Systemic treatments in Canada’s remote communities
Considering the barriers to biologic treatments for dermatologic conditions in Indigenous people (1,300 words, 6 minutes)
The monitoring requirements and risk of side effects from some systemic therapies make treating psoriasis and atopic dermatitis particularly challenging in remote communities, Dr. Rachel Netahe Asiniwasis told physicians at the second annual Indigenous Skin Spectrum Summit on June 11, 2022. These factors have a significant impact on the health of Indigenous peoples, she said.
Dr. Asiniwasis is a dermatologist in Regina. She and her team serve remote northern First Nations communities through fly-in visits and teledermatology clinics.
She noted many of her patients with immune-driven skin conditions are on immunosuppressants or biologics. Because labs may be inaccessible or a long distance away, it can be challenging to arrange the X-rays or tuberculosis tests necessary for those patients, many of whom have poorly controlled comorbidities and no regular general practitioner (GP). Watching for signs of infection or side effects is also necessary for physicians who have patients on immune-suppressing medications.
Even before the challenges facing patients undergoing these treatments, there can be significant barriers to prescribing them to Indigenous patients on the non-insured health benefits (NIHB) plan.
To be prescribed a biologic psoriasis treatment, a patient must have moderate-to-severe disease. As well, other treatment options must be unavailable or inappropriate. Patients must not have access to phototherapy. They must have shown an intolerance to methotrexate and cyclosporine, have not responded to treatment with those medications before or have a contraindication. The prescription must also come from a dermatologist. It can be a battle and require significant paperwork to clear those hurdles, Dr. Asiniwasis said.
Psoriasis patients treated with methotrexate or cyclosporine must be under ongoing supervision by a physician due to the risk of severe side effects. These side effects can be difficult to manage in remote and northern communities.
“I will be honest, this has been the most challenging thing for me to date in my practice, trying to manage these patients and get them on something safe,” said Dr. Asiniwasis. “What is the safe practice if we cannot monitor them properly? Are the GPs and NPs [nurse practitioners] comfortable managing the potential for the side effects, or does the burden fall on the most responsible prescriber and primary physician, which is me?”
She said that patients with atopic dermatitis (AD) can more easily be prescribed the biologic dupilumab through NIHB. There are fewer requirements to try other medications before dupilumab can be used, Dr. Asiniwasis said.
Bottom Line: It can be difficult for patients with psoriasis or AD living in remote Indigenous communities to have proper testing done because these communities are underserved by medical practitioners. This can delay treatment with biologics or make monitoring impractical. Poor access to biologics puts patients at greater risk of side effects from other medications.
From the literature on treating psoriasis in limited-resource areas
Occurrence and challenges in the management of severe chronic plaque-type psoriasis in a limited resourced setting: A case report
The authors of this paper discuss how psoriasis cases can often be complex in areas with limited medical resources. Using the case of a 50-year-old man living with severe psoriasis for some time, they discuss the challenges in obtaining newer treatment options. They also discuss the importance of physicians and other health workers counselling to keep patients on a treatment regimen.
They conclude that incentives aimed at subsidizing newer systemic agents for patients in low-resourced populations would be very valuable in improving their psoriasis.
Psoriasis in Tigray, Ethiopia: Focusing on available treatments
This paper reviews the records of 1,288 individuals with psoriasis or psoriatic arthritis treated in hospitals in Tigray, Ethiopia. Among their findings, the authors note there is poor access to modern therapies, with the only available conventional treatments for psoriasis being methotrexate, topical steroids, salicylic acid, and sun exposure. In more impoverished, rural areas, patients use some traditional African plants such as Kigelia africana. These plants have been shown to have partial benefits in treating psoriasis.
The authors conclude that more studies are needed on the appropriate management of people with psoriasis in low-income regions, including standardization of Indigenous therapies and a reduction of costs of conventional medications.
Exploring biologic treatment hesitancy among Black and Indigenous populations in Canada: A review
This literature review was performed to try and identify what might be driving a disparity in the use of biologic treatments in Black and Indigenous populations in Canada.
The authors identify several broad categories of influences on these decisions. These include social inputs from family and community; biological factors including prior negative reactions to injections; cultural tenets; and historical and systemic factors.
The authors highlight the socioeconomic factors, including medication costs and lack of access to specialists. One recommendation for eliminating the disparity in biologic use is removing or reducing financial barriers to care.
VIDEO: Webinar June 29 - Social determinants of health: Key concepts and practical considerations
At the intersection of skin and society
There is a need to define the Black population in medical research more accurately, said Jude Mary Cénat, Ph.D., in a commentary published in CMAJ (Canadian Medical Association Journal).
Dr. Cénat is an associate professor of psychology and the director of the University of Ottawa’s Interdisciplinary Centre for Black Health, Canada's first academic research centre dedicated to studying the biological, social and cultural determinants of health for Black communities.
In his commentary, Dr. Cénat notes that in recent research into the health of Black people in Canada, the way that researchers have defined who is Black has varied considerably. These have included “Black Canadians,” “Black individuals, people or communities,” “African-Canadian,” “African,” “Caribbean,” composite categories such as “African, Caribbean and Black,” and more.
He argues that the use of many different expressions when describing Black people in health research makes study findings less valuable and more challenging to compare studies.
He notes that the inconsistency in terminology may lead to study populations including people who do not self-identify as Black. For example, individuals from North Africa may self-identify as Arab or from parts of the Caribbean where people consider themselves first as Latin Americans.
“Accurate, reliable and unambiguous data should be used for research to inform public health policies, training policies for health care workers and culturally appropriate and antiracist health care practices for Black communities,” Dr. Cénat writes in the commentary.
“Inability to find a common term to describe Black people in health research in Canada may perpetuate the inequities observed in the nascent state of health research on Black health in Canada.”
Dr. Cénat suggests one way to deal with this ambiguity is for researchers to ask follow-up questions when asking study participants to identify their race.
“For example, if participants indicate that they identify as Black, they can then be asked to elucidate their country of origin or that of their parents, and generation status, if applicable,” he said.
Researchers can also break down samples into more subgroups, such as Nova Scotians, people from the Caribbean, Africa, South or Central America, etc.
“It is also important to give participants the opportunity to indicate more than one answer when answering regarding racial identification, to allow multiracial people to accurately self-identify,” Dr. Cénat said.
August 12 is International Youth Day
Something to think about in the week ahead. . .
We cover a presentation at the 2022 Indigenous Skin Spectrum Summit by Dr. Kun Tian, an allergist and clinical immunologist who often practices in Yellowknife. Dr. Tian discussed the barriers to care for Indigenous patients with eczema and allergic diseases in Canada’s remote northern communities.
Upcoming events and learning opportunities
Registration is open for the 2022 Summer of Dialogue: Focus on Black Skin, which will be held virtually on Wed. August 17, 7:00 PM to 8:30 PM EDT.
In recognition of persistent gaps in dermatologic training regarding skin of colour, the Summer of Dialogue colloquium, Focus on Black Skin, will discuss recent progress on advancing the inclusion of diverse skin tones in research and medical education.
This 90-minute live discussion will address treatment challenges specific to Black skin (Fitzpatrick Types V & VI), including phenotypic variations from standard training models and the necessity of cultural competence.
This non-accredited program will be available to attend at no charge, thanks to the support of our sponsors.
Highlights of the event include:
The Dr. Mercy Alexis Keynote Lecture: Gaps in Aesthetic Treatment for Richly Pigmented Skin by Dr. Pearl Grimes of Los Angeles
Moderator: Dr. Andrew F. Alexis
Educating new and existing HCPs on optimal skincare for Black patients
Register for the 2022 Summer of Dialogue: Focus on Black Skin here:
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Enjoy podcasts? In the fourth episode of season two of the Vender on Psoriasis Podcast, Canadian dermatologist Dr. Ronald B. Vender talks about treating psoriasis with teledermatology during the pandemic, air pollution triggering psoriasis flares, and ixekizumab response in pediatric plaque psoriasis patients.