In this column, I often speak about how racialized and indigenous people may have lower access to healthcare and may receive worse treatment in the healthcare system when compared to white individuals. The color of a person’s skin can be a prime factor in exactly how systemic racism and discrimination show up. Yet, physicians’ knowledge of different presentations with white skin versus skin of color can make the difference between accurate and inaccurate medical diagnoses.
I’m talking about psoriasis, a chronic skin condition characterized by patches of thick, scaly skin that may be itchy, dry, and painful. Psoriasis Awareness Month this past August inspired me to dig into the many skincare-related health equity challenges that racialized and Indigenous people commonly face.
The naturopathic approach to psoriasis considers the whole person—including their skin color. As Julie Greenberg, ND, RH (AHG), MBA, points out, psoriasis symptoms depend on the skin tone. On white skin, affected areas are red. “On skin of color, it’s less likely to be red,” Greenberg explains. “It’s more likely the skin looks darker or lighter.”
A 2022 review1Yadav G, Yeung J, Miller-Monthrope Y, et al. Unmet Need in People with Psoriasis and Skin of Color in Canada and the United States. Dermatol Ther (Heidelb). 2022;12(11):2401-2413. https://doi.org/10.1007/s13555-022-00811-0 took a deep dive into 26 recent studies to understand the challenges and unmet needs that psoriasis patients with “skin of color” (SoC) in Canada and the U.S. face in getting access to healthcare, accurate diagnoses, and appropriate treatment. The results were startling.
The study’s authors plainly state that healthcare is less accessible for people with psoriasis and SoC than white individuals. Indeed, a strong body of research indicates that people with SoC have lower access to healthcare in general than white individuals—including access to specialists such as dermatologists.
Barriers to Seeking and Receiving Psoriasis Care
A Canadian study found that First Nations people had 1.5 times more visits to primary care physicians for psoriasis (and psoriatic arthritis) and 0.6 times fewer specialist visits when compared to non-First Nations people.2Barnabe C, Jones CA, Bernatsky S, et al. Inflammatory Arthritis Prevalence and Health Services Use in the First Nations and Non-First Nations Populations of Alberta, Canada. Arthritis Care Res (Hoboken). 2017;69(4):467-474. https://doi.org/10.1002/acr.22959 This lack of access may influence how their psoriasis is both diagnosed and treated. The potentially high cost of psoriasis treatment is a key barrier to seeking treatment, particularly for non-white groups, due to socioeconomic inequalities. One study revealed that almost three times more Black people than white people considered high cost a barrier.3Bray JK, Cline A, McMichael AJ, Feldman SR. Differences in healthcare barriers based on racial and/or ethnic background for patients with psoriasis. J Dermatolog Treat. 2021;32(6):590-594. https://doi.org/10.1080/09546634.2019.1687824
Interestingly, people with psoriasis and SoC are more likely to be hospitalized for psoriasis than white patients.4Hsu DY, Gordon K, Silverberg JI. The inpatient burden of psoriasis in the United States. J Am Acad Dermatol. 2016;75(1):33-41. https://pubmed.ncbi.nlm.nih.gov/27210045 First Nations people in Canada with psoriatic disease were over three times more likely to be hospitalized, while a U.S. study found that patients hospitalized for psoriasis were more likely to be Hispanic, Asian, Black, or multiracial/other than white. I can’t help but wonder whether the prospect of hospitalization may further deter people with SoC from seeking out psoriasis treatment.
Researchers found that cultural views can significantly impact whether people with SoC seek psoriasis care, especially among Black individuals. There have been reports of Black people being told that psoriasis does not affect them, which could mean a delay in seeking care or not seeking care at all.5Nicholas MN, Chan AR, Hessami-Booshehri M. Psoriasis in patients of color: differences in morphology, clinical presentation, and treatment. Cutis. 2020;106(2S):7-10;E10. https://doi.org/10.12788/cutis.0038
Reinforcing this cultural barrier is a shortage of healthcare providers who provide culturally competent care. The same study that identified cost issues also found that non-white people with psoriasis were much more likely than their white counterparts to report a lack of culturally competent care as an important barrier to seeking psoriasis care.
Diagnosis Difficulties
All these factors come into play before a racialized or Indigenous person considers seeking psoriasis care. So what happens when a person with SoC decides to see a healthcare practitioner?
It all goes back to medical school. When medical and dermatology students learn about what different skin conditions look like, they’re not seeing the whole picture. Even in 2023, most teaching materials still use examples of white skin.
This is shocking and unacceptable. Racialized people are the global majority (and approaching the majority across North America). Imagine going to your doctor as a racialized person to see if you have psoriasis. Their diagnosis will include factors such as the color and texture of your skin, how long you have had those symptoms and your age. If they are unaware that psoriasis can present quite differently in SoC compared to white individuals, how accurate will their diagnosis be? And what about the treatments they recommend based on that diagnosis – how safe and effective will they be?
The intersection of the many ways psoriasis can present across the skin spectrum and a lack of culturally competent care makes accurate diagnosis for people with SoC a huge challenge. People with SoC tend to have psoriasis plaques with different coloration, less noticeable inflammation, and greater post-inflammatory pigmentation changes (dark skin patches that appear when the skin is healing from injury or inflammation) than white patients.
There may also be differences in where on the body psoriasis appears, how severe it is, and what makes it worse between racial groups.6Abrouk M, Lee K, Brodsky M, et al. Ethnicity affects the presenting severity of psoriasis. J Am Acad Dermatol. 2017;77(1):180-182. https://pubmed.ncbi.nlm.nih.gov/28619563 Scalp psoriasis, for example, may be more common in Asian and Black patients than white patients. Scalp psoriasis can be more severe in Black women, partially due to differences in hair care practices.7Abrouk M, Lee K, Brodsky M, et al. Ethnicity affects the presenting severity of psoriasis. J Am Acad Dermatol. 2017;77(1):180-182. https://pubmed.ncbi.nlm.nih.gov/28619563/ And let’s not forget about the impact of stress. One study found that Asian and Hispanic patients reported stress as a factor that made their psoriasis worse more often than white patients.8Yan D, Afifi L, Jeon C, Cordoro KM, Liao W. A cross-sectional study of psoriasis triggers among different ethno-racial groups. J Am Acad Dermatol. 2017;77(4):756-758.e1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5612377 Overall, numerous studies have shown that, for people with SoC, psoriasis plaques can be thicker, more scaly, and cover more of the body than in white individuals.
Treatment Challenges
As I noted earlier, a treatment based on an inaccurate diagnosis could be ineffective or even make things worse. Here, too, cultural considerations come into play. A common treatment for scalp psoriasis is using certain hair shampoos daily. But Black women do not typically wash their hair every day due to differences in their hair texture compared to other hair types. Further, Black hair cleaning products are more likely to be oil-based suspensions, lotions, and foams instead of shampoos. If a daily shampoo is the only treatment option offered, Black individuals are not receiving culturally competent care. Overall, providing culturally competent care increases patient satisfaction with treatment options, improves patients’ odds of following treatment plans, and increases trust in physicians.
Underrepresentation in Psoriasis Research
Providing culturally competent care to people with SoC and psoriasis is not only about racial diversity in skin health education of healthcare professionals.
I was astonished when I looked into the statistics of how many people with SoC are included in dermatological research. One review exploring 626 randomized controlled trials (RCTs) of several skin conditions showed that over 74% of participants were white.9Charrow A, Xia FD, Joyce C, Mostaghimi A. Diversity in Dermatology Clinical Trials: A Systematic Review. JAMA Dermatol. 2017;153(2):193-198. https://doi.org/10.1001/jamadermatol.2016.4129 But wait, it gets better. For trials focused only on psoriasis, over 84% of participants were white. Then, they looked at how many RCTs in the U.S. had at least 20% non-white participants. It was 74% for acne trials and over 91% for eczema trials—sounds pretty good. But psoriasis? A measly 30%.
This significant underrepresentation also applies to skincare medication trials. A study that explored 82 clinical trials for psoriasis drugs showed a mere 14.2% of non-white participants, while Black individuals accounted for only 3% of participants when the data was reported.10Reddy VD, Myers BA, Chan SY, et al. A review of current phase III clinical trials of plaque psoriasis: under-representation of nonwhite participants and need for reform. Br J Dermatol. 2021;184(2):348-350. https://doi.org/10.1111/bjd.19468 The intersection of underrepresentation in clinical trials and underreporting of racial data in those trials only raises the possibility of undertreatment or inaccurate treatment for people with SoC.
Ultimately, we all want our healthcare practitioners to see us as people, not as case numbers. While there is no one-size-fits-all approach to psoriasis, certain providers such as naturopathic doctors take the time to do a deep dive into your past and present health and lifestyle to identify and address root causes such as inflammation and gut imbalance.
“In conventional medicine, psoriasis is in the dermatology and rheumatology bucket, and they’re not really looking at the gut,” Dr. Greenberg explains. “I have found that when I clean up problems in the gut, I clean up the psoriasis.”
“Psoriasis is an autoimmune condition, which means that the body’s immune system is attacking itself,” adds Trevor Cates, ND. “Why is the immune system overreacting? There can be genetic factors. But with autoimmune conditions, it all goes back to the gut.”
“If we just suppress it, we’re not listening to our bodies,” says Dr. Cates. “But if we stop and say, ‘Something is out of balance here. What is that?’ We can use diet, lifestyle, and supplements to help restore balance and not only clear up things like psoriasis, but other health issues too.”
Footnotes
- 1Yadav G, Yeung J, Miller-Monthrope Y, et al. Unmet Need in People with Psoriasis and Skin of Color in Canada and the United States. Dermatol Ther (Heidelb). 2022;12(11):2401-2413. https://doi.org/10.1007/s13555-022-00811-0
- 2Barnabe C, Jones CA, Bernatsky S, et al. Inflammatory Arthritis Prevalence and Health Services Use in the First Nations and Non-First Nations Populations of Alberta, Canada. Arthritis Care Res (Hoboken). 2017;69(4):467-474. https://doi.org/10.1002/acr.22959
- 3Bray JK, Cline A, McMichael AJ, Feldman SR. Differences in healthcare barriers based on racial and/or ethnic background for patients with psoriasis. J Dermatolog Treat. 2021;32(6):590-594. https://doi.org/10.1080/09546634.2019.1687824
- 4Hsu DY, Gordon K, Silverberg JI. The inpatient burden of psoriasis in the United States. J Am Acad Dermatol. 2016;75(1):33-41. https://pubmed.ncbi.nlm.nih.gov/27210045
- 5Nicholas MN, Chan AR, Hessami-Booshehri M. Psoriasis in patients of color: differences in morphology, clinical presentation, and treatment. Cutis. 2020;106(2S):7-10;E10. https://doi.org/10.12788/cutis.0038
- 6Abrouk M, Lee K, Brodsky M, et al. Ethnicity affects the presenting severity of psoriasis. J Am Acad Dermatol. 2017;77(1):180-182. https://pubmed.ncbi.nlm.nih.gov/28619563
- 7Abrouk M, Lee K, Brodsky M, et al. Ethnicity affects the presenting severity of psoriasis. J Am Acad Dermatol. 2017;77(1):180-182. https://pubmed.ncbi.nlm.nih.gov/28619563/
- 8Yan D, Afifi L, Jeon C, Cordoro KM, Liao W. A cross-sectional study of psoriasis triggers among different ethno-racial groups. J Am Acad Dermatol. 2017;77(4):756-758.e1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5612377
- 9Charrow A, Xia FD, Joyce C, Mostaghimi A. Diversity in Dermatology Clinical Trials: A Systematic Review. JAMA Dermatol. 2017;153(2):193-198. https://doi.org/10.1001/jamadermatol.2016.4129
- 10Reddy VD, Myers BA, Chan SY, et al. A review of current phase III clinical trials of plaque psoriasis: under-representation of nonwhite participants and need for reform. Br J Dermatol. 2021;184(2):348-350. https://doi.org/10.1111/bjd.19468
