Psoriasis Is Misdiagnosed and Undertreated in Nonwhite Patients

By Linda Rath | Jan. 5, 2024

More than 7.5 million people in the U.S. have psoriasis, a chronic autoimmune disorder marked by scaly, inflamed patches of skin. About one-third of them go on to develop psoriatic arthritis (PsA), usually a decade or so after skin symptoms appear. It’s also possible to have PsA without psoriasis or for arthritis and psoriasis to occur at the same time.

No one can predict who will develop PsA — at least not yet — though obesity, smoking, certain genes and imbalances in the skin and gut microbiomes increase the risk. Having scalp or nail psoriasis makes PsA more likely, too. Studies suggest that diagnosing and treating psoriasis early may delay or prevent arthritis, even in at-risk patients. Yet people of color generally have a slim chance of getting timely treatment. Fewer than half are ever referred to a dermatologist, and they often wait three years longer than whites before they receive a correct diagnosis.

Psoriasis worse in people of color

Recent research shows that whites are twice as likely to have psoriasis compared to other races and ethnicities. Yet studies also show that psoriasis and other skin conditions are often missed in Blacks, Hispanics and Asians and are likely undercounted.

Furthermore, psoriasis is worse in people of color. In one survey of psoriasis patients, African Americans had lesions over 3% to 10% of their body compared to 1% to 2% for whites. Hispanics and Asians also had more severe symptoms. Yet in the U.S., it’s common for people of color to receive little or no effective treatment for psoriasis. Black Medicare recipients, for example, are 70% less likely to receive a biologic drug for severe psoriasis than white patients are.  

Poor treatment and undertreatment have serious consequences. Psoriasis gets worse without effective therapy, damaging skin and taking a psychological toll. The inflammation that fuels psoriasis worsens, too, increasing the chance of complications like diabetes and heart disease. Overall, nonwhite psoriasis patients have worse outcomes and are more likely to be hospitalized than white patients are.

Because their condition often isn’t recognized at first, they also miss the window of opportunity when psoriatic arthritis might be prevented, and they have more serious symptoms if they develop it. A 2023 study  at NYU’s Arthritis Center in New York City found that nonwhite PsA patients had more pain than white patients, more co-existing health problems and higher rates of axial arthritis, which can permanently damage the joints and spine.

Another problem with delayed treatment is discolored scars that develop in nonwhite patients after psoriasis lesions heal. These sometimes unsightly scars often can be prevented if people are treated early enough.

Reasons for dermatology’s skin color problem

Inequity pervades American health care, but certain inequities are particular to dermatology, the specialty that diagnoses and treats skin, hair and nail conditions. There are lots of reasons for this, many based on faulty beliefs and practices dating back generations. As recently as 2016, 40% of U.S. medical students believed Black people had thicker skin than whites.

Dermatology is a nearly all-white specialty in the U.S., where only 3% of dermatologists are Black and a little more than 4% are Hispanic. This means an almost complete lack of culturally competent providers — that is, doctors who understand, look like and know how to treat diverse patients. And like their white counterparts, specialists of color are trained on white skin.

The gold standard test for psoriasis, the Psoriasis Area and Severity Index (PASI) measures the redness, thickness and scaliness of psoriasis lesions. But psoriasis isn’t red on dark skin — it’s purplish or brown and may be hard to see. Scale may also look different. PASI can be unreliable on white skin and can lead to misdiagnoses or missed diagnoses in nonwhite people.

Dermatology textbooks, too, are notorious for ignoring people of color. In one study of more than 1,200 medical images of nail psoriasis, only 4% showed the disease on nonwhite skin. During the COVID-19 pandemic, dermatologists compiled a worldwide registry of skin conditions associated with the virus. Of more than 700 patients in this international registry, 24 were Hispanic or Latino, 15 were Asian and seven were Black.  

The same lack of diversity plagues clinical trials, where women and racial and ethnic minorities other than Asians are historically underrepresented. Nonwhite groups make up 40% of the U.S. population but just 13.4% of participants in psoriasis clinical trials. In trials that are more inclusive, common medications that seem safe and effective for white patients may not work as well or at all for people of color. This includes both topical ointments and systemic drugs like adalimumab (Humira).   

Then there’s direct-to-consumer advertising. One study looked at 13 psoriasis drug ads that aired on TV during a two-week period. (The U.S. and New Zealand are the only countries in the world that allow such ads.) The vast majority of patients in the ads were white and those ads ran almost three times as often as those with Asian or Black actors.

The American Academy of Dermatology issued a plea in 2023 for more and better depictions of skin conditions in people of color and equity in clinical trials. It’s now backing various efforts to rectify dermatology’s color problem by actively recruiting providers of color and doing a better job of educating white ones.

Social determinants of health

Having too few providers who look like and can relate to people of color is one problem. A lack of health insurance is another. Native Americans, Alaska Natives and Hispanics have the highest uninsured rates, followed by Native Hawaiians and Blacks. But finding a remedy for these ills is only a small part of health equity, which is the right for everyone to be as healthy as possible. It’s now clear that social factors outside of medicine play the biggest role in health outcomes.

Those factors include discriminatory practices that affect health — everything from food and job insecurity to decades of redlining that forced nonwhite communities into neighborhoods with substandard schools, cancer-causing pollution and no safe places to play and exercise. Children and adults of color are also more likely to experience daily microaggressions as well as the potential for violence. Discrimination leads to poor health, which, without affordable, culturally sensitive heath care, only gets worse.