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  • Presentation

Psoriasis Treatment Disparities and Skin of Color: Challenges, Evidence, and Solutions

Description

The speaker argues that although psoriasis is a highly successful example of modern immunology and targeted therapy, outcomes still differ by skin tone because of external factors rather than biology alone. The main drivers of disparity are delayed diagnosis from less recognizable presentations in darker skin, access barriers tied to social determinants of health, limited clinician training in skin of color and hair-specific nuances, and evidence gaps caused by underrepresentation of non-white patients in clinical trials. The talk highlights that psoriasis may appear purple, gray, or reddish-brown rather than classic pink, leading to misdiagnosis and more frequent biopsies in Black patients. Minority patients are less likely to see dermatologists, start biologics, or stay on treatment, and they are underrepresented in advertising and educational materials. Although available data suggest biologics generally work across racial groups, some genetic and population differences exist, and the need for dedicated studies in patients with skin of color is emphasized. The speaker also stresses that post-inflammatory pigmentary change is common, especially in darker skin, may affect quality of life and mental health more than residual plaques, and may require specific management strategies. Finally, scalp psoriasis in afro-textured hair requires vehicle and regimen adjustments to avoid hair damage, and earlier systemic therapy may sometimes be preferable. The overall goal is to improve recognition, access, evidence, and culturally and biologically appropriate care so outcomes are not determined by skin color.

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Conclusions

  • Psoriasis is biologically similar across skin tones, but treatment outcomes are still worse in patients of color because of non-biologic factors such as diagnostic delay, access barriers, treatment nuances, and limited evidence.
  • Psoriasis is harder to recognize in darker skin because erythema and scale may appear violaceous, gray, or brown, so clinicians should have a lower threshold to biopsy when the diagnosis is uncertain.
  • Racial and ethnic minority patients face major access gaps, including fewer dermatology visits, delayed care, lower biologic initiation, poorer adherence, and higher discontinuation rates.
  • Representation in commercials and differences in beliefs about injections, immunosuppression, and side effects may reduce comfort with biologic therapy among some patients, especially Black patients.
  • Psoriasis trial populations are overwhelmingly White, which limits how confidently efficacy, safety, and pigment-related outcomes can be generalized to patients with skin of color.
  • Despite limited trial diversity, biologics appear to work consistently across racial groups overall, suggesting that the major disparities are usually driven more by access and recognition than by treatment failure.
  • A dedicated study in non-White patients showed guselkumab produced strong and consistent skin clearance across Fitzpatrick skin types, validating its use in skin of color.
  • Post-inflammatory pigmentary alteration is common after psoriasis clears, is more frequent and longer lasting in darker skin, and may affect quality of life and mental health more than residual plaques.
  • Pigmentary change should be treated as a meaningful outcome in psoriasis, because standard endpoints like PASI and IGA do not capture it well.
  • Early control of inflammation, careful use of phototherapy, and avoidance of irritating topicals are important strategies to reduce or manage post-inflammatory pigmentary alteration.
  • Home phototherapy appears to be at least as effective as in-office phototherapy and may offer particular benefit for patients with darker skin phototypes.
  • Scalp psoriasis in patients with afro-textured hair requires hair- and vehicle-aware treatment choices, with preference for moisturized, low-irritation formulations and less frequent washing.
  • The overall conclusion is that better outcomes in psoriasis of skin of color will require earlier recognition, improved access, more inclusive evidence generation, and treatment plans tailored to pigmentary and hair-related differences.
  • Takeshita J et al. J Invest Dermatol. 2019;139(8):1672-1679.e1.
  • Gelfand JM et al. JAMA Dermatol. 2024;160(12):1320-1328. doi:10.1001/jamadermatol.2024.3897.#10.1001/jamadermatol.2024.3897