Photo Credit: Jun
Geeta Yadav, MD, and colleagues used a Canadian Delphi consensus to produce guidelines to optimize psoriasis management in patients with skin of color.
At Maui Derm 2025, multiple sessions focused on current challenges in managing psoriasis, including a panel discussion with Joel Gelfand, MD, and April W. Armstrong, MD, MPH.
One goal of the presentation by Dr. Gelfand and Dr. Armstrong focused on the development of “patient-centered treatment plans to maximize outcomes and improve quality of life (QOL),” according to Dr. Gelfand.
In his introduction, Dr. Gelfand addressed the healthcare disparities in psoriasis. “It’s a little less common in Black patients, but still prevalent, and these patients tend to have more severe or more extensive disease than White patients and tend to experience a greater HRQOL impact than White patients. For some of these, there are currently no great answers,” Dr. Gelfand continued.
Multiple recent studies not presented at the meeting have also covered this topic. Amy McMichael, MD, and colleagues examined this starting at the clinical trial level.
In another study, a Canadian Delphi consensus aimed to address the significant lack of evidence-based guidelines specifically tailored for psoriasis for people with skin of color (SOC) through the development of consensus statements. Those findings were published in JAAD International.
Challenges in Diagnosing Psoriasis in SOC
Geeta Yadav, MD, and colleagues noted that the clinical presentation of psoriasis in patients with SOC differs significantly from that of White patients. Misdiagnosis is common because violaceous or hyperpigmented presentation in people with SOC can be mistaken for other dermatologic conditions such as eczema, lichen planus, or even post-inflammatory hyperpigmentation. Consequently, patients with SOC often face delays in receiving appropriate care and treatment, leading to worsening symptoms and decreased QOL.
The consensus highlighted the need for dermatologists to recognize these differences in presentation and recommended enhanced training and education to improve diagnostic accuracy. Additionally, the panel advocated for developing comprehensive image databases representing diverse skin tones to aid in accurate diagnosis.
Barriers to Effective Treatment & Access to Care
SOC patients with psoriasis face multiple barriers to effective treatment, including limited access to dermatologic care, lack of awareness of available therapies, and underrepresentation in clinical trials. Dr. Yadav and colleagues found that SOC patients are less likely to be treated with biologics compared with White patients, despite evidence showing their effectiveness in moderate to severe psoriasis. This disparity is partly due to the lack of data on the safety and efficacy of biologics in non-White populations, leading to hesitancy among both patients and healthcare providers.
Moreover, current assessment tools, such as the Psoriasis Area and Severity Index (PASI), rely heavily on erythema to indicate disease severity. This poses a challenge for SOC patients, as erythema may not be as visually pronounced, leading to underestimation of disease severity and inadequate treatment. The consensus panel emphasized the need for assessment tools that do not rely solely on erythema and suggested incorporating measures of pigmentary alteration and plaque thickness.
Consensus Process Produces Guidelines
The Canadian Delphi consensus produced several key guidelines to optimize psoriasis management in patients with SOC.
- Dermatologists should be aware that psoriasis may present differently in patients with SOC, often with violaceous, gray, or brown plaques instead of the classic erythema.
- Pigmentary alteration, such as post-inflammatory hyperpigmentation or hypopigmentation, disproportionately impacts patients with SOC and can profoundly affect their QOL.
- Treatment plans should consider the risk for pigmentary alteration, especially when prescribing topical therapies or phototherapy. In SOC, phototherapy may temporarily darken the skin, which may not be acceptable for some patients.
Early initiation of systemic therapies is recommended to minimize the risk for pigmentary sequelae.
- Scalp psoriasis is particularly challenging to treat in patients with SOC due to differences in hair texture, care patterns, and cultural practices. The consensus recommended considering hair washing frequency, head coverings, and patient preferences when developing treatment plans.
Dr. Yadav and colleagues noted that patients with SOC are underrepresented in clinical trials, limiting the generalizability of the findings. The panel called for more inclusive clinical trials that equitably represent patients with SOC.
They continued that addressing health disparities requires improving education, engagement, and representation of patients with SOC in care and research.
Developing Inclusive Dermatologic Terminology
The consensus statements also addressed the need for standardized terminology. Current classification systems, such as the Fitzpatrick phototype scale, are inadequate as they do not accurately reflect the diversity of skin tones. The panel emphasized the importance of a more comprehensive classification system and using objective scientific tools like colorimeters and spectrophotometers to provide reproducible and quantitative measurements of skin color.
The experts recommended avoiding terms like “race” or “ethnicity” as proxies for skin color, as these are not scientifically justified and do not accurately describe skin traits. Instead, descriptive and culturally appropriate vocabulary should reflect cutaneous diversity.
Dermatologists are encouraged to adopt these guidelines to improve diagnostic accuracy, optimize treatment outcomes, and promote health equity for patients with SOC and psoriasis. However, the study also underscores the need for more research to address the gaps in evidence and develop better assessment tools to ensure effective and equitable care for this underserved population.
