Although moderate to severe plaque psoriasis is a condition well-documented among light skin tones, it’s not as well-represented or understood in people of color. We spoke to Dr. Andrew Alexis about this chronic disease, how it affects people of color and the efforts underway in dermatology to address gaps in research and care.
What is moderate to severe plaque psoriasis?
Dr. Alexis: Moderate to severe plaque psoriasis is a common immune-mediated disease that can affect any part of the skin, including the scalp, torso, hands, and feet. The nails can be involved as well. It causes a build-up of skin cells that form plaques on the skin—red to darker brown or purple raised areas with scales. It can sometimes also be itchy, painful and burn, and it often impacts quality of life.
How does plaque psoriasis present on skin of color and what symptoms should people look out for if they have darker skin?
Dr. Alexis: When we look at plaque psoriasis in people with lighter skin as the baseline, the plaques often appear as red, scaly, elevated lesions. But in patients with darker skin tones, the plaques might appear as a different shade, including purple, grayish or darker brown. Because plaque psoriasis can appear differently in darker skin tones, patients of color may not recognize the symptoms, and many do not regularly see a dermatologist who specializes in skin conditions and can make an accurate diagnosis and develop an appropriate treatment plan. Due to these obstacles, people of color with plaque psoriasis often face delays in diagnosis or misdiagnosis and have limited access to therapies to treat the condition. For people who suspect that they have plaque psoriasis, I recommend making an appointment with a board-certified dermatologist as soon as possible.
Beyond the physical symptoms, what other challenges do people of color face when living with plaque psoriasis?
Dr. Alexis: Delays in diagnosis, misdiagnosis, treatment barriers, and overall obstacles in navigating the healthcare system as a person of color can take a toll. In addition to these challenges, having scaly plaques that are highly visible to others can lead to embarrassment or questions, whether it’s at work or in social settings. A survey also found that people of color with this disease were more likely to feel the burden of pigmentary changes, which can further fuel feelings of embarrassment or shame.
In some cases, people of color don’t feel comfortable seeing a healthcare provider or they don’t feel heard by their physician. How can patients build an effective relationship with their dermatologist and work together to develop a treatment plan personalized to their needs?
Dr. Alexis: There is a concept that we call “shared decision-making,” which involves the patient’s goals and perspective on their condition. My advice for patients is to recognize that their voice is critical and to be forthcoming with how the condition is affecting them. Is it disturbing your sleep? Your ability to interact with others, either on a social or professional level?
If you have specific concerns or preferences about types of therapies — for example, injectable therapies versus oral therapies, versus creams and ointments — share your perspective and don’t hesitate to ask questions. Being open with your healthcare provider helps you both build a personalized treatment plan together that takes your specific needs, lifestyle and daily routine into account.
Does plaque psoriasis treatment vary depending on race or skin color?
Dr. Alexis: While clinical studies for treatments approved for plaque psoriasis have included patients of color, their proportions have not been representative and clinical data pertaining to people of color living with plaque psoriasis are still limited. There are also additional nuances. For people living with scalp psoriasis who are of African descent or who self-identify as Black with afro-textured hair, a daily medicated shampoo treatment may not be feasible with their haircare routine. This is a great example of why it’s so important to communicate your needs and preferences to your healthcare provider upfront.
Research shows Black patients are less likely to be prescribed biologic therapy. What are biologics and why is there this gap in treatment?
Dr. Alexis: Biologic therapies reduce inflammation by targeting specific proteins produced by immune system cells that are implicated in plaque psoriasis. These medications have been particularly effective in helping patients living with more severe forms of plaque psoriasis. However, a study found that Black patients were 69% less likely to receive biologic treatment for their plaque psoriasis. This may be due to a number of complex factors, including underdiagnosis, access barriers to specialty care and limited awareness that these therapies exist. Additionally, people of color are underrepresented in plaque psoriasis clinical research, which has limited our understanding of how the disease and plaque psoriasis medications impact diverse patients.
There is a recent study that is helping to bridge these gaps in care for people of color. Can you tell us a little bit more about the VISIBLE study?
Dr. Alexis: To address these barriers, I am working with Janssen on VISIBLE, a large-scale study designed specifically to understand and characterize moderate to severe plaque psoriasis in Black, Hispanic, Asian, Indigenous people, and other people of color. The study will further evaluate the efficacy and safety of one of Janssen’s treatments for moderate to severe plaque psoriasis to uncover additional data and provide valuable information about disease burden and the patient journey for people of color. We designed VISIBLE to help create a more equitable and inclusive clinical research process by taking new approaches to enrollment and retention, as well as broader community engagement, site selection and investigator training support.
What are the goals of the VISIBLE study?
Dr. Alexis: People of color have historically been underrepresented in previous plaque psoriasis studies, so our hope is that this data ultimately helps healthcare providers better understand, identify and treat patients with darker skin tones who are living with this disease. Additionally, the study will generate a bank of clinical images of plaque psoriasis on a broad spectrum of skin tones. These images are limited in the dermatology field, so we are looking forward to using them to help educate healthcare providers and patients on how to better recognize plaque psoriasis on skin of color to aid in earlier and more accurate diagnoses.
What more can be done to ensure equitable care for people of color living with plaque psoriasis?
Dr. Alexis: Across the medical and industry communities, efforts like the VISIBLE study that are prioritizing diversity in clinical research are key to helping achieve health equity because they help complete our understanding of how plaque psoriasis impacts people of color. Additionally, research shows that diversity in the physician workforce improves outcomes not only for people of color, but for all patients. Studies also reveal that physicians of color are more likely to provide care to underserved populations. This strongly suggests that increasing the number of practicing dermatologists from these populations can help reduce healthcare disparities. Diversity makes our specialty stronger and it’s key that we continue to inspire the younger generation to explore a career in dermatology to ultimately support our communities.
To learn more, including finding a doctor near you, visit the Skin of Color Society.