Andrew Alexis, MD, MPH
Professor of Clinical Dermatology
Weill Cornell Medical College, Cornell University
New York, New York, United States
As Professor of Clinical Dermatology and Vice-Chair for Diversity and Inclusion for the Department of Dermatology, Professor of Clinical Dermatology at Weill Cornell Medical College in New York City, former Chair of the Department of Dermatology at Mount Sinai Morningside and Mount Sinai West, and current President of the Skin of Color Society, Dr. Andrew Alexis has worked tirelessly to advance patient care, research, and education on dermatologic disorders prevalent in populations with skin of color for nearly two decades and ongoing.
In a recent interview, Dr. Alexis shares the clinical nuances of diagnosing and treating psoriasis in skin of color patients and the need to include non-white participants in clinical trials to further advance our ability to care for this patient population.
Psoriasis is Not Always Red – It Can Be Shades of Red, Gray, or Purple
Despite our classical training that plaque-psoriasis tends to be erythematous, the clinical presentation may vary when caring for patients of skin of color who have various shades of richly pigmented skin tones. It is essential to remember that these patients may present differently to improve the accuracy of diagnosis and clinical assessment in both the outpatient clinical and clinical trial settings.
Dr. Alexis explains, “Psoriasis in patients of skin of color may present as various shades of red such as violet or purple, red-brown, gray, gray-violaceous, or hyperchromic.”
It is crucial to broaden the definition of erythema to include the other shades of inflammation to garner precise PASI scores more accurately, which may play a role in research and the clinic. According to Dr. Alexis, one way to do this is to calibrate your eyes to non-lesioned skin areas and then assess lesioned skin areas.
More Severe Quality of Life Impact in Non-white Psoriasis Patients
Despite all the advances in psoriasis treatments through the years, non-white psoriasis patients continue to have more severe quality of life impact compared to white patients in numerous studies, even among those on biologic treatments. The reasons for the persistent statistically significant decreases in quality of life in psoriasis patients of color remain unknown. Dr. Alexis speculates that they may be due to cultural factors such as social stigma with dermatologic diseases in certain populations and the post-inflammatory pigment alteration sequelae that many patients of skin of color suffer after psoriasis plaques have healed. Some patients may also have delays in diagnosis or lack of access to effective treatments due to insurance factors or other social determinants of health.
“The burden of scaly erythematous plaques and how they leave behind persistent alterations contribute to social burdens of disease in these patients,” explains Dr. Alexis.
How to Treat the Pigmentary Sequelae of Psoriasis in Pigmented Skin
Treatment recommendations for hypo- and hyperpigmentation in these patients are, first and foremost, to treat the psoriasis itself. Due to topical steroids having a higher risk of hypopigmentation, careful and judicious use of these agents for a short duration is recommended.
Dr. Alexis recommends the consideration of newer agents such as tapinarof or roflumilast in the armamentarium for caring for patients of skin of color as long-term maintenance therapy. He explains, “It is important to treat until clinically obvious inflammation and subclinical inflammation is completely resolved to control both the inflammatory aspect of disease and improve the pigmentary sequelae.”
He recommends using lightening agents such as azelaic acid foam compounded lightening creams that include hydroquinone, fluocinolone, tretinoin, and adjunctive non-ablative fractional lasers for hyper-pigmentation. Dr. Alexis suggests using Excimer laser or narrowband UVB light therapy for hypopigmentation.
How Can Healthcare Providers Support?
To improve the clinical gaps in caring for psoriasis patients of skin of color, we must recognize our own limitations in diagnosis and treatment in this patient population. Dr. Alexis recommends turning to readily available resources such as the Skin of Color Society’s website, textbooks on dermatologic disorders of skin of color, atlases of skin of color, the American Academy of Dermatology’s (AAD) Skin of Color Curriculum, and the Journal of the American Academy of Dermatology’s (JAAD) Skin of Color Image Atlas.
Dr. Alexis explains it is also important to be culturally sensitive in providing treatment recommendations, especially regarding hair care practices in women of African descent. These women may have stigmatizations when it comes to scalp psoriasis due to the idea that it may signify a “dirty scalp.” “Treatment of scalp psoriasis in this patient population requires a plan to align with patient hairstyle and hair care practices,” says Dr. Alexis.
Looking to the Future for Psoriasis in Skin of Color
Given the lack of available data for non-white participants in clinical trials for psoriasis, there has been a growing need to include these groups in upcoming clinical trials. “We are at the inflection point where there has been greater awareness of the disparity of research in psoriasis in skin of color patients,” says Dr. Alexis.
Studies are undergoing or recently completed for psoriasis in skin of color patients. He explains that more than ever, there has been greater collaboration from industry, community, and physician organizations to improve overall care, reduce barriers, and improve access to the best available therapies for all our patients.
While we wait for more data to be available, Dr. Alexis has found that there are not many significant differences in treatments of choice between different racial and ethnic populations. He recommends treating one individual at a time based on the patient’s impact, severity of disease, and risk profile.
Dr. Alexis hopes that we can raise awareness of psoriasis in skin of color. Historically, literature suggested that psoriasis was not very common in populations of skin of color. Now, we know it is not rare and is likely underrecognized and underdiagnosed. He believes that increased awareness and interest will hopefully improve the significant burden of the disease in psoriasis patients of skin of color.