Dr. Amy McMichael discusses psoriasis in skin of color, which she says is more common than many dermatologists think. She shares her approaches to recognizing, diagnosing, and treating psoriasis in darker skin tones.
Amy McMichael, MD, Professor of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
“What we found over the years …is that oftentimes patients with psoriasis who have brown skin or darker skin don’t get diagnosed early. Actually, they get diagnosed much later than other ethnicities,” said Amy McMichael, MD, who presented “My Approach to Recognizing, Diagnosing and Treating Psoriasis in Diverse Skin Tones,” at the Skin of Color Update meeting in New York, New York.
Part of that reason is that pigmentation colors the skin in darker skin types and doesn’t allow classic psoriasis plaques with erythema or redness to peek through, said Dr. McMichael.
“What we see instead is either a hyperpigmented plaque or violaceous plaque. And if the plaques are not where they typically occur—on the knees, elbows— …a lot of the time psoriasis goes undiagnosed.”
Instead, dermatologists might think a patient has an unusual form of eczema or prurigo nodularis, and the patient doesn’t get the treatment they need, said Dr. McMichael.
“I think another thing that we don’t expect in patients with skin of color is the significant hypertrophy. The hyperkeratotic changes are quite thickened in some patients of color, especially African American patients. This has been reported in several articles in the medical literature.”
But again, the lesions look more like lichen simplex chronicus or prurigo nodularis, she said.
“There really is no approved treatment for lichen simplex chronicus, though a treatment was just approved for prurigo [in October 2022]. So, patients go through topical steroids and intralesional steroids—things to try to decrease manipulation. But [psoriasis is] not really a manipulation issue, [and] one would not want to mistakenly diagnose prurigo and give the wrong medication class to patients with psoriasis.”
Biopsy Early
It is imperative to biopsy early for possible psoriasis in skin of color, according to Dr. McMichael.
“If you feel your patient is not responding to treatment and you’re trying to treat eczema or prurigo nodularis, biopsy early in those skin of color patients to make sure you’re not missing psoriasis.”
Dermatologists should biopsy a lesion that has not been treated for a couple of weeks, which might be in a hard-to-reach area for patients. Or they should ask patients to refrain from using topical steroids on their lesions for a couple of weeks before taking the biopsy and sending the lesion to a dermatopathologist for a diagnosis, said Dr. McMichael.
Control Hyperkeratosis
“When we think about treatment of patients with skin of color with psoriasis, we think about things that we really have to control. What we have to control is the pruritis, which is the same for every patient with psoriasis. We have to control the scaling. We have to control the inflammation. And we also have control the thickness, this hyperkeratosis, that appears so much more in patients with skin of color. …hyperkeratosis probably trumps everything else because all the medicines do a great job of taking down pruritis and inflammation but if you don’t get that hyperkeratosis down the patient is going to continue to have problems.”
Controlling hyperkeratosis means going to systemic agents much more quickly, said Dr. McMichael.
“Instead of trying topicals, injections—things that maybe aren’t going to affect them systemically for a very long period of time—give your patients options.”
Today, those other options include what Dr. McMichael calls “fabulous” systemic agents—including phosphodiesterase inhibitors, biologics, and other new agents coming onboard, such as JAK inhibitors.
“So, giving your patients options—whatever their insurance will bear with regard to systemic agents—will really be key. We don’t want to have patients sitting around waiting.”
Don’t Be Fooled
“The reason that we’re talking today about psoriasis in African American patients is because in years past it was thought that African American patients didn’t get psoriasis. What we now know due to some really wonderful database research is that while it isn’t at the level of incidence or prevalence as in Caucasian patients, it’s actually pretty significant.”
“We don’t want to miss out on this very important diagnosis that could be quite disfiguring for our patients of color, whether it’s with hyperpigmentation or hypopigmentation around the forehead, ears, and scalp areas. We want to recognize that these patients are suffering and get them the treatments that they deserve very quickly, just like we do with all our patients with psoriasis,” said Dr. McMichael.
Disclosures: Dr. McMichael receives grants and does research for Concert, Procter and Gamble, Incyte; consults with Lilly, Janssen, Pfizer, Arcutis, Almirall, Abbvie, Galderma, Bristol Meyers Squibb, Sanofi-Genzyme, UCB, Procter and Gamble, Revian, Johnson & Johnson, L’oreal, and Nutrafol.
