Dr Mona Shahriari Talks Unique Challenges in Treating Psoriasis in Patients With Skin of Color

Dermatologists may underestimate the severity of psoriasis in patients with skin of color, because the presentation may look like other diseases, Mona Shahriari, MD, assistant clinical professor of dermatology at Yale University and associate director of clinical trials at Central Connecticut Dermatology said in an interview.

Transcript

What unique challenges and considerations do dermatologists face when treating plaque psoriasis in people of color and how does the condition manifest differently in individuals with diverse skin tones?

I think the number one piece is the clinical presentation of the disease. It can look very different than what we're used to seeing in our lighter skin tones. Usually when we're trying to assess disease severity, we look at what's called erythema, which is defined as the redness that the skin has, and that gives us an idea of how severe the disease is.

Now, the use of the word "erythema", though it applies to our lighter skin tones, actually is problematic for patients with melanin-rich skin, because their erythema doesn't necessarily look red. It can look violet, it can look gray, it could look brown, and oftentimes, it's mistaken for post-inflammatory hyperpigmentation, because the individual assessing it doesn't necessarily know what to look for.

As a result, patients either end up with the wrong diagnosis because there are a lot of conditions that can look violet or gray like Lichen Planus, for example, can have those similar shades. Sarcoid can look like that. I've had patients come to me with scalp psoriasis who were diagnosed with tinea capitis. So again, the presentation can look like other diseases. But if you get that diagnosis right, you are still at risk of underestimating the disease severity.

When I was in residency, one of my attendings told me that anything you think the severity is, you need to upgrade it by 1 point in your patients with skin of color, to get closer to being accurate in terms of your overall assessment, because we don't want to under-treat these patients, because what we're finding in a lot of studies is the burden of disease on our patients with skin of color is much higher than their White counterparts.

And the other piece is the post-inflammatory pigmentary alteration that they face–that's a much bigger deal in our patients with melanin-rich skin. For starters, some cultures are not going to be okay with the dark marks that are left behind because of a psoriasis plaque.

But also, sometimes as the disease clears, the inflammation clears and the dark marks are left behind, the patient thinks you're making their condition worse, they don't fully understand what's happening. So it's a lot of education around that post-inflammatory change, what it means, and how we can address it moving forward.

So, we're going to really do a deep dive in terms of how our patients with skin of color want that post-inflammatory pigment alteration to be addressed, you really want to acknowledge that head-on and make sure that the patient knows this is just as important to you as it is to them.

And then when it comes to the treatments for plaque psoriasis in general, we have had an explosion of oral and injectable medicines for the treatment of plaque psoriasis. So you'd think this is a great time to have plaque psoriasis, but when you look at the nitty-gritty of the clinical trials, we still have an underrepresentation of our patients with skin of color in our key clinical trials that were used to get the efficacy and safety data for some of these greatest drugs.

So, we don't know if these drugs are going to work the same in our patients with skin of color. We would hope that they would. But obviously, that's to be determined. One key study that we're going to highlight is the VISIBLE study, which is a study that was sponsored by Janssen, looking specifically at the performance of TREMFYA (guselkumab) in patients with skin of color. But I always say if anyone thought the point of that study was to see if TREMFYA worked in skin of color, has lost the entire point of the study.

The main goal was to really understand those nuances that our patients with skin of color face and help clinicians be much more educated in terms of how to treat these patients and how to approach them. What are those cultural competence parameters that you want to keep in mind? How do you reduce bias? How do you stay sympathetic toward what that patient is dealing with at home? How do you not tell them that cream that your grandma's been using generation after generation is actually making your psoriasis worse? These are all little tidbits that we were able to gain from that particular study.