Psoriasis Disparities Among Different Racial and Ethnic Groups

Dr. Chovatiya:
Welcome to On The Frontlines of Psoriasis on ReachMD. I’m Dr. Raj Chovatiya, Associate Professor at the Rosalind Franklin University, Chicago Medical School, and Founder and Director of the Center for Medical Dermatology and Immunology Research in Chicago. And with me today to talk about disparities in psoriasis among different racial and ethnic groups is none other than Dr. Tina Bhutani. Dr. Bhutani is an Associate Adjunct Professor of Dermatology at the University of California San Francisco School of Medicine and owner of Synergy Dermatology in beautiful San Francisco. 

Dr. Bhutani, welcome to the program.

Dr. Bhutani:
Thank you for having me.

Dr. Chovatiya:
So first, Tina, can you give us an overview of what kinds of disparities exist in psoriasis?  When I use the word disparity, I know it can mean a lot of different things. What does that mean to you when it comes to psoriasis?

Dr. Bhutani:
­Well, there’s a few different factors. So let’s start with the disease itself. One area where I think disparities exist is in diagnosis of the disease, for example. So what we understand now is that oftentimes patients with skin of color are diagnosed at a later stage than our Caucasian patients, and what that means is that they might walk into the office with more severe disease, more comorbidities, more manifestations of the disease, like psoriatic arthritis.

I think another area is when it comes to treatment of psoriasis is disparities in access to treatment, and also willingness to use certain treatments. So for example, there was a study done out of UPENN, which showed that, for example, Black patients are less willing to treat their psoriasis with systemic medication, so they have more severe disease, but they’re less willing to take systemic medications, and there’s a lot of factors involved there.

And then lastly, I think it’s representation in our literature, in our education materials. I think there’s a lack of representation of skin of color in a lot of psoriasis education aspects.

Dr. Chovatiya:
And maybe you could tell me what some of the main factors are that contribute to these larger categories of disparities. I know that you touched on race, and I’d love for you to talk a little bit more, but maybe broadly about the entire system and structure of thinking about what’s involved in these disparities.

Dr. Bhutani:
Well, I think first of all, with many different, racial, ethnic groups, but also cultural factors come into play here, and so what we know is across the board that oftentimes patients with skin of color are less likely to have touchpoints with the healthcare system.  There is, first of all, maybe it comes down to things like insurance coverage and the types of insurance but also trust in the healthcare system and hesitancy, trying home remedies, things of that sort so they have less touchpoints, and I think that contributes again to that delayed diagnosis, maybe that unwillingness to treat with our Western medicine.

Dr. Chovatiya:
When I think about disparities in psoriasis among other inflammatory diseases, it’s very convenient that we end up using categories, like race, ethnicity in part because it’s the way our research is structured with the epidemiologic factors we look for. But as we know, these are complex, multilayered variables that probably are not homogeneous in nature.  And I want to get your take on how does all of this feed into some of the differences in severity that we think about across groups, both racial and ethnic, and other ways to really categorize our patients?

Dr. Bhutani:
Well, I guess one factor that will come into play is genetics. So there might be differences in the genetics of the disease between different racial ethnic minority groups, so that’s one thing that’s built in. But also, like you just said, due to social determinants of health and other structural inequities, these patients are reaching us at a later point. They might go treated by their primary care doctor for a little bit longer or don’t have access to a dermatologist. There’s still many parts of our country where there aren’t as many dermatologists practicing, and so patients just can’t get in to see us. And so what that leads to is again, finally, when they do present, leading to more severe disease. 

I already talked about the mistrust, so they might not be using treatments. Even if they were prescribed the right treatments, they might not have gotten the education around how best to use them, making them feel more comfortable with those treatments, and so again, they will present with worse disease severity.

Dr. Chovatiya:
For those of you just tuning in, you’re listening to OnThe Frontlines of Psoriasis on ReachMD. I’m Dr. Raj Chovatiya, and I have the privilege of speaking with Dr. Tina Bhutani on the disparities in psoriasis. 

So with the disparities that we discussed earlier in mind—and we talked about those big categories of access, education, among other things that were important—what could we as healthcare providers do to reduce these disparities for our psoriasis patients? What are the kinds of things you think about the individual can implement into their day-to-day practice? And maybe as a healthcare system as a whole, what can we do?

Dr. Bhutani:
I think no matter how hard we try, unfortunately, I think there is this unconscious bias oftentimes when we are seeing patients or providing recommendations for treatments and things related to that. So I think one thing we can do individually as healthcare providers is to just really provide our patients or educate our patients about the disease, why it’s important to treat the disease, and then what treatment options are available and keep that part very unbiased, and then let the patients tell you, and listen to them, what they’re saying, let the patients tell you, what treatments they might feel comfortable with and what are the reasons. And if you don’t think that’s the right treatment for that patient, then you would chime in, and tell them, “Well, I think you might need more because of this,” and then try to make them more comfortable with the treatment. So I think just again it comes down to spending time in the room with the patient. I know that’s oftentimes the hardest thing to do, but it really can make a huge difference I think for our psoriasis patients.

And then as an overall healthcare system question, I think that could be a whole other podcast on its own, but we understand that there are problems with getting access to care and treatments for many patients, and so I think we need to be more cognizant to that. We need to, first of all, I think, be enrolling more diverse populations into our clinical trials, which will then, hopefully, help with future access. I think we need to create more access to specialties for our patients, and then again, come up with maybe more equitable programs for providing medications to patients—not ones that, for example, will restrict government health plans and things of that sort.

Dr. Chovatiya:
You touched on a really nice point as somebody like yourself who’s done a lot of research when thinking about even starting at the point of our studies before we even get to medications, and I always wonder—do you think that there is a future for really figuring out ways that we can decentralize not only our studies but our care so we can reach individuals that, perhaps, need it more? And this goes beyond even race when thinking about just general socioeconomic barriers that sometimes prevent our most severe patients from making it to us at a regular interval.

Dr. Bhutani:
Yeah. I really hope so, and I think we’re on our way there, not so much in research as much but in our clinical care. Thanks to COVID, telemedicine has really become a true entity, and we’re using it quite a bit. Could we utilize it more? Yes. And I think that’s going to come down to, again, providing the infrastructure for doctors to provide that and providing incentives for people to do that. But yeah, I hope we’re on our way there.

Dr. Chovatiya:
And you touched a lot on education earlier, and I want to return to that point because it’s an important one. And you’re someone I know who’s tirelessly worked to help educate the community when it comes to thinking about psoriasis for a good long while, and maybe you can tell me how you might think about tailoring not only education to patients to better support some of our affected populations but also to other healthcare providers because I know while the two have some similarities, there are some differences in terms of what we need to do to help uplift our patients but also uplift our fellow dermatologists.

Dr. Bhutani:
Yeah. One thing that’s really important for me for patient education is actually, I already talked about verbally talking to patients, but showing them photographs and pictures I think can be really impactful because when we’re talking about improving psoriasis to a patient, in their head, they might think they’re going to go from a lot of psoriasis to maybe a little bit less psoriasis. But if you can show them photos of their disease, completely clearing up after taking some of these medications, I think that’s a total game-changer when patients see these photos. I also like to show them the photos because I like them to understand that, for example, patients with more pigment in their skin might actually have some manifestations left over, like post-inflammatory hyperpigmentation or hypopigmentation, and so it might not mean completely having no sign of psoriasis left over. They might still have footprints. And so again, I like to show them that too so that they’re prepared that might happen. 

And I think that’s the same for healthcare providers. So first of all, we need to be better about including more diverse photographs in our textbooks, and we know that there are studies that show that our current educational material is just not diverse enough, and I think that will help again, hopefully, prevent delays in diagnosis, will get people the right diagnosis quicker, and that usually means getting them treatment faster. And then again,  talking to them about what to look for, what signs to look for as they’re treating patients, and if things are not going well, what other things should they be thinking about because we all have been wrong. We think something is psoriasis, and it turns out it’s not, and so  educating them on what to look for there.

Dr. Chovatiya:
So before we end this amazing discussion today, maybe you can take a glimpse into the future for us, and what impact do you think better care for our patients that face some of the biggest barriers may actually have on their quality of life? What could good look like five, 10, 20 years from now?

Dr. Bhutani:
Yeah, I think you know better than anyone that this is a topic that’s near and dear to my heart because a lot of my research over the years has focused on improving quality of life and mental health for patients, but in particular, diverse populations. And so, I think again, if we can improve a lot of the things that we talked about; access, treatments, education, I definitely, can see improvements in quality of life and people just living better with their disease, living healthier with their disease, and so that’s always a goal.

Dr. Chovatiya:
This has been such a great discussion on the disparities that exist among minority patients in psoriasis world, and I really want to thank my guest, Dr. Tina Bhutani, for sharing her insights. Dr. Bhutani, it was amazing speaking with you.

Dr. Bhutani:
Thank you. Always nice talking to you.

Dr. Chovatiya:
You’ve been listening to On The Frontlines of Psoriasis on ReachMD. To access this and other episodes in our series, visit On The Frontlines of Psoriasis on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.