PracticalDermatology

The label skin of color has been utilized and recognized across academic medical journals and health care professionals to inclusively characterize and differentiate non-white identifying individuals from their white counterparts. This term skin of color was intended to refer to a broad group of individuals with colored skin who are of African, Asian, Native American, Middle Eastern, and Hispanic descent.¹ However, within the dynamic field of dermatology, this term has developed a divisive connotation and association with patients to describe and represent only those with darker skin tones who mainly identify as Black. Furthermore, it can indicate racial biases and undermine the existence of patients with brown and lighter beige skin tones who identify with other ethnic backgrounds: Hispanic/Latinx, Asian/Pacific Islander, Middle Eastern, and Native Indian. For this reason, dermatologists and clinical researchers should incorporate a more inclusive and culturally sensitive form of diction when referring to people of all different skin tones with the term diverse skin tones. This choice of language aims to accurately represent patients, holistically, from a biological and cultural perspective. It takes into consideration, not only, all racial and ethnic backgrounds but the understanding that colored skin is defined as non-white pigmented skin encompassing a wide spectrum of hues and tones. Ultimately, this term strives to create a more inclusive approach by acknowledging all types of skin tones in patients and further minimizing the cultural biases and racial implications that tied to our country’s complex history of race and racism.

Underrepresentation of Ethnically Diverse Patients with Psoriasis

Based on the 2011-2014 data from the National Health and Nutrition Examination Survey (NHANES), the prevalence of adults with psoriasis in the United States was estimated to be 3% with no significant change since the first evaluation in 2003-2004.^2,3,4 Psoriasis presents in Asians at 2.1%, and at a significantly lower percentage for Hispanics and Blacks at 1.9% and 1.5%, respectively, compared to 3.6% in Caucasians, according to the National Psoriasis Foundation and NHANES.^2,4,5 Given these reports, most individuals with psoriasis identified as Caucasian, which continues to accentuate the lack of representation for non-white patients with psoriasis from ethnic backgrounds.

The lack of representation for these underserved ethno-racial groups in clinical data and research is one of the underlying factors contributing to physicians’ challenges with effectively treating, identifying, and diagnosing psoriasis in patients with diverse skin tones.

Clinical Presentation of Psoriasis in Diverse Skin Tones

Psoriasis in patients with diverse skin tones is often misunderstood, overlooked, and mistaken for other common skin conditions that are more prevalent in darker skin types such as atopic dermatitis, lichen planus, and mycosis fungoides.⁶ There is limited clinical training and reference material available to dermatology residents and professionals that provides quality clinical images of psoriasis presentation on all different skin types.⁷ There will be a continued lack of confidence and competency when diagnosing psoriasis in patients with diverse skin tones without proper representation and cultural training on psoriasis in diverse patient populations.

This is apparent due to the prominent physical characteristics that psoriasis and its subtypes manifest on pigmented skin that would not normally be seen on white skin.^3,5,6 The notable hallmark differences for psoriatic patients with diverse skin tones are post-inflammatory dyspigmentation resulting in hypo- or hyperpigmented patches, raised and thickened plaques, a violaceous gray hue, minimal noticeable erythema, silvery-white scales, and extensive disease involvement.^1,3,4

Addressing Health Disparities and Inequities in Psoriasis Care

There is a plethora of social determinants that psoriatic patients from diverse ethnic backgrounds face, more so than their white counterparts, which negatively influences their overall health outcomes such as financial insecurities, quality of education, and access to transportation.⁷ As a result, clinical dermatology is faced with a bigger burden having low numbers of ethnically diverse psoriasis patients with diverse skin types receiving consistent care and being observed for safety and efficacy of new treatment options, thus exacerbating the unmet needs of this underserved patient population.

It is essential that dermatologists and clinical researchers continue the conversation to implement more effective ways to increase access to clinical trials, address cost barriers to treatment, and provide consistent psoriasis care for people from all ethnic backgrounds. A greater focus on these health inequities will serve to close the gaps in cultural competency, patient education, diagnoses, and treatment for psoriatic patients with diverse skin tones.

1. Kundu RV, Patterson S. (2013). Dermatologic conditions in skin of color: part I. Special considerations for common skin disorders. American family physician, 87 (12), 850–856.

2. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CE. (2021). Psoriasis prevalence in adults in the United States. JAMA Dermatology, 157(8), 940.

3. Kaufman BP, Alexis AF. (2017). Psoriasis in skin of color: Insights into the epidemiology, clinical presentation, genetics, quality-of-life impact, and treatment of psoriasis in non-white racial/ethnic groups. American Journal of Clinical Dermatology, 19(3), 405–423.

4. Nicholas MN, Chan AR, Hessami-Booshehri M. (2020). Psoriasis in patients of color: Differences in morphology, clinical presentation, and treatment. Cutis. 106(2S).

5. Koons S. (2021, February 16). Psoriasis and skin of color. National Psoriasis Foundation. https://www.psoriasis.org/advance/diagnosing-psoriasis-in-skin-of-color

6. Kim WB, Jerome D, Yeung J. Diagnosis and management of psoriasis. Can Fam Physician. 2017;63(4):278-285.

7. Yadav G, Yeung J, Miller-Monthrope Y, et al. Unmet need in people with psoriasis and skin of color in Canada and the united states. Dermatol Ther (Heidelb). 2022;12(11):2401-2413.