The negative impact of psoriasis reaches beyond the physical pain and discomfort and can severely impact mental stability and overall QOL. Studies have shown a link between psoriasis and psychiatric comorbidities such as anxiety and depression. The disease has also been linked to diminished workplace productivity, reduced social interaction, and compromised family and friend relationships.

“A complex interaction of socioeconomic and demographic factors including race, ethnicity, language, sex, age, geographic location, income, and insurance coverage influence access to care and treatments for psoriasis, contributing to differential outcomes,” Roman Drozdowski, MD, and colleagues wrote in Dermatologic Clinics. “Recognizing these disparities and understanding their causes is critical so that clinicians can appropriately recognize and advocate for patients at higher risk of undertreatment to promote optimal outcomes.”

The researchers elaborated on the barriers to psoriasis care they found in their detailed literature review and suggested potential remedies.

Racial, Ethnic, & Language Disparities

Psoriasis is diagnosed more often in White patients, while Black, Asian, Native American, and Hispanic patients are more likely to go undiagnosed, have their disease recognized and treated later, and have more severe disease. Black, Hispanic, and Native American patients also have increased rates of psoriasis related inpatient admissions compared with White patients. However, a review of national Medical Expenditure Panel Surveys data showed that Hispanic patients had around 20% fewer annual visits for psoriasis than White patients.

In addition, the researchers found that Asian patients have less face-to-face time with dermatologists, are around twice as likely as White patients to be hospitalized for psoriasis, and tend to have longer stays and higher related expenses.

Patients with limited English proficiency are prescribed biologics less often. Further, in a 2011 study of Medicare beneficiaries, researchers found that Black patients were 69% less likely to receive biologics than were White patients.

Providers should schedule adequate clinic time for these patients and provide them with follow-up, referrals to specialists, counseling, and educational materials that explain the risks and benefits of specific therapies in their primary languages, Dr. Drozdowski and colleagues noted.

Sex Disparities

While psoriasis prevalence is similar in men and women, men tend to have more severe plaque psoriasis as measured by Psoriasis Area and Severity Index and are more likely to have undiagnosed disease. In a study in Poland, women with psoriasis tended to have more depressive symptoms and psoriasis-related psychological distress than men.

Data on sex differences in psoriasis treatments are conflicting, however. A multicenter review of more than 150 patients found no difference in biologic or disease-modifying antirheumatic drug use between men and women; however, in a multicenter study with more than 2,000 Spanish patients, women were more likely than men to be prescribed biologic therapy for psoriasis.

During evaluation, providers should inquire about these issues and refer their patients for appropriate care, according to researchers.

Age Disparities

Although psoriasis affects people of all ages, its prevalence tends to increase with age, with onset peaking at 30-39 and again at 60-69. Even though biologics show similar efficacy in older and younger populations, geriatric patients are more likely to be prescribed topical agents than systemic medications.

The authors emphasized that comorbidities should be carefully considered when prescribing systemic therapies to elderly patients, but age alone should not exclude them from receiving biologic treatments.

Geographic Disparities

Psoriasis treatment differs slightly by geographic region, with biologics use highest in the South. A trends analysis of 2013-2017 Medicare data suggested significantly greater annual growth in biologic prescriptions in the Northeast, the West, and urban and high income counties.

Time-intensive phototherapy that requires travel to a phototherapy center can be infeasible for rural residents, people without transportation, and those with schedule conflicts.

Investigating the reasons for geographic differences in psoriasis treatment may help to inform future policy decision-making.

Need for Equitable Care

“Promoting equitable care for patients with psoriasis is increasingly important amid a growing armamentarium of systemic treatments that can alter the disease course, improve QOL, and minimize associated comorbidities,” the authors wrote.