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Psoriasis is diagnosed in people of all ethnic and racial backgrounds. But it can look and behave differently in people with different skin tones. This can cause many issues for people with darker skin including long periods of undiagnosed or misdiagnosed psoriasis.
Overall, psoriasis is an autoimmune disease that affects around 7.5 million people in the United States and 125 million people across the globe. A skin rash is often the first sign that leads to a diagnosis of psoriasis, but arthritis often occurs also. Usually, a person will notice thick scaly skin that is itchy. Many things can cause psoriasis or be psoriasis triggers.
In the United States, psoriasis is diagnosed in 3.6 percent of white people, 1.9 percent of Black people, and 1.6 percent of Hispanic people. This lower percentage in people of color could be partially caused by underreporting. Racial disparities in health care access are widely documented in the United States. Specifically, Black people are at a greater risk for having undiagnosed psoriasis than other ethnic groups. Dark skin tone can make the skin condition hard to see, which could lead to misdiagnosis in people of color.
Symptoms of psoriasis will look different on different skin tones. Patchy and dry skin has a pink color in fair-skinned people. But it can look violet or salmon-colored in Black and Latino people. The scaly patches of skin can also look different between skin tones. Gray scales are most common in Black people. But silvery scales or white scales are common for Hispanic people and those with fair skin. Psoriasis flare-ups can also be dark brown in people with darker skin.
Skin tone can also change the look of skin when the psoriasis symptoms heal. People with a medium or darker skin color may notice changes to their skin tone after the active inflammation goes away. This is called dyspigmentation (discoloration). Usually, darker patches, called postinflammatory hyperpigmentation, are left on the skin. These patches will fade, but it may take months to a year for them to disappear fully.
Psoriasis is usually diagnosed after evaluation by a dermatologist. The dermatologist will look at the affected areas of the skin to determine if the rash is psoriasis. Next, the dermatologist may order a biopsy, blood tests, perform a physical exam, or order imaging tests to confirm the diagnosis and evaluate other symptoms such as joint damage.
People with darker skin tones have less noticeable skin lesions, which can delay diagnosis. One study found that Black people have different psoriasis symptoms at diagnosis than other races. For example, Black people had more dyspigmentation and less erythema (skin redness).
People of color also tend to have wider regions of skin injury at diagnosis when compared with white people. In one study, Asians experienced a significantly more severe form of psoriasis at diagnosis than whites. Black people often have a larger percentage of their skin affected at diagnosis than other ethnic groups.
Two factors that create barriers to the correct diagnosis for people of color are the lack of diversity in the field of dermatology and lack of representation in dermatology textbooks.
In the United States, Black doctors represented only 3 percent of dermatologists in 2016, and Hispanic doctors represented just over 4 percent of dermatologists, making it one of the least diverse medical specialties.
The lack of dermatologists of color can lead to poorer experiences for people of color seeking dermatological care. A small study of 19 Black adults found that participants reported greater satisfaction when seeing a dermatologist of the same race (or with skin of color expertise) than seeing a dermatologist of a different race without skin of color expertise. Specifically, participants reported greater knowledge of Black skin and hair and more trustworthiness.
Dermatology residents are not adequately taught how to diagnose certain skin conditions in people with darker skin tones. Representative images are very helpful training tools for these new doctors. However, images of dark skin in textbooks are still underrepresented and have shown little improvement over the last 15 years.
Although the field of dermatology has a long way to go regarding the lack of diversity in textbooks and in the field, there are efforts to make progress. Below are a few examples of initiatives to improve representation in dermatology education.
In the United States, dermatologists at The George Washington University and University of California Los Angeles are developing a textbook called “Dermatology: A Diverse and Inclusive Color Atlas.” The textbook will provide side-by-side images of common skin conditions as they manifest on multiple skin tones. Dr. Misty Eleryan is a woman of color who helped to spearhead the project as a medical resident.
In the United Kingdom, Malone Mukwende launched a project called BlackandBrownSkin after noticing how his dermatology textbooks primarily featured images of white people. Mukwende developed "Mind the Gap: A Handbook of Clinical Signs in Black and Brown Skin" to help students and physicians understand how various skin conditions appear on skin of color.
The Skin of Color Society is a professional organization founded in 2004 to support dermatologists of color and to promote knowledge about skin of color in the field of dermatology. The organization also provides mentorship for residents and new doctors looking to grow their expertise in treating people of color.
The American Academy of Dermatology Association also offers a mentorship program for medical students of color to improve diversity within the specialty.
MyPsoriasisTeam is the social network for people with psoriasis and their loved ones. On MyPsoriasisTeam, more than 91,000 members come together to ask questions, provide advice, and share their stories with others who understand life with psoriasis.
Are you a person of color living with psoriasis? Do you feel that you were not diagnosed as quickly as you would have liked? How do you think your psoriasis symptoms are different from other people’s? Share your experiences or advice to others in the comments below or by posting your story to MyPsoriasisTeam.