Psoriasis Healthcare Barriers: Uncovering Underrepresented Patient Populations

Dr. Turck:
Welcome to DermConsult on ReachMD.  I’m Dr. Charles Turck, and joining me today to discuss healthcare barriers associated with race and ethnicity for patients with psoriasis is Dr. Amy McMichael.  Dr. McMichael is a Professor in the Department of Dermatology at Wake Forest School of Medicine in Winston-Salem, North Carolina.

Dr. McMichael, thanks for being here today.

Dr. McMichael:
Hi, it’s definitely my pleasure. Thank you, Dr. Turck.

Dr. Turck:
Well, diving right in Dr. McMichael, what prompted you to look into barriers associated with racial and ethnic backgrounds for patients with psoriasis?

Dr. McMichael:
Well, that’s a great question.  It actually stems from my experience in residency.  We used to see people of color, Brown and Black people, who had psoriasis, and they always seemed to have thicker lesions to me and didn’t seem to be as frequent, maybe, as people who were fair-skinned—in terms of their incidence of psoriasis—but, when I actually got to my work here in Winston-Salem at Wake Forest, I was doing extra research in epidemiology, and I said to one of my professors—actually, he was an internist who had become an epidemiologist—and I said, “I think I want to do my final paper on psoriasis in Black patients.”  And he said to me, “Well, I practiced in South Carolina for a very long time, had a lot of Black patients, and I never saw one who had psoriasis. I don’t think that’s a very good idea.”  And I think that that stirred something in me because I said, “Well, you may not have seen it, but I think it might have seen you,” and by that I mean that we know now, of course, from work from Dr. Joel Gelfand and others that psoriasis does occur in all skin types and is not uncommon in Black patients, and so it’s always been something that I’ve looked into and wanted to know more about.

Now in this particular study that I think we’re going to talk about today, I actually had some wonderful, dermatology fellows, research fellows, who were working with Steve Feldman, who many of us know as a international psoriasis expert, and because of my interest in skin-of-color patients and skin-of-color disease, they brought me on to the project, so it was a group effort in this case.

Dr. Turck:
Now what methods did you use to assess these barriers, and what distinguished the patient population you examined?  Who did you include in your research?

Dr. McMichael:

Yeah, so this was an interesting study.  It was what we call an mTurk study.  So it’s no play on words that your name is actually Dr. Turck, but this is a study on Amazon, where you can crowdsource information.  So you can put information out there.  You can also choose to gather information.  And that is exactly what happened is that a survey was designed to reach patients with psoriasis, both those who were Caucasian, those who were Black, those who were Asian, whatever ethnicity, and that’s how we gathered that data.  So in all, I think there are just over 300 patients in the study, so it’s an interesting and neat way of doing research.  Some journals are not fond of this way of doing it because it’s not truly epidemiologic in nature, but it does get you to some of the important things that people think about with skin disease.

Dr. Turck:
For those just tuning in, you’re listening to DermConsult on ReachMD.  I’m Dr. Charles Turck, and I’m speaking with Dr. Amy McMichael about her research on healthcare barriers associated with race and ethnicity in psoriasis care.

Now that we have some background on your research, Dr. McMichael, what were the key findings?

Dr. McMichael:
Well, I think that it was quite interesting that there weren’t a significant number of differences in the factors that we studied anyway between patients with skin of color and Caucasian patients.  The one thing that was really quite impactful for patients who are Black though is that they wanted to see more physicians who could speak to their cultural and ethnic backgrounds, and I think that that’s something that we’ve seen over and over again in dermatology particularly.  But as far as distance traveled to clinic, there wasn’t any significant difference in terms of ability to get treatment.  There wasn’t a significant difference, so we’re not seeing that patients, at least in this survey study, that they were really significantly off the bar when it came to how their disease felt and how it was being treated, but it was right at that point where you have a provider that maybe doesn’t understand everything about your skin that they were concerned.  And of course, we know that that’s important because we know from lots of other studies that racial concordance can actually improve compliance and outcome in a lot of diseases, not just skin disease.

Dr. Turck:
And looking a little bit more into racial concordance, how would you say that impacts the overall quality of the healthcare experience for our patients with psoriasis?

Dr. McMichael:
Well, I think my goal really and truly is to get everyone who’s in dermatology to the point where they can take care of every type of patient.  That’s the goal.  I certainly take care of skin cancers all the time.  They primarily form in people who are fair-skinned, and I don’t think it would seem like it makes much sense for me to say, “Well, because I’m Black, I don’t take care of skin cancer.”  Well, we shouldn’t use that excuse for other cultural kinds of things.  There’s no reason that we can’t learn it.  We’re all very smart people.  We do a lot of studying to get where we are.

So while I think that we have a clear desire for patients to see more of themselves reflected in their caregivers, I think it certainly is important to get more people of color in our specialty because right now we’re around about three to four percent African American dermatologists, where as our US Census suggests that the population is about 14.5 percent in the country in terms of African Americans.  So we’re certainly nowhere near the US Census percentage, but at the same time, I think we all need to extend ourselves a bit to understand all cultural kinds of things, at least those that we can understand and ethnic kinds of issues because I think that just makes us all around better doctors.

Dr. Turck:
And are there any other recommendations you have for healthcare providers to help mitigate disparities in psoriasis care?

Dr. McMichael:
Oh, absolutely.  I don’t think we really got to it in this study, but I think that there are enough studies right now to let us know that, number one, we know that patients who are African American often don’t have access or don’t get access to biologics as frequently as those who are Caucasian do, and I think that’s something that we really need to close the barrier on.  And we’re not sure all the factors that go into that.  Some of it may be access, some of it may be what’s offered to patients or how the treatments are explained to patients and how maybe there’s some fear around taking medications that are not clearly explained.  So I think we have to do a better job of that.  And also, I think that when we look at caregivers research, and we’ve done some of that as well at Wake Forest, the caregivers really do feel like a lot of times the lesions, the actual lesions that African American patients have for psoriasis are much more lichenified; they’re thicker; they’re harder to treat with topicals; and which makes the idea that they’re not getting access to biologics and other systemic medications easily, a little bit hard to swallow.  These are patients that have very recalcitrant lesions, yet they’re not getting the care that they need.

So I think, number one, we need to recognize the types of lesions that patients of color present with when they have psoriasis.  Sometimes they’re not bright red, they’re not super scaly, they may be violaceous or hyperpigmented; and then they’re also quite thick and may take more than a topical approach, even at the get-go when they’re first seen.  And then we need to improve access.  So I think there are a lot of places that are points of improvement for getting this population where they need to be in terms of psoriasis.

Dr. Turck:
Now before we close, let’s look ahead.  What other research still needs to be done to improve the healthcare experience for patients with psoriasis from diverse racial and ethnic backgrounds?

Dr. McMichael:
Well, I think that the recent study, looking at guselkumab in patients of color, which was called the VISIBLE study, really gave us a bird’s-eye view of how research can be done.  So this was a study that took a medication that had already been approved for psoriasis shown to be effective in the treatment of this disease, but didn’t have a lot of patients of color in the original study.  So this study was simply only patients of color, both looking at the scalp, as well as the body, disease, and it was interesting because this study recruited patients in record time, so it actually ended early.  The patients did extremely well on the medication, and now we have a composite of all these patients with skin of color in terms of what their psoriasis looks like, so I think that’s where research needs to go.  I think we need to be more effective in how we recruit.  We need to recruit diversity into our studies.  It needs to be built in, and it needs to be a requirement for every site that you go to, at least many of the sites that you go to for clinical trials as we move forward.

Dr. Turck:
Well, this has been a great discussion of some of the healthcare barriers that exist for our patients with psoriasis, and I want to thank my guest, Dr. Amy McMichael, for sharing her insights.

Dr. McMichael, it was great speaking with you.