Dermatology: how to manage psoriasis and recognize differences in pathophysiology and presentation in patients with skin of colour

35050 How to manage psoriasis in patients with skin of color

Atopic dermatitis (AD) is a chronic inflammatory cutaneous disease prevalent in all skin types but can differ in pathogenesis and clinical presentation. It has been documented in the literature that AD is more prevalent in Asian and Black individuals than in white individuals. Genetic variations as well as cultural and socioeconomic factors have important implications for susceptibility to AD and response to treatment in skin of colour. In this narrative review, we discuss differences in the epidemiology, pathophysiology, clinical presentation and treatment of AD in skin of colour. Additionally, we highlight the need for greater inclusivity of non-white ethnic groups in clinical trials to develop targeted treatments for diverse populations. Moreover, awareness of differences in AD presentation amongst non-white individuals may encourage patients to seek medical care earlier, leading to timely management and improved outcomes.

Mental health outcomes and their association to race and ethnicity in acne patients: A population-based study

Psoriasis is a chronic inflammatory skin condition affecting diverse racial/ethnic groups throughout the world. Large population-based studies suggest that psoriasis occurs most often in individuals of European ancestry, followed by black and Hispanic individuals, although the true prevalence of psoriasis in non-white individuals is likely underestimated. Despite similarities in psoriasis between ethnic groups, there are notable differences in thepresentation, quality-of-life impact, and treatment of psoriasis with important implications for the management of non-white individuals. Overall, heterogeneity in psoriasis susceptibility alleles, in combination with cultural and socioeconomic factors, may explain these differences. In this article, we review the epidemiology, clinical presentation, genetic polymorphisms, quality-of-life impact, and treatment nuances of psoriasis in patients with skin of color.

Psoriasis is a chronic immune-mediated inflammatory disease affecting individuals across all races and ethnicities with reports of varying prevalence in different populations. Apart from similarities, there are nuances in various aspects of psoriasis in populations with skin of colour (SOC) as well as disparities in access to care and research.1 Our objective was to further understand the unique characteristics of plaque psoriasis in SOC patients. A literature search from January 2018 until August 2023 in Pubmed/MEDLINE and Cochrane Library was performed. Level of evidence for each study was assessed using the Oxford Centre for Evidence-Based Medicine recommendations and only studies with a level of evidence of I–III were included. The prevalence of plaque psoriasis is higher in White populations compared with those with SOC, although the disease is more severe, with higher body surface area affected and with a greater impact on quality of life in the latter group. The clinical picture in SOC patients may vary as lesions can appear as violaceous/grey and postinflammatory pigmentary alteration is a common associated feature. High-impact site involvement might be more common and more severe in patients with SOC. In terms of management, disparities in care have been reported. Data about the use of biologics or oral small molecules have shown similar efficacy and safety profiles across self-identified racial and ethnic groups. Psoriasis has been shown to have a greater impact on quality of life (QoL) in patients with SOC and new QoL tools that are more culturally appropriate for SOC patients may be required for use in global populations. Historically, access to clinical care and research has been more limited in people with SOC due to multiple factors. Inclusion of representative patient populations in registration trials has not changed significantly over the last years; however, postmarketing studies specifically involving SOC populations in North America have recently emerged. A limitation of our study is the lack of a universal definition and use of terms, such as ethnicity, race and SOC. In conclusion, racial and ethnic variations in epidemiology, clinical presentation, access to care, and QoL impact in psoriasis have been reported. However, data involving global populations with SOC are limited. This study raises awareness about the need to better understand psoriasis in patients with SOC so as to improve patient care globally.

Ethnicity affects the presenting severity of psoriasis

This is a retrospective study conducted on patients who underwent any type of autologous flap breast reconstruction performed by the two senior authors at an academic center between January 2010 and December 2021. The sole primary outcome variable was flap loss. Patient skin tone was assessed using the Fitzpatrick scale on clinical photographs of patients. A total of 1115 pateints underwent autologous flap breast reconstruction, of which only 56 met both exclusion and inclusion criteria with 58 individual breasts being included in the final study population. The most common race of subjects was White (n = 33; 56.9%) while the most common Fitzpatrick score skin tone was type II (n = 22; 37.9%). The Cochran-Armitage test of trend showed a statistically significant linear trend, P = 0.006, with darker Fitzpatrick score skin tones associated with a higher proportion of flap loss in patients who had vascular compromise. A logistic regression showed that none of the predictor variables were significant. Patients with darker Fitzpatrick skin tones were associated with flap loss after vascular compromise. To prevent flap loss in patients who have darker Fitzpatrick score skin tones, more aggressive flap monitoring should be taken into consideration in the immediate postoperative setting.

Should Estimated Glomerular Filtration Rate Be Adjusted for Race?

Introduction. Although alcohol abuse is associated with hypertension in whites and nonwhites, it has been scarcely investigated in HIV-infected patients. Objective. To investigate whether the association of alcohol abuse with hypertension is influenced by skin color in HIV-infected individuals. Methods. Cross-sectional study in HIV-infected individuals aged 18 years or older. Demographic characteristics, lifestyle, and HIV infection were investigated. Alcohol abuse was defined as ≥15 (women) and ≥30 g/alcohol/day (men), and binge drinking by the intake of ≥5 drinks on a single occasion. Hypertension was defined by blood pressure ≥140/90 mmHg or use of blood pressure-lowering agents. Results. We studied 1,240 individuals, with 39.1 ± 10 years, 51% males and 57% whites. Age and body mass index were associated with blood pressure, and there was an independent association of alcohol abuse with hypertension in whites (RR = 1.9, 95% CI 1.1–3.3) and nonwhites (RR = 2.4, 95% CI 1.4 to 4.0). Among nonwhite individuals who were alcohol abusers, systolic (9.3 ± 3.2; P = 0.001) and diastolic blood pressures (6.4 ± 2.1; P = 0.008) were higher than in nonabusers. Conclusion. Alcohol abuse is a risk factor for hypertension in white and nonwhite HIV-infected individuals. The association of ethanol consumption with blood pressure is not explained by AIDS-related conditions.

Background Inflammatory dermatoses have a varied prevalence and appearance in diverse skin tones. The under-representation of people with skin of colour in medical education and clinical trials is widely acknowledged. However, there has been limited research on experiences from a patient perspective. Aim To explore the experiences of eczema, acne and psoriasis in adults with skin of colour in the UK. Design and Setting A qualitative study of 20 people with eczema, acne and psoriasis and skin of colour, recruited using online methods. Methods Participants took part in online, one-to-one, semi-structured interviews. NVivo qualitative data analysis software was used to code and organise the data. Reflexive thematic analysis was used to generate themes using an iterative approach. Results Participants were mostly female (65%), Asian/Asian British ethnicity (45%) and had eczema (55%). We identified eight themes: (i) delayed or missed diagnosis; (ii) preferences regarding healthcare professionals; (iii) lack of online information and social media use; (iv) misunderstanding in cultural communities; (v) concerns about treatment and lack of research in skin of colour; (vi) complementary and alternative medicine use; (vii) experiences and impact of dyspigmentation; and (viii) challenges with structural racism. Conclusions The themes generated highlight the unique experiences and challenges faced by UK adults with eczema, acne and psoriasis. The findings can help guide diagnostic approaches, culturally sensitive communication and treatment discussions for patients with skin of colour. Further research is needed in this under-represented group.

Proposed solutions by the American College of Allergy, Asthma, and Immunology and advocacy experts to address racial disparities in atopic dermatitis and food allergy

Psoriasis is a chronic inflammatory disease that affects approximately 3.2% of the adult population of the USA. Amongst this population, Caucasians have the highest prevalence rate at 3.6%, while in non-Caucasians or individuals with skin of color the prevalence is lower, 1.9%, 1.6%, and 1.4% in African Americans, Hispanics, and other non-Caucasians, respectively [1]. Based on these statistics, one might gather that psoriasis is less likely in skin of color [2]. One of the earliest review articles detailing psoriasis prevalence by ethnic origin highlights several groups including the specific categories: Caucasian, African American, black-skinned South African, Fiji Islands, American Indian, Latin American Indian, Japanese, and Indonesians [3]. The 1965 text perpetuates the idea that psoriasis is relatively common in Caucasians and much less frequent in skin of color while acknowledging that psoriasis may not be as rare in those of African descent as previously believed. It was proposed that in evaluating the incidence of psoriasis among different ethnic groups, the potential influence of variables such as genetics, climate, diet, degree of skin pigmentation, exercise, stress level, economic factors, social factors, and hygiene factors must be considered [3]. This study was subject to selection bias as the text concluded that psoriasis was uncommon in black-skinned individuals during a time period when black-skinned individuals with psoriasis were much less likely to visit the dermatologist than white Caucasians.

Sun exposure is responsible for deleterious effects such as sunburn, photoaging, and skin cancer. Ethnic origin and skin color, related to constitutive pigmentation represent major parameters involved in skin responses to solar ultraviolet (UV) exposure. Epidemiologic studies show higher incidences of basal and squamous cell carcinoma as well as melanoma in Caucasians compared with African Americans.1 Skin susceptibility to photoaging alterations such as solar elastosis, dermal damage, and wrinkle formation, also depends on constitutive pigmentation. Furthermore, experimental data show the relationship between the minimal erythemal dose (MED) and skin color (i.e., MED is lower in light skin and higher in dark skin).2 The skin color type is usually assessed according to Fitzpatrick’s phototype classification, which is based on ethnic origin, erythema sensitivity, and tanning ability. Nevertheless, this classification may raise various problems such as limits in terms of quantification, reliability, and ex vivo conditions. In addition, its relevance for Asiatic or African skin types has been questioned as all Asian skin types were grouped into a unique phototype V and all African skins in phototype VI. To document the relationship between the response to UV light and skin color type, we analyzed 42 ex vivo skin samples. Skin color type was determined through the measurement of the individual typology angle (ITA), which is based on colorimetric parameters.4 This allowed us to objectively classify the skins into five groups, namely light, intermediate, tanned, brown, and dark. Skin color classification according to ITA was checked with regard to physiological relevance to constitutive pigmentation by Fontana–Masson staining, revealing clear differences in melanin content and distribution regardless of ethnic origin. Colorimetric parameters obtained from African women living in France and the USA showed that African skins were distributed from intermediate to dark skin type (Fig. 1). African skin colorimetric classification in the skin color volume projected on the L*/b* plane of the L*a*b* space (CIE 19763). The vertical axis L* is the luminance or lightness of the skin and the horizontal axis b* is the yellow component of the skin. Skin color categories from very light to dark are indicated As a biological end-point of the MED, which corresponds to just perceptible erythema, we analyzed the number of sunburn cells (SBC) 24 h after exposure to increasing doses of solar-simulated radiation (UVB + UVA). This led to determination of the biologically efficient dose (BED) for each sample. We found a dose-dependent SBC induction in all skin color types. More interestingly our results revealed a direct relationship between skin color type and BED value, with a statistically significant correlation between ITA and BED (i.e., the lighter the skin the lower the BED value) (Fig. 2). Other typical biological markers are associated with erythemal reaction and have been linked to the development of skin cancer, such as DNA lesions and p53 accumulation. The latter markers were evaluated and, as found with SBC, showed a correlation between the value of ITA and dose-inducing biological damage. Interestingly, immunolabeling of cyclobutane pyrimidine dimers, a major UV DNA damage in human skin, showed dose-dependent accumulation of lesions throughout the epidermal layers and uppermost dermal cells in light, intermediate, and tanned skin. In contrast, cyclobutane pyrimidine dimers could not be detected in the basal epidermal layer and dermal cells of brown and dark skins (Fig. 3). They were strictly restricted to suprabasal epidermal keratinocytes, even when exposed to doses greater than the BED. To investigate the greater resistance of dark skin to UV exposure, three different dark skin samples were collected and exposed to high UV doses corresponding to two- or threefold the average BED for this skin type. Surprisingly, no pyrimidine dimers were detected in the basal layer of the epidermis and in the upper dermis. Individual typology angle (ITA°) versus biologically efficient dose (BED): linear regression (R2 = 0.70; P < 0.001). Corresponding skin color types are indicated. Int, intermediate Fontana–Masson staining: one example of each skin type is illustrated and corresponding ITA values are indicated. Immunolabeling of CPD immediately SSR exposure: one example of each skin type is illustrated before exposure (0 J/cm2) and at the BED (in J/cm2). Broken line indicates the dermal–epidermal junction. Small arrows point to dermal positive cells. Vertical arrows indicate the depth of staining. Circles surround the basal layer of brown and dark skins where no CPD was detected. BED, biologically efficient dose; CPD, cyclopyrimidine dimers; ITA, individual typology angle. Altogether, from a biological point of view, our results show a decreasing UV sensitivity from light to dark skin.5 The different distribution of DNA lesions between ITA-based groups supports the relationship between UV sensitivity and skin color type at the molecular level. The location of DNA lesions in the epidermis is of utmost importance with regards to the onset of skin carcinogenesis. DNA lesions in suprabasal keratinocytes committed to terminal differentiation do not carry the same biological impact as lesions in the basal proliferative layer highly suspected to be at the origin of epidermal carcinoma development. These results may explain the lower risk of darker skin to develop UV-induced skin cancer. Furthermore, the presence of DNA lesions in the upper dermis of light skin may be relevant to greater susceptibility to dermal damage related to photoaging. Skin color classification based on ITA values seems to be related to skin sensitivity to UV exposure at the cellular and molecular levels. Our results indicate a progressive decrease in sensitivity to UV exposure with increasing skin pigmentation. This sensitivity is likely to be predictive of the individual proneness to develop deleterious consequences of sun exposure, photoaging, and skin cancer. We believe that the determination of ITA may be a useful tool to predict individual “UV exposure risk” profiles for designing adequate photoprotection or skin cancer prevention programs.

Introduction Historically, dermatology research and clinical practices have overlooked important considerations in the care of individuals with skin of color (SOC). The ongoing disparities in dermatological care and increasing proportion of non-White individuals in the United States (US) underscores the need to understand and address existing care gaps through targeted initiatives. The dermatological medical community seeks to shift towards a more equitable, patient-centered model of care that considers the distinct needs of racial and ethnic groups across the US. Objectives To provide an updated literature search with publications from April 2022 to October 2023, that offers insights into new versus persisting care gaps in dermatology for individuals with SOC and detect if any gaps have closed from our previous search. We also reviewed past and present initiatives in the dermatological care of patients with SOC to identify current focus of efforts and if there are opportunities for improvement. Methods A comprehensive literature review was performed using PubMed to identify care gaps in SOC dermatological care in the US. Articles published between April 1, 2022, and October 1, 2023, were filtered based on predefined search-term combinations related to subpopulations, indications, healthcare systems, stakeholders, and established researchers in the field. Titles and abstracts of resulting publications were prioritized based on their relevance (i.e., low, medium, or high) and those identified as highly significant were further analyzed to extract relevant care gaps. Using a similar search and prioritization strategy, we examined initiatives focusing on addressing gaps in the dermatological care of patients with SOC. Resulting initiatives (e.g., awards, congresses, curricula, campaigns, and events) were classified by type of organization (e.g., medical society, pharmaceutical industry, patient organization) and assessed for their relevance to each literature-identified care gap. Finally, a comparison of past (from 2020 to 2022) versus current initiatives was conducted to reveal how initiatives have evolved. Results The literature review identified 18 gaps in SOC dermatological care, which were further categorized based on their relevance to patients, access to care, HCPs, and clinical research. Of the 18 care gaps, 17 were previously identified and are therefore shown to be persistent challenges. We identified an additional gap that has since emerged: advances in artificial intelligence (AI)-based diagnostic tools lack accuracy in patients with SOC due to their underrepresentation in image databases. We reviewed the growing landscape of dermatology-specific initiatives for patients with SOC and found approximately 191 initiatives across national and international organizations, including medical societies, patient advocacy organizations, and non-profit organizations. There exists a large focus on initiatives pertaining to healthcare professional (HCP) medical education (MedEd), SOC dermatology research, and diversity in the dermatology profession. Compared to our previous search, we found that the number of initiatives has increased, with approximately 100 new initiatives since April of 2022. The largest increase in number of initiatives was in HCP MedEd curricula and SOC research. Nevertheless, there are still care gaps with insufficient focus; very few initiatives target HCP communication or access to treatment. Conclusions Previously identified care gaps remain as persistent issues in the dermatological care of patients with SOC, but a new care gap has since emerged due to developments in AI-based diagnostic tools in dermatology. There was a significant rise in SOC-related dermatological initiatives, with the largest increases in HCP MedEd curricula and SOC research. However, opportunities still exist in HCP communication and access to treatment, where there continues to be limited activity. This study provides a crucial overview of both progress and shortcomings in the SOC-related dermatological landscape and highlights that a coordinated approach may be needed to create impactful change and address the dermatological care gaps affecting patients with SOC.

ABSTRACTPatients with skin of color (SOC) face unique dermatologic challenges that are often underrepresented in research and in dermatological education, creating critical gaps in care. We aimed to identify and explore key gaps in research and clinical management for SOC across four domains: skin diseases, hair disorders, photoprotection, and aesthetic procedures. An international panel reviewed articles retrieved from PubMed using the search terms “skin of color” or “skin of colour” in titles and abstracts from September 2019 to September 2024. Inflammatory skin diseases, including acne, atopic dermatitis, psoriasis, and rosacea, are common in SOC subjects, necessitating tailored diagnostic and therapeutic approaches due to unique clinical presentations and specific challenges such as post‐inflammatory hyperpigmentation and erythema detection. Pigmentary disorders such as melasma and acne‐induced hyperpigmentation significantly impact quality of life in SOC, requiring cautious treatment to avoid exacerbation, while the unregulated use of skin bleaching agents containing high‐potency corticosteroids can pose serious health risks. Skin cancer in SOC often presents at advanced stages with poorer outcomes due to lower awareness and unique clinical manifestations, resulting in delayed diagnosis. Hair disorders in SOC populations require tailored diagnostic and therapeutic approaches due to unique hair properties. Gaps in photoprotection education on SOC exacerbate pigmentary disorders and other dermatologic conditions, with limited research on effective sunscreens for this population. In aesthetic dermatology, misconceptions and knowledge gaps regarding the prevention of complications hinder access to safe and effective procedures for SOC subjects, compounded by inadequate diversity in clinical trials. Inclusive research, improved diagnostic accuracy, and customized procedures are needed to ensure equitable dermatologic care.