A Guide to Treating Psoriasis on Black and Brown Skin
Psoriasis is a chronic skin condition that affects more than 8 million people in the United States. While it affects about 3.2 percent of Caucasians, it can also affect people of color—about 1.9 percent of African Americans and 1.6 percent of Hispanics, according to research published in the Journal of the American Academy of Dermatology.
It’s unclear whether the lower numbers in these ethnic groups are because the condition is truly less common or because the condition simply isn’t diagnosed as often by physicians.
“As the years go on, those numbers are going up,” says Nikki Hill, M.D., a board-certified dermatologist at the Skin of Culture and Hair Center in Atlanta, Georgia. “It’s likely more prevalent in people of color than we’re assuming. We think that they’re grossly underdiagnosed.”
Here, we explain how diagnosis, appearance, and treatment of psoriasis differs for people with black or brown skin.
What Psoriasis Looks Like in People of Color
The textbook definition of psoriasis is red, scaly, inflamed patches of skin that may itch, sting, or burn, but that’s not necessarily the way it looks on black or brown skin.
“These lesions are easily spotted in a Caucasian person, and the diagnosis is never in doubt,” says Saakshi Khatri, M.D., assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai Hospital in New York City. “In people of color, the lesions can be less scaly, less red-looking and more purple, as well as more hyperpigmented, meaning unusually darkened.”
That’s why it’s important to find a provider familiar with diagnosing psoriasis and other skin conditions in black and brown skin. A place to start is the Skin of Color Society website, which has a database of doctors who treat patients with skin of color.
“I definitely feel that the inadequacy of the definition for psoriasis in people of color has impacted my care, especially being younger and encountering doctors who may not have been well versed in servicing people with dark skin,” says Alisha Bridges, 33, who was diagnosed with psoriasis at the age of 7, and is now an advocate for the condition.
Misdiagnosis: A Common Issue in People of Color
This discrepancy in what psoriasis looks like in people of color not only can leave psoriasis undiagnosed, it can also lead to misdiagnoses.
“It can be confused with things like lupus or lichen planus, because it’s not as flaky and it’s more purple,” explains Khattri. Hill adds that scalp psoriasis is commonly misdiagnosed as other scalp problems in people of color. Bridges says she was once misdiagnosed as having a fungal infection.
Getting a proper diagnosis is important in order to find the right treatment. “In high school, doctors were trying to guess what was going on with me, because none of the treatments they had given me were working,” says Bridges. “Being misdiagnosed exposes you to treatments that aren’t going to be effective, which can also come with side effects.”
A delay in diagnosis not only means that people may endure uncomfortable symptoms for longer, but it also means that by the time they’re properly diagnosed with psoriasis, it’s likely later in life, when they have more severe disease, says Hill.
Medical treatment can slow progression of the disease, which is why, if you think you may have psoriasis, it’s important to speak up. “If you have lesions that look like psoriasis, advocate for your dermatologist to consider that diagnosis,” says Khattri. “If your dermatologist is not as clear on the clinical appearance, advocate for a biopsy to pinpoint the diagnosis.”
Treating Psoriasis in People of Color
Once you have a confirmed diagnosis, generally speaking, psoriasis treatment options are the same for people of color as they are for anyone else—but there are a few considerations to keep in mind.
Topical treatment: Khattri explains that topicals can vary and are often a matter of personal preference—for example, some people prefer oils and ointments over creams. “Make sure you discuss your preference and choose one that you’re most likely to stick with.”
The same goes for any topicals or shampoos you use for your scalp. “A lot of scalp psoriasis treatments are shampoos that you need to use three to four times a week,” explains Bridges. “As an African-American woman, I don’t wash my hair that often, because it can be damaging and drying.” However, in caring for skin of color, it is still effective to use once a week. Often, dermatologists recommend their patients bring medicated shampoo to their hair stylist so that they can help wash their hair with it.
Another thing to keep in mind? “If you’re using steroid creams, you have to use them consistently. We try to alternate them with nonsteroidal treatments, since that constant use can cause lightening on and around the psoriatic area, which can be very upsetting for some people,” adds Hill. This is a common side effect called hypopigmentation that doesn’t occur in everyone. If it does for you, consider asking your doctor for a different topical medication.
Phototherapy: Phototherapy is a common psoriasis treatment, but talk to your doctor about what to expect before you decide to try it. “You might notice tanning of your skin—your doctor should explain that to you, so you don’t fear it and skip out on treatment,” adds Khattri. There’s also a risk of burns.
Systemic treatment: Systemic treatment can be effective, but they may require regular trips to the doctor’s office or self-administering an injection. And they may lose effectiveness over time, prompting you to switch to a new treatment.
Not only should you talk to your doctor about your lifestyle and treatment preferences, you should also tell them if you incorporate other alternative or culturally traditional therapies into your treatment regimen, like cupping, coining, or herbal remedies, advises Hill, who says they could potentially cause psoriasis flares as a result to trauma to the skin. However, they could help, too. Studies show that stress-reducing techniques can help numerous inflammatory skin diseases, especially psoriasis.
Discuss your treatment goals, and ask how realistic it is for you to achieve clear skin.
“Psoriasis treatment should really be individualized for people of color,” says Hill. “It’s a fine balance of trying to find something that’s effective and provides positive outcomes, in appearance to the skin, that also resolves psoriasis without impacting your quality of life or how you present yourself on a day-to-day basis.”
Before you start treatment, it’s important to talk to your doctor if you have a history of:
- Heart disease
- Cholesterol issues
- High blood pressure
- Joint issues
- Gastrointestinal issues like Crohn’s or ulcerative colitis
- Inflammation in the eyes or vision changes
People of color have disproportionately high rates of these conditions and comorbidities, says Khattri. “Make sure you also see your primary care physician about your overall health.”
What’s more, a study published in the Journal of Drugs in Dermatology found that psoriasis was more likely to negatively impact quality of life for people of color than it was for Caucasians. In fact, “That’s something to keep in mind—the mental impact that psoriasis can have on patients,” says Hill.
There are also physical scars. Once healed, psoriasis can often leave dark patches (hyperpigmentation) or light spots (hypopigmentation) that are more noticeable on dark skin compared to light skin. And certain treatments can bring out a more noticeable contrast than others.
Often, these discolorations may last for weeks, even months, after a flare has healed. And while there are bleaching creams that could help fade hyperpigmentation, the key is prevention. According to the National Psoriasis Foundation, treating psoriasis early can prevent hyperpigmentation occurring in the first place.
Consider Getting Involved
Currently, people of color tend to be underrepresented in psoriasis research.
“If you look at the demographics in psoriasis clinical trials, the majority of people enrolled are Caucasians,” adds Khattri. “The representation of people of color in clinical trials is low.”
For example, studies on phototherapy are limited to begin with, but those studies that have been done haven’t included many people of color, says Bridges. So it’s not fully understood how it may affect darker skin differently than lighter skin.
“I’m a patient researcher on a lot of different initiatives, and people of color are not well represented [there either],” says Bridges.
Bridges herself never thought she’d become an advocate for psoriasis, but it organically happened after she joined support groups and started blogging to share her story. “It’s grown into something I never would never have imagined,” she says.
“But I can only be a voice for what I can relate to as a woman with psoriasis, having been an adolescent who had to deal with the disease, and being an African American with psoriasis.”
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