Study: Psoriasis Patients with Skin of Color Wait 3x Longer for Diagnosis

Announcer:
You’re listening to On the Frontlines of Psoriasis on ReachMD. And now, here’s your host, Dr. Charles Turck.

Dr.  Turck:
Welcome to On the Frontlines of Psoriasis on ReachMD.  I’m Dr. Charles Turck, and joining me to discuss a study that investigates racial disparities in the diagnosis of psoriasis is lead author Dr. Taylor Dickerson.  She’s a board-certified dermatologist and micrographic dermatologic surgeon at U.S. Dermatology Partners in Texas.

Dr. Dickerson, it’s great to have you here today.

Dr. Dickerson:
Thank you, Dr. Turck.  So excited to be here today with you all.

Dr. Turck:
So if we could start with some background, Dr. Dickerson, would you tell us what prompted you to conduct this study?

Dr. Dickerson:
So I was at LSU for my medical training and residency, and we’re not a big research institution, and so some of the thought was, “Okay, what do we have here unique in New Orleans that, say, some of these other big schools don’t have?”  And one of those things was patients with skin of color.  That’s the majority of patients that we would actually see during the day.  And if you look at the time of when we did our paper, it’s kind of when some of the social injustices and things were really in the news all the time, and we realized, as dermatologists, most of our learning and atlases were all in Caucasian patients and lighter skin tones, and so we really felt that there might be something there, and so we really just started a big chart dive into looking at the Caucasian patients—non-Hispanic—versus patients that we called skin of color, or SoC patients, at our institution.

Dr. Turck:
And what else can you tell me about how your study was designed?

Dr. Dickerson:
So it was essentially just a chart review series.  So we dove into the hospital EMR system and pulled patients that had a diagnosis code of psoriasis on their chart, and that could have been put in by anybody, but then we filtered that out by patients that eventually made their way to the dermatology department.  We looked at just very basic characteristics, so when were they seen? How old were they? What was their sex? What type of psoriasis did they have because there’s several different presentations? And how long did it take for them to get diagnosed? Were they biopsied? Were they not?  And then we had patients that were self-identified as far as their race and ethnicity.

So one of the interesting things that we did is we looked at how long it took us to actually diagnose some patients with their psoriasis.  So with this being a big university system, obviously, patients could be with a diagnosis on their chart seen outside of the dermatology department and carry that into our department, or they may tell us, you know, “I have psoriasis,” or “I have eczema,” but they would get a formal diagnosis with us at the end of the appointment.  So any patients that came in with a diagnosis of psoriasis and we agreed with that diagnosis, they were excluded out of the days-to-diagnosis analysis that we did, but we still had essentially half of our patients that had either just dermatitis or rash or the wrong diagnosis that we formally diagnosed with psoriasis.  And sometimes that would happen the very first visit, and so their days to diagnosis of psoriasis would be zero days, and in other patients, it would be significantly longer, and maybe they never returned to clinic, etc. etc.

Dr. Turck:
Is there anything else we need to know about the patients who were included in your research?  Were they all adults?

Dr. Dickerson:
They were all adults, yes, so everybody was 18 and older.  This is in an adult hospital where we were.  It’s an academic institution, so that’s a catch-all, so a lot of socioeconomic things kind of come into there.  We did have some private patients, but for the most part, those were going to be government-funded, like Medicaid patients.

Dr. Turck:
For those just tuning in, you’re listening to On the Frontlines of Psoriasis on ReachMD.  I’m Dr. Charles Turck, and I’m speaking with Dr. Taylor Dickerson about her study that investigated racial disparities in the diagnosis of psoriasis. 

So, Dr. Dickerson, now that we have a better understanding of the background and design of your study, let’s focus on the findings.  What did you discover about the presentation and diagnosis of psoriasis in skin-of-color patients?

Dr. Dickerson:
So one of the biggest take-homes that we found was patients who had skin of color were going to get biopsied more often than White patients, which I really think just boiled down to our failing as dermatologists of not being as easy to recognize a skin condition in a darker skin tone. Our skin-of-color patients almost four times were more likely to be biopsied to get to that diagnosis of psoriasis. You know, as dermatologists, we really pride ourselves on walking in the room, looking at it, and telling the patient what it is, and we just had a lack of resources.  There weren’t as many atlases on that, and the presentations are different.  They’re not the same.  So patients who had darker skin tones were getting mislabeled with the wrong diagnoses, so they were not being treated appropriately, and they were obviously having to endure biopsies if it took us to that to figure out what was going on with them.

Dr. Turck:
Now taking this a little bit beyond the diagnosis, how do you imagine these racial disparities impact outcomes in our skin-of-color patients?

Dr. Dickerson:
The patients had a significant delay in care, so that was kind of another big point and take-home from our study as these patients were waiting three times as long to receive their official diagnosis of psoriasis.  So essentially, they would present to the dermatology department with a diagnosis of dermatitis unspecified or maybe even as atopic dermatitis or eczema or a different skin presentation, and then they would finally get biopsied because things weren’t progressing as they should have, and those biopsies would end up being consistent with psoriasis. We had been just mislabeling them the entire time.  It was taking, I believe, on average 180 days to diagnose a skin-of-color patient, and it was closer to 60 for our Caucasian patients.

Dr. Turck:
And were there any other notable or surprising findings to come out of your study?

Dr. Dickerson:
Another surprising one, which I guess not that surprising considering how we were not diagnosing these patients effectively, is they were presenting with more severe disease.  So severe psoriasis is defined as if more than 10 percent of their body surface area is involved, and obviously, with a delay in diagnosis, the disease is progressing, and so skin-of-color patients often have significantly more surface area than 10 percent.  I mean, we even had some that were almost covered head to toe, but it wasn’t being appreciated.  And then a unique presentation of psoriasis is really the palmoplantar skin involvement.  It’s a pretty tough area of psoriasis to treat.  And those, in fact, when you would biopsy them, it wouldn’t even be a clear-cut answer to psoriasis or not, so sometimes it was a little bit of trial and error with using medications for patients to get those problems addressed for them.

Dr. Turck:
Now as we come to the end of our discussion today, Dr. Dickerson, how might these findings impact our approach in clinical practice in managing patients with psoriasis?

Dr. Dickerson:
I think the biggest take-home, especially if you’re someone looking at skin, is look at different skin.  I know when I am training people, I pull them in specifically and show them, you know, in someone who is White, this would be bright red, but this patient has a much deeper skin tone, so this is going to be more purple or violaceous, we call it, or, you know, it might not be quite as scaly.  And one of the interesting findings we found is most of the time psoriasis isn’t a very itchy condition, but for whatever reason, it’s almost like our skin-of-color patients had significantly more itching, which was throwing off diagnosing them because eczema is typically itchy, not as classically psoriasis.  But skin-of-color patients had significantly more itching, which led to more morbidity, so we just need to really expand our education.  And then even though it’s not fun for a patient to biopsy, if you’re not getting where you think you should be, biopsy them.  Get more objective data to help you because in the long run, that’s going to help the patient with their quality of life: treating the correct condition.

Dr. Turck:
Well, with those final thoughts in mind, I want to thank my guest, Dr. Taylor Dickerson, for joining me to share her research and perspectives on addressing racial disparities in psoriasis care.  Dr. Dickerson, it was great speaking with you.

Dr. Dickerson:
Thank you so much for having me.  It was a pleasure.

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