What Factors Should Clinicians Consider When Treating Psoriasis in Skin of Color?

Mona Shahriari, MD

Credit: Middlesex Health

In a session presented at the 2023 Fall Clinical Dermatology Conference, Mona Shahriari, MD, and Andrew F. Alexis, MD, MPH, discussed the many factors dermatologists should consider when treating patients with skin of color diagnosed with plaque psoriasis.¹

Psoriasis is often underdiagnosed in this patient population due to the social determinants of health, including transportation barriers, geographic location, and economic limitations. Additionally, gaps in medical education, such as an underrepresentation of skin of color in textbooks and resources and limited training on the nuances of both diagnosing and treating this condition.

Erythema, a condition resulting in reddening of the skin, generally in patches, presents differently in melanin rich skin. Although plaques are generally pink or red in patients with lighter skin tones, they may be dark brown or gray in melanin rich skin.

The quality of life is disproportionately impacted in patients with skin of color and a psoriasis diagnosis. Shahriari recommended examining the multidimensional burden of disease using patient-reported assessments like the Dermatology Life Quality Index (DLQI) questionnaire. Alexis noted alterations in pigment, as well as cultural aspects and perceptions as factors may impact quality of life and encouraged further research evaluating these aspects.

Patients with skin of color often report a delay to systemics. Recent research demonstrated Black patients were less likely to receive biologics for psoriasis compared with White patients (13.3% vs 46.2%, respectively). Other research showed Black patients with psoriasis were less likely to receive cyclosporine and etanercept. Additionally, there may be an underestimation of disease severity, disparities in access, and a lower awareness of the disease state and treatment options.

This patient population is often under-represented in clinical trials, as demonstrated by a historical low enrollment of patients of color, which then leads to limited data on the safety and efficacy of the US Food and Drug Administration (FDA)-approved systemics for treating plaque psoriasis.

The VISIBLE study was the first large-scale psoriasis study dedicated to patients with skin of color. The Phase 3b multicenter, randomized, double-blind, placebo-controlled trial assessed the efficacy and safety of guselkumab in patients self-identified as non-White. The study included patients across the Fitzpatrick skin type scale, which may be prone to bias and lead to the exclusion of some groups, such as Middle Eastern patients.

An initial blinded placebo-controlled period randomized patients 3:1 to receive either guselkumab or placebo to week 16, after which patients in the placebo group were switched to guselkumab through week 48. Patients were then able to enter the long-term extension trial, which ran through week 112.

The primary endpoints at week 16 were ≥90% improvement in the Psoriasis Area and Severity Index (PASI90) and Investigator’s Global Assessment (IGA) 0/1 in cohort A, and ≥90% improvement in the Psoriasis Scalp Severity Index (PSSI90) and scalp-specific Investigator’s Global Assessment (ss-IGA) 0/1 in cohort B.

At week 16, 57.1% of patients receiving guselkumab achieved PASI 90 response and 74% had an IGA score of 0/1.² Patients with scalp involvement saw improvements after only 1 dose of guselkumab, with a 53.8% mean improvement from baseline in PSSI. Additionally, health-related quality of life, as evaluated using the DLQI, Skin Discoloration Impact Evaluation Questionnaire, and the Psoriasis Symptoms and Signs Diary, was improved in patients receiving the drug compared with placebo.

Shahriari noted therapeutic considerations, such as the impact of over-washing on curly or textured hair, hair care practices, and using the best formulation for a variety of hair textures and styles.

References

1. ^{Shahriari M, Alexis A. The Many Shades of Plaque Psoriasis: Considerations for Treating Patients With Skin of Color. Presented at: Fall Clinical Dermatology 2023 Conference. Las Vegas, NV. October 19 – 22, 2023.}
2. ^{Janssen Pharmaceutical Companies of Johnson & Johnson. Janssen announces Tremfya (guselkumab) demonstrates significant skin clearance in first-of-its-kind prospective, large-scale study dedicated to people of color living with moderate to severe plaque psoriasis. PR Newswire: press release distribution, targeting, monitoring and marketing. October 20, 2023. Accessed October 20, 2023. https://www.prnewswire.com/news-releases/janssen-announces-tremfya-guselkumab-demonstrates-significant-skin-clearance-in-first-of-its-kind-prospective-large-scale-study-dedicated-to-people-of-color-living-with-moderate-to-severe-plaque-psoriasis-301963282.html}