Melanin & Misdiagnoses: The Hidden Struggles of Psoriasis in People of Color
Underneath the canopy of a sun-kissed sky, imagine a garden in full bloom. Each flower, distinct in its hue and texture, represents our skin – our body’s largest and most visible organ. Yet, like every garden has its uninvited guests, many of us combat the unexpected presence of psoriasis. This skin story, while universal, often plays out differently on the canvas of darker complexions.
Did you know?
- About 1.9% of Black Americans battle psoriasis, compared to 2.5% of white Americans.
- While Black Americans may have lower incidence rates of psoriasis, they are often plagued with delayed diagnosis therefore delayed treatment.
And here’s why…
Diagnosing psoriasis in people of color involves recognizing the unique manifestations of the condition on darker skin tones, understanding the broader context of healthcare disparities, and using a combination of clinical examination, patient history, and sometimes biopsy.
Lets First Take a Closer Look at the Skin
Psoriasis is an autoimmune condition that affects the skin, causing cells to build up rapidly on its surface. While the exact cause of psoriasis remains uncertain, it’s believed to result from a combination of genetic, immune system, and environmental factors. Psoriasis can appear anywhere on the body, but it commonly affects the elbows, knees, scalp, back, face, palms, and feet.
In white skin, psoriasis typically appears as well-defined, raised, red patches covered with silvery scales. However, on darker skin tones, these patches might look different:
- Color Differences: Instead of the typical red patches seen on white skin, psoriasis on brown or black skin, can appear purple, dark brown, or even grayish. The silvery scales that overlay the patches might appear white or lighter than the surrounding skin, especially when contrasted against a dark skin tone. his difference in appearance can lead to confusion with other skin conditions like eczema, lichen planus, or discoid lupus.
- Thickness of Lesions: Black individuals might also have thicker, more hyperkeratotic (extremely thickened) lesions. When these thick scales are present, they can appear white, especially as they start to flake or if they’re scratched.
- Skin Cell Turnover: The rapid turnover of skin cells, which are naturally white when they are dead and about to shed, can appear prominently white against darker skin.
- Post-Inflammatory Hypopigmentation: Sometimes after a psoriasis flare, there can be areas of lighter skin (hypopigmentation) due to inflammation affecting the melanin-producing cells (melanocytes). This temporary loss or reduction of melanin can make spots appear white or significantly lighter than the surrounding skin.
Taking a Detailed History
A comprehensive patient history can provide crucial clues. The dermatologist SHOULD inquire about:
- The duration and progression of the skin changes.
- Any family history of psoriasis.
- Known triggers such as recent infections, medications, or stress.
- Other symptoms, like joint pain, which might hint at psoriatic arthritis.
The Definitive Test: Biopsy
If there’s any doubt about the diagnosis after the clinical examination and patient history, a skin biopsy can be performed. This involves taking a small sample of the affected skin and examining it under a microscope. The cellular patterns seen in psoriasis are distinctive and can help confirm the diagnosis.
Barriers to an Accurate Diagnosis
While psoriasis can affect any racial or ethnic group and the process seems straightforward, several challenges persist:
- Lack of Representation: Historically, medical education has primarily shown psoriasis images on white skin, making it challenging for even seasoned dermatologists to recognize it on darker skin if they haven’t been trained to do so.
- Cultural and Societal Barriers: Societal stigma, especially in communities of color, might deter individuals from seeking medical care. Misconceptions and lack of awareness about psoriasis can also play a role in under-diagnoses and under-treatment.
- Delayed Diagnosis: Black patients may experience delayed diagnosis due to differences in the clinical appearance of psoriasis on dark skin, leading to misdiagnoses.
- Access to Care: Healthcare inequalities such as access to dermatological care can be limited for some communities of color due to socioeconomic barriers or geographic constraints. Socioeconomic factors, including insurance status and income, can influence access to specialized care. Black and Hispanic populations in the U.S., for instance, might face barriers accessing dermatological care.
- Treatment Utilization: Some studies suggest that Black patients with psoriasis are less likely to receive biologic treatments than white patients. The reasons are multifaceted and can include economic barriers, lack of awareness, and healthcare system challenges.
While psoriasis affects individuals across all racial and ethnic backgrounds, there are disparities in prevalence, presentation, and access to effective treatment. Addressing these disparities requires a multifaceted approach, including improving healthcare access, enhancing medical education, and increasing representation in clinical research. Diagnosing psoriasis in people of color, like in anyone, is a blend of art and science. It demands both a keen clinical eye and an understanding of the broader sociocultural landscape. With increasing awareness and education, the goal is to ensure timely and accurate diagnosis for everyone, regardless of their skin color.