Psoriatic Disease in People of Color: How Can We Close the Diagnostic Gap?

Dr. Greenberg:
Psoriatic disease looks and feels different for people of color, and these differences may affect their diagnosis, treatment, and by extension quality of life.  In fact, more than 50% of people with psoriatic arthritis experience a 2-year delay in diagnosis and a lower quality of life compared to white patients.  So how can we close the diagnostic gap and provide better care for our patients of color with psoriatic arthritis?  

Welcome to DermConsult on ReachMD.  I’m Dr. Michael Greenberg.  And joining me to talk about this important topic is Dr. Lynn McKinley-Grant, who’s an Associate Professor of Dermatology at Howard University College of Medicine. 

Lynn, welcome to the program. 

Dr. McKinley-Grant:
Thank you.  It’s a pleasure to be here. 

Dr. Greenberg:
It’s a pleasure to have you.  So to start us off, Lynn, can you tell us what psoriatic disease looks like in people of color? 

Dr. McKinley-Grant:
I think in people of color, as in all patients, you really have to look at the whole picture.  You can’t just look at 1 lesion and say, “Oh, it’s dry and scaly,” and “that’s psoriasis” or “eczema,” whatever you want to diagnose it.  You really have to look at the whole patient.  And in psoriasis I find that’s very important because that’s the one thing that appears in people of color and in white patients is that the lesions are symmetrical generally: their elbows, knees, back, and abdomen.  In all the Fitzpatrick types, psoriasis will generally be very symmetrical.  In people of color, the color of the redness of the psoriasis that we see in the textbooks which don’t have as many pictures of people of color, is not necessarily red.  It’s more of a purplish color or it’s brown, or there’s the scale makes everything look very gray, and it’s a deeper burgundy, so I encourage people to really look at the color.  And then the patterns are generally the same as plaque psoriasis, but it’s really the color that is different. 

Dr. Greenberg:
Okay.  So how are we as a profession doing when it comes to diagnosing and treating people of color with psoriasis? 

Dr. McKinley-Grant:
So we don’t do as well as we would like to do because the patients often come later.  Our training in all areas has been not so much in skin of color, so we get trained in the textbooks, online, in diseases that are mostly in white patients, and that’s really being corrected now.  I think there are a lot of efforts made to include all skin types in lectures.

So, it’s really a combination of the education and the residency training that puts us at a disadvantage, and this is all dermatologists, all doctors, really, so the effort has to be to try to get those experiences.  Train at a place where there were a lot of patients of color.  Do CMEs.    There are a lot of CMEs online that you can do to learn to recognize psoriasis in skin of color. 

Dr. Greenberg:
So then let’s zero in on diagnosing psoriatic disease in people of color.   Are there any specific challenges that are unique to this population? 

Dr. McKinley-Grant:
Challenges, yes.  People of color will come in with advanced disease because they maybe live in an area where they haven’t seen a dermatologist before or they’ve been to someone who has misdiagnosed them.  They’d been told they had psoriasis, and they had T-cell lymphoma,  and the other way around too.  They were told they had T-cell lymphoma, and it was really psoriasis, but nobody had biopsied it.  So the challenge is, if you don’t know, to biopsy. 

The other special areas are I think the appearance of it in darker skin seems like it’s more traumatic, and then the other challenge with psoriatic disease in patients of color is the scalp and the hair and the recommendations of the treatments that we have to do.

Dr. Greenberg:
Okay, great.  So, Lynn, what are some of the ways that we can help with the diagnostic gap? 

Dr. McKinley-Grant:
So I think one of the most important things that I tell doctors is to listen with your eyes because you have to look at the patient and listen to what they’re saying, and if you can’t see the redness, the patient says, “No, my skin is red here,”  you know, touch it, feel it.  It’s going to be warm.   Take the effort to listen with your eyes and your ears too.  You have to see with your ears because a scale sounds different.  If you rub against psoriasis scale, it actually sounds a little different than atopic dermatitis.  So you want to listen with your ears and your eyes. 

Dr. Greenberg:
I would add one more thing.  Listen with your heart.  You said something very important.  “Touch the patient.”  Psoriatic patients need to be touched.  They need to know that they’re not untouchable. 

For those just tuning in, you’re listening to DermConsult on ReachMD.  I’m Dr. Michael Greenberg, and I have the pleasure of speaking with Dr. Lynn McKinley-Grant about how we can better diagnose and treat psoriatic disease in people of color. 

So, Lynn, let’s turn our attention to treatment.   How should we be treating people of color with psoriatic disease?  And what are some of our options?  What are some of the great new options? 

Dr. McKinley-Grant:
So the first thing is to make the correct diagnosis.  Then, some of the old-fashioned ways still do work for patients.  You know, it really will depend on what their environment is and how much time they can come if they’re going to come for ultraviolet light.  What’s accessible to them?  I think that’s where you start to see what’s available, what kind of treatment. 

You do have to look at their insurance.   You have to be open to biologics.  You have to be open to making the effort maybe if their insurance isn’t covering it to see if the companies will have a special program.  So you need to really understand the patient’s lifestyle.  Who’s home?  What’s the situation?  You know, what’s their job situation?   You really kind of have to get into their life a little bit to understand what’s going to work for them as the best treatment. 

Dr. Greenberg:
So, Lynn, we know you’re partnering with a new group called Determination.  Can you tell us about this? 

Dr. McKinley-Grant:
Determination is a group that has brought together  pharmaceutical companies and healthcare providers in various fields.  So dermatologists, nurse practitioners, a lot of different healthcare providers, the scientists, the chemists, they’re all as a part of this group to figure out some solutions to the healthcare disparities in psoriasis and psoriatic arthritis. 

And the most important part of this group, actually, are the patients.  I’ve learned more from the patients than anyone else.  They are very open.  Many of them are advocates, but they really come up with the practical ideas of things that have happened to them.  And I find myself so often like almost apologizing for the specialty.  I’m like, “Oh, no.  We don’t want that to happen.”  So it gives us a focus of where we can improve in terms of getting doctors to take psoriasis seriously in skin of color and increasing the access and the training in underserved areas.  We’re going to have to have some healthcare providers who are really well-trained in caring for psoriasis too, so that’s been really the focus of the group with this. And rheumatologists are in the group also, but it’s the patients that are really taking the lead in this I think. 

Dr. Greenberg:
I think that that’s important, and it’s time we made some changes here, so thank you. 

Well, this has been a brilliant and informative discussion with how we can better care for our patients of color with psoriatic disease.  And I’d like to thank my guest, Dr. Lynn McKinley-Grant, for sharing her insight.   Lynn, boy, this was a joy and a pleasure to speak with you today. 

Dr. McKinley-Grant:
Well, this has been a great interview.

Dr. Greenberg:
For ReachMD, I’m Dr. Michael Greenberg.  To access this episode and others from this series, visit ReachMD.com/DermConsult where you can Be Part of the Knowledge.  And we thank you for listening.