, clinical presentation and genetic differences in patients with skin of colour with psoriasis may impact treatment strategies. Additionally, pharmacological therapies available to date in these diverse patient cohorts are summarized in this article. The limited data published on this topic reveal a significant need for more investigations with the ultimate goal of incorporating recommendations for patients with skin of colour into the current guidelines for psoriasis treatment. Moreover, awareness of differences in psoriasis presentation amongst individuals with skin of colour may support patients to seek medical care sooner, which could result in earlier diagnosis and lead to improved patient outcomes.

Skin of colour: essentials for the non-dermatologist

“…With a prevalence of 2-3% and a peak incidence in young and middle-aged adults, psoriasis is another frequently encountered condition in hospital inpatients. 25 It is less common in SOC but statistics in this group might be underestimated because of a lack of research. 25 Black patients reportedly have a larger surface area of skin involved and Asian-Indian and Hispanic patients are more likely to have severe psoriasis compared with White patients.…”

“…25 It is less common in SOC but statistics in this group might be underestimated because of a lack of research. 25 Black patients reportedly have a larger surface area of skin involved and Asian-Indian and Hispanic patients are more likely to have severe psoriasis compared with White patients. 26,27 Psoriasis typically presents as well-defined plaques affecting the extensor surfaces, umbilicus and hairline in all skin types.…”

“…In contrast to the red-pink plaques seen in white skin, plaques in SOC can appear violaceous or hyperpigmented with an overlying silvery scale (Fig 4a). 25 Therefore, in patients with darker skin, active psoriatic lesions are harder to diagnose and can be mistaken for post-inflammatory hyperpigmentation (Fig 4b). 28 Furthermore, plaques in Black patients tend to be thicker with more scaling compared with those in White patients.…”

“…28 Furthermore, plaques in Black patients tend to be thicker with more scaling compared with those in White patients. 25 As in AD, patients with SOC are more prone to long-term pigmentation changes, which can be psychologically distressing and persist for years after lesion resolution. 29 Treatment for psoriasis is generally similar across patients of different ethnic backgrounds and is guided by disease severity, comorbidities and patient preference.…”

“…29 Treatment for psoriasis is generally similar across patients of different ethnic backgrounds and is guided by disease severity, comorbidities and patient preference. 25 In terms of biological therapy, minor clinical differences in efficacy and safety between races have been noted. 30 Ixekizumab is thought to provide the highest skin clearance for Asian-Indian and Latino patients, whereas brodalumab is most efficacious among black patients.…”