Psoriasis underdiagnosed in skin of colour
A lack of data and limitations on tools for measuring severity may be causing patients to go untreated (1,300 words, 6 minutes)
Psoriasis may be being under-diagnosed in patients of colour, Dr. Yvette Miller-Monthrope told attendees at the 8th annual Skin Spectrum Summit on Sept. 17, 2022. Limited data around the world make prevalence estimates difficult, she said, and this is compounded by standard measuring tools, such as PASI, not being designed with patients with skin of colour in mind. She noted that physicians might need to resort to biopsies for a confirmed diagnosis in these patients.
Dr. Miller-Monthrope is a physician in the Department of Dermatology at Women's College Hospital in Toronto.
The true prevalence of psoriasis between skin types is unknown, Dr. Miller-Monthrope said, noting that 81 per cent of countries lack information on psoriasis epidemiology.
Some research suggests that non-White populations in the U.S. are more likely to have undiagnosed psoriasis, possibly due to factors such as a lack of access to healthcare, lower utilization of healthcare, or misdiagnosis.
Standard measurements for the severity of psoriasis—such as PASI—may contribute to an underestimation of the prevalence of severity of psoriasis in skin of colour due to the weighting of redness or other features often not present in darker skin.
“I've seen patients with psoriasis misdiagnosed as lichen planus, cutaneous sarcoidosis, fungal infections, syphilis, lupus, and so on,” Dr. Miller-Monthrope said. “And [this misdiagnosis] is primarily because we are not taught a lot, especially in medical schools, about how psoriasis looks in this population.”
More inclusive psoriasis assessment tools that rely less on redness and include hyperpigmentation are needed, said Dr. Miller-Monthrope. She said a similarly inclusive tool is also necessary to measure patients' quality of life with psoriasis.
If a physician doubts a diagnosis, Dr. Miller-Monthrope suggests performing a biopsy, which should provide a clear answer.
To help ensure increased recognition and better treatment of psoriasis in people of colour, there needs to be an increase in the number of patients of colour in psoriasis clinical trials, she said. In an evaluation of 62 phase-three clinical trials, five out of six patients were described as white, said Dr. Miller-Monthrope.
“Psoriasis, for some reason, has the least representation of patients with Brown and Black skin of any disease in dermatology,” she said.
Bottom Line: Psoriasis is widespread, and its prevalence in populations of colour may be underestimated because textbooks and measuring systems are not designed for patients of colour. Physicians should be more willing to perform a biopsy to diagnose psoriasis and willing to start systemic therapy earlier to prevent sequelae such as hyperpigmentation.
From the literature on psoriasis in skin of colour
A pilot study to assess the reliability of digital image-based PASI scores across patient skin tones and provider training levels
Researchers evaluated the reliability of face-to-face (FTF) versus digital image-based (DIB)-PASI scores in patients of different skin tones.
A total of 14 patients with varying skin tones and moderate-to-severe plaque psoriasis were included. All had been treated with adalimumab. In-person PASI assessments and digital photography were done in clinic at weeks 0, 12, and 24. Four independent assessors reviewed the photographs to derive a DIB-PASI score. Investigators then assessed how well FTF-PASI and DIB-PASI agreed across patient and assessor factors.
They found an overall high agreement between the two, with good agreement between the assessors. Digital and FTF assessors also agreed when the data was broken down by PASI score component or body region. DIB-PASI and FTF-PASI also matched well between patients with medium-to-dark skin tones and those with light skin tones.
Higher prevalence of generalized pustular psoriasis in Asia? A population-based study using claim data in China and a systematic review
This population-based study used data from the Urban Basic Medical Insurance in China database from 2012 to 2016. Researchers also conducted a systematic literature review.
Investigators found the crude prevalence of generalized pustular psoriasis (GPP) in 2016 was 1.403 per 100,000 person-years, while the incidence was 0.629 per 100,000 person-years. Prevalence and incidence were higher among males than females (1.429 vs. 1.135 and 0.635 vs. 0.520, respectively).
There were two age-related peaks in prevalence and incidence, one in the 0 to 3 years age group and a second in the 30 to 39 age group.
The seven studies identified in the systematic review suggested that the prevalence of GPP tended to be higher in Asian countries than in France (0.176), Sweden (6.25) and Brazil (0.7).
Efficacy and safety of spesolimab in Asian patients with a generalized pustular psoriasis flare: Results from the randomized, double-blind, placebo-controlled Effisayil 1 study
This paper looks at the efficacy and safety of the anti-IL-36 antibody spesolimab in 29 Asian participants of the Effisayil 1 study. In this population, 10 patients in the spesolimab group reached the primary endpoint of a Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) pustulation subscore of 0 (no visible pustules) at Week 1. Only one patient in the placebo group reached that endpoint in the same period.
The key secondary endpoint, a GPPGA total score of 0 or 1 (clear or almost clear skin) at Week 1, was achieved by eight (50.0%) and two (15.4%) patients in the active and placebo groups, respectively. The paper’s authors note
that these findings were similar to previously published data in the overall population of 53 patients in the Effisayil 1 study.
More than 60% of Asian patients in the active group with a GPPGA pustulation subscore of 0 and GPPGA total score of 0 or 1 sustained those scores for up to 12 weeks. In these patients, patient-reported outcomes improved, and systemic inflammation markers were normalized.
Risk of skin cancer with phototherapy in moderate-to-severe psoriasis: An updated systematic review
Researchers searched Cochrane, PubMed, and Embase databases for literature published from July 1, 2010, to Dec. 31, 2020, on phototherapy for psoriasis in all Fitzpatrick skin phototypes (FSP).
Of the eight articles included, five studies did not report an increased skin cancer risk with narrowband-ultraviolet blue (UVB) and unspecified UVB for FSP II through VI, with one study not reporting FSP.
Three studies reported an increased risk of skin cancer with narrowband-UVB and broadband-UVB for FSP I-VI, with one study not specifying skin phototypes or UVB phototherapy type.
One study of psoralen and ultraviolet A with and without narrowband-UVB demonstrated an increased risk of skin cancer in phototypes III and IV. T
The most commonly reported secondary outcomes with phototherapy were actinic keratosis (123) and solar lentigines (10). Many patients were also on additional therapies, including methotrexate, acitretin, and biologics.
VIDEO: Psoriasis and Skin of Colour—National Psoriasis Foundation
At the intersection of skin and society
A new report from Statistics Canada states that while racialized people in Canada are generally more likely than their non-racialized, non-Indigenous counterparts to earn a bachelor’s degree or higher, they are less likely to find jobs that offer the same pay and benefits in the years following graduation.
These findings come from two studies: “A portrait of educational attainment and occupational outcomes among racialized populations in 2021” and “Early career job quality of racialized Canadian graduates with a bachelor’s degree, 2014 to 2017 cohorts.”
Two years after graduating, racialized graduates reported lower employment earnings and rates of unionization and pension plan coverage than their non-racialized, non-Indigenous counterparts. However, the findings varied considerably by racialized group and gender.
The report with a breakdown of the data based on racialized groups and gender can be read here.
Jan. 24 is International Day of Education
Jan. 25 is National IV Nurse Day in the U.S.
Jan. 27 is International Day of Commemoration in memory of the victims of the Holocaust
Something to think about in the week ahead…
—Frederick Douglass, American social reformer and author, 1818-1895
During a talk at the 2022 Skin Spectrum Summit, Dr. Gary Sibbald discussed the risk of hypertrophic or keloid scarring when managing wounds in dark skin types. During his presentation, he also gives recommendations for treating and managing these scar types.
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