PracticalDermatology

Lynn McKinley-Grant, MD, FAAD, past president of the Skin of Color Society and former Vice Chair for Diversity and Community Engagement at Duke University School of Medicine, has long worked to raise awareness of the needs of patients with skin of color. Dr. McKinley-Grant, who now is Associate Professor of Dermatology at Howard University College of Medicine and an Adjunct Professor, is working with Janssen on Determi-Nation (determi-nation.com), a health movement comprised of diverse health care providers, patients, researchers, and advocates who are applying their individual backgrounds and lived experiences to develop solutions to help people of color with psoriatic disease receive equitable and high-quality medical care.

She spoke with Practical Dermatology® magazine about the challenges and opportunities in treating psoriatic disease in patients with skin of color.

What are some of the insights that Determi-Nation has uncovered when it comes to the experiences of people of color with psoriatic disease?

Lynn McKinley-Grant, MD: The psoriasis patients involved with Determi-Nation have shared their stories with us about how they’re treated as patients, how they are misdiagnosed so often, and the impact that this has on their lives and the lives of their families. They point out things that can be corrected, which is so valuable for us as healthcare providers. Many of us have trained in different areas of the country, including areas where there are no people of color or very few. And on top of that, we’re taught with textbooks where you rarely have cases featuring people of color represented. These gaps in medical education are contributing to the higher rates of misdiagnosis and delayed diagnosis that people of color with psoriatic disease experience.

Beyond this, the Determi-Nation patients have pointed out how doctors don’t always listen to them. I see a lot of referrals of patients who have had CTCL for a while but were told they had psoriasis because they never had a biopsy. The reverse also occurs, where they were told it was lymphoma and it was psoriasis. One area of focus of Determi-Nation is to look at how we can train healthcare providers better and help equip them to recognize psoriatic disease and to treat it.

How can dermatologists be mindful of treating each patient as an individual? Do you have tips for listening better and being more attentive?

Dr. McKinley-Grant: When a patient comes in, it’s really important to first listen to the patient, hear what their chief complaint is, and the description of how their condition has manifested and what their past medical history looks like. It’s also important to really look at the whole patient. You can’t make the diagnosis of psoriasis in any patient without really looking at the whole patient.

A real, easy clue to look for is symmetry of the lesions. Lesions do tend in psoriasis to be fairly symmetrical—especially on the elbows and knees. This is not always the case, but it’s wise to look at those areas. You also have to listen to them about their arthritis, because psoriatic arthritis often can occur before psoriasis. And of course, it can occur with psoriasis, too. When they say, “Oh, no, I’ve had arthritis forever,” that might be the clue that what you’re looking at is psoriasis. If they don’t volunteer it and you don’t ask, you can’t figure it out just by looking.

I think we under-biopsy in people of color, because we’re sometimes concerned about scarring. But the most important thing is to get the correct diagnosis, so you can decide on the correct treatment.

Should patients feel more comfortable and willing to challenge the health care provider who they feel may not be listening?

Dr. McKinley-Grant: I tell patients to speak up if the doctor is not seeing what is wrong. For example, many doctors will say, “Erythema doesn’t exist in brown skin,” but it does. Erythema is a physiological process that exists; it just manifests as a different color. It’s a brown, or purple, or gray, depending on the Fitzpatrick skin type, or even depending on if the patient’s anemic or levels of oxygen in the blood. All of these things affect the color of erythema. It’s important to recognize that. If the patient sees that and you can’t, then take a closer look, touch their skin, feel where they are saying it’s red.

For doctors—and I used to do this myself and still do sometimes—don’t say “I think this is psoriasis.” Patients don’t want to hear that. That sounds like you don’t know what you’re talking about. If there is uncertainty, present it from the point of view of your expertise and present a plan. You can say, “I have never seen psoriasis look like this. I do want to make sure that this is psoriasis, so we need to do a biopsy.” If you really don’t know, then it may be beneficial to state that, but show that you’re willing to work with the patient to find out. It’s also appropriate to say, “I’m going to send you to another specialist, because I think I need some help here.”

Is there any evidence that psoriasis or psoriatic arthritis would occur with different frequency in any racial or ethnic population?

Dr. McKinley-Grant: The data show that plaque psoriasis does occur less frequently in people of color. But the severity of the psoriasis and the fact that it’s often not properly diagnosed are significant issues. The fact is that psoriasis exists in African Americans, Hispanics, Asians. Dermatologists need to look for it.

Do doctors spend enough time educating patients about psoriatic arthritis?

Dr. McKinley-Grant: It’s very important to educate your patients. The patients will gain more confidence in you if you provide them with an education and don’t talk down to them. We always try to simplify, but you can start off at a higher level and back down so that you’ll figure out where it is that they can understand what you’re talking about.

The key to psoriatic arthritis is that if you treat early, you can stop the progression of joint damage. I think that’s very important. Often, patients will come in who have had psoriatic arthritis first, and now they have this scaly rash that they can’t figure out. And their parents had the same thing. That’s important history to ask.

What is the key take-away in terms of improving outcomes for patients with skin of color?

Dr. McKinley-Grant: I think specifically with psoriasis, but with all of dermatologic diseases, we really need to listen with our eyes and our ears. It’s so important in terms of patient care to first of all, make the correct diagnosis, but also to get the patient to that bond where you earn trust. Patients need to understand they have access to resources. Most of the companies who offer treatment options like biologics have resources for patients who have difficulty with payment.

I think it’s up to the doctors to pursue that for their patients and to have people on their staff who can do it. It’s a bit of a challenge, but I think to help the patients get better, it’s a challenge that’s worth it.