Scalp psoriasis in skin of colour
To improve patient outcomes, practitioners must take into account hair-care practices, have a higher degree of suspicion (1,500 words, 7 minutes)
Psoriasis can affect the scalp and hair follicles, and that can present differently in patients with Afro-textured hair, Dr. Jaggi Rao told the 9th annual Skin Spectrum Summit.
Dr. Rao is a clinical professor in the Faculty of Medicine and Dentistry and director of the dermatology program at the University of Alberta in Edmonton, and the founder and team lead of ConsultDerm, a national teledermatology project.
It can be important to address hair styling methods with patients with psoriasis and Afro-textured hair, since psoriasis can cause dryness or breakage of hair, and some medications may interfere with normal hairstyling methods. In those cases, compliance with treatment can be poor, as patients try to avoid these side-effects. Different hairstyles can also conceal psoriasis, meaning the condition presents later and at a more severe stage, making it more difficult to treat.
It is important to establish a skincare regimen that is compatible with the patient's haircare practices, said Dr. Rao (pictured below.) That could mean weekly washing of hair instead of daily, supplementation with a topical corticosteroid to reduce inflammation, or using oils or oil-based suspensions instead of lotions or water-based solutions as treatment vehicles.
Treating psoriasis more aggressively or systemically early on may also be an option. Dr. Rao said he often starts patients with Afro-textured hair on methotrexate first instead of waiting for other treatments to fail.
Because the effect on the scalp can have a severe impact on quality of life, insurance plans may be more amenable to covering the cost of biologics, he said.
Bottom line: Managing scalp psoriasis in patients with Afro-textured hair requires accommodation of cultural hair styling practices, including topical vehicle selection, a higher degree of suspicion, and considering systemic treatments earlier.
From the literature on psoriasis in skin of colour
Assessing the quality, comprehensiveness, and readability of online patient health resources about psoriasis in skin of colour
This study was conducted to evaluate the quality, comprehensiveness, and readability of websites providing patient information about psoriasis in skin of colour.
Investigators searched the internet for the terms “skin of colour psoriasis” and “skin of colour psoriasis treatment” using Google in Oct. 2022. They evaluated the first 50 search results for each search term with inclusion criteria including reference to psoriasis, reference to skin of colour, and patients as the primary intended audience.
The final analysis included a total of 19 websites.
Researchers found the quality of the websites was variable. The average modified DISCERN score [an instrument for assessing the quality of written information on treatment choices for a health problem] was 47 out of 80, which is categorized as fair (range: 27–64). The average JAMA Benchmark score was 2.3 out of 4 (range: 0–4, where 4 signifies higher quality). Most sources provided a publication/modification date (78.9%), provided references (63.2%), and identified an author (73.7%). Two websites listed disclosures. Most sources discussed postinflammatory hypo- or hyperpigmentation (73.7%, 14/19), oral and biologic therapies (63.2%, 12/19), and scalp psoriasis (57.9%, 11/19). Nearly one-half of the websites discussed special consideration of phototherapy in skin of colour patients, and 26.3% discussed psoriatic arthritis. Roughly 30% of the online resources included images of psoriasis in skin of colour. All sources were found to be above the recommended sixth-grade reading level.
Comorbidity burden in psoriasis patients with skin of colour
This study compares the comorbidity burden in skin of colour psoriasis patients vs. White patients, as measured by the Charlson Comorbidity Index (CCI) score.
Researchers utilized the U.S. National Ambulatory Medical Care Survey (NAMCS) to identify visits for adult psoriasis patients occurring in the years 2002-2016 and 2018. The CCI was used to objectively measure comorbidity burden. Patients were identified by race, and skin of colour was defined as any reported race besides White Only. A multiple linear regression was run to compare the CCI among adult psoriasis patients based on race and ethnicity, controlling for age, sex, insurance status, and geographic region.
The investigators analyzed a total of 39,176,928 weighted visits. Compared to White patients, patients with skin of colour did not have statistically significant differences in comorbidity burden, as measured by CCI score (p=0.073 for Black/African American Only vs. White Only, p=0.073 for American Indian/Alaska Native Only vs. White Only, p=0.435 for Asian Only vs. White Only, p=0.403 for Native Hawaiian/Pacific Islander Only vs. White Only, p=0.195 for Other vs. White Only).
The authors conclude their findings highlight that social factors such as socioeconomic status and access to healthcare may contribute more directly to psoriasis treatment outcomes than patient race.
Outcomes for psoriasis by self-identified racial groups in ixekizumab clinical trials: A pooled analysis
In this study, researchers analyzed pooled data from five clinical studies (UNCOVER-1, UNCOVER-2, UNCOVER-3, IXORA-R, and IXORA-S) with patients of different self-identified racial subgroups, who were treated with an on-label dose of ixekizumab for psoriasis through 12 weeks. The authors assessed treatment response to ixekizumab using the Psoriasis Area and Severity Index (PASI) and static Physician’s Global Assessment response rates. Patient Global Assessment of Disease Severity, Itch Numeric Rating Scale, Skin Pain Visual Analog Scale, and Dermatology Life Quality Index were used to evaluate the patient-reported outcomes (PROs) and impact on quality of life (QoL).
In all, 1,825 ixekizumab-treated patients were included. The investigators found, consistent with the clinical outcomes from the overall population, all self-identified racial groups showed rapid improvement in PASI through Week 12, although the response was somewhat slower in American Indian/Alaska Native patients. The observed differences in PROs and QoL assessments among racial groups, especially in patients who identified as Black/African American and American Indian/Alaska Native.
Evaluating minority representation across health care settings in hidradenitis suppurativa and psoriasis
This study reports racial, ethnic, and sex data of hidradenitis suppurativa and psoriasis patient populations across the emergency department, inpatient, clinical trial, and registry settings. In addition, the authors use 95% confidence intervals as proxies of statistical significance to compare demographics between settings.
Female and Black patients were underrepresented in psoriasis clinical trials compared to their population prevalence (female: 33.0% vs 54.8%; Black: 2.2% vs 5.7%). The investigators found female, Hispanic, and Black patients were underrepresented in hidradenitis clinical trials compared to their population prevalence (female: 63.7% vs 73.5%; Hispanic: 3.8% vs 12.0%; Black: 9.1% vs 20.3%). Black patients were overrepresented in the inpatient and emergency department settings in hidradenitis suppurativa (inpatient vs emergency department vs population prevalence: 49.9% vs 49.9% vs 20.3%) and in the inpatient setting in psoriasis (inpatient vs population prevalence: 19.8% vs 5.7%).
VIDEO: Exploring racial disparities in psoriasis
In part one of a three-part interview, Julia Riley, MD, Northwestern Medicine, Chicago, speaks with the authors of a study examining racial disparities in patient travel distance and time to psoriasis clinical trial sites.
At the intersection of skin and society
Dr. Tashmeeta Ahad has been awarded the first Dr. Mercy Alexis Research Grant in Skin of Color Dermatology for her project on “Longitudinal non-invasive optical biopsy of keratinocyte cancers to monitor efficacy and response to treatment.” The grant, issued by the Canadian Dermatology Foundation (CDF) through the support of CeraVe Canada, is made to an outstanding dermatologist investigator with a research project designed to improve dermatologic care for patients across the skin spectrum.
Dr. Ahad is a clinical instructor and director of translational photomedicine research at The University of British Columbia (UBC) Department of Dermatology and Skin Science, Vancouver.
This research grant celebrates the life and memory of Canada’s first Black female dermatologist, Dr. Mercy Akuffo Alexis (photo below). Growing up in Ghana and later in the U.K., Dr. Alexis practiced dermatology in Toronto for more than four decades. Her legacy of inspiring progress and inclusivity will continue to have a profound impact on the specialty, most notably on her son, Dr. Andrew Alexis, Professor of Clinical Dermatology and Vice-Chair for Diversity and Inclusion for the Department of Dermatology at Weill Cornell Medical College in New York City.
“My mother was a trailblazer and a true inspiration to me,” said Dr. Alexis in a press release. “I am deeply touched that she is being honoured in such a way and that her mission of inclusivity can live on through this research grant.”
“At CeraVe, we firmly believe in research that pushes the boundaries of science to help Canadian doctors provide care for all,” said Julie Horil, CeraVe General Manager. “This landmark partnership with the CDF honours our commitment to addressing need gaps in dermatological care to improve quality of life for a diverse patient population.”
— with notes from Allan Ryan, Editorial Director, The Chronicle of Skin & Allergy
This week
April is Sarcoidosis Awareness Month
April is Sikh Heritage Month in Canada
April 7 is World Health Day
Something to think about in the week ahead. . .
—A.P.J. Abdul Kalam, 11th President of India (1931-2015)
Next week
Dr. Raed Alhusayen discusses variations between skin types that may contribute to differences in the prevalence and appearance of hidradenitis suppurativa.
If you like Skin Spectrum Weekly, why not check out Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Drs. Brittany Waller (Regina, Sask.), Charles Lynde (Markham, Ont.), Gurbir Dhadwal (Surrey, B.C.), Ashley O’Toole (Peterborough, Ont.) and Monica Li (Vancouver) discuss new treatments for challenging diseases available or expected in 2024.
Dr. Afsanah Alavi (Rochester, Minn.) details recent research showing a link between lower limb lymphedema and skin cancer.
Drs. Reetesh Bose (Ottawa), Morvarid Hessami (Toronto), and Marissa Joseph (Toronto) describe the establishment of dermatology clinics specializing in skin of colour, and the outcomes they are achieving.
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Season three of the Vender on Psoriasis podcast with Dr. Ron Vender has begun. Listen to the new season here. In episode five, Dr. Vender discusses whether or not vitamin D has any impact on psoriasis severity, sex differences in psoriatic inflammation itch, and the risk of psychiatric disorders associated with acitretin.
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