At the 2025 Skin of Color Update conference, Mona Shahriari, MD, FAAD, gave a presentation on evaluating and managing psoriasis and psoriatic arthritis (PsA) in patients with skin of color. Through epidemiologic data, clinical pearls, and real-world insights, she underscored the need for a broader diagnostic lens and more equitable treatment strategies.
Epidemiology and Disparities in Psoriasis and Psoriatic Arthritis
Psoriasis affects approximately 3% of the U.S. population (about 7.5 million people), but prevalence and presentation differ by race and ethnicity. Rates are highest among White individuals (3.6%), followed by Asian (2.5%), Hispanic (1.9%) and Black patients (1.5%). Interestingly, while psoriatic arthritis occurs twice as often in Caucasians, Black patients tend to experience greater disease severity.
These statistics, however, only tell part of the story. Dr. Shahriari emphasized that geographic and socioeconomic barriers exacerbate disparities. Many patients of color may struggle to access dermatologic care due to transportation and economic barriers and lack of nearby specialists, often leading them to seek help in urgent care or emergency room settings where access to specialty dermatologic care is limited. Compounding this issue, gaps in healthcare provider education can delay or obscure diagnoses, while a lack of culturally competent care can further postpone timely and effective therapy.
Beyond physical symptoms, the psychosocial toll of psoriasis is greater in skin of color populations. Studies show greater levels of self-consciousness, frustration, helplessness, and anger, even when controlling for disease severity (e.g., similar PASI scores). In addition, patients with PsA and skin of color are more likely to have severe plaque psoriasis and radiographic axial disease.
Diagnostic Challenges in Skin of Color: Rethinking “Red”
One of the biggest hurdles in psoriasis diagnosis among patients with skin of color is recognizing erythema. Dr. Shahriari encouraged the audience to “broaden our color palette.” In darker skin tones, erythema can appear violet, dark brown, or gray rather than bright red. Scale may be less apparent, and induration can be masked by background pigmentation.
Polarized dermoscopy can be a valuable tool, allowing better visualization of subtle erythema and differentiating active inflammation from post-inflammatory hyperpigmentation (PIH).
Scalp and Nail Psoriasis in Skin of Color
Scalp and nail involvement are particularly challenging for patients with skin of color. Scalp psoriasis is more common and more severe in Asian and Black patients, but is often underdiagnosed (or misdiagnosed) and undertreated, especially with systemic therapies. For example, in many patients with tightly coiled or afro-textured hair, haircare and washing/styling practices may limit the use of some topical formulations and daily medicated shampoos. The diagnosis of nail psoriasis in skin of color can be delayed owing to longitudinal melanonychia and darker nail beds obscuring classic features of nail psoriasis. As such, nail disease can be more severe at diagnosis. Beyond the skin, those with scalp psoriasis are at a 3- to 4-fold higher risk of PsA, and nail psoriasis is an independent risk factor for PsA, which is why timely diagnosis and intervention is critical.
Diagnosing Psoriatic Arthritis in Skin of Color
Diagnosing PsA is inherently complex, and even more so in patients with skin of color. Over 80% of PsA presents with skin as the first sign of their joint disease with only 10-15% of patients having joint pain before the psoriasis develops. However, due to challenges in diagnosing psoriasis in skin of color, it is not surprising that PsA goes undiagnosed or misdiagnosed as another inflammatory arthritis in those with skin of color.
Furthermore, lower health literacy and limited disease awareness in our skin of color communities, and the absence of uniform diagnostic or biomarker criteria contribute to diagnostic delay. Early identification through thorough history (including review of systems and a modified PEST questionnaire) and physical exam (joint palpation) remains essential.
Delays in Systemic Therapy in Skin of Color
Even when diagnosed, patients with skin of color are less likely to receive systemic or biologic therapy. Studies show Black patients are less frequently prescribed biologics or cyclosporine and are less likely to receive disease-modifying anti-rheumatologic therapies for newly diagnosed PsA.
Dr. Shahriari highlighted some reasons for this, including underestimation of disease severity, limited access to dermatologic care, and lower disease awareness. Another significant contributor is the underrepresentation of skin of color patients in dermatology clinical trials, in particular for psoriasis and PsA. Encouragingly, emerging data from post-hoc analyses of approved treatments (e.g., etanercept, brodalumab, risankizumab) and the first large-scale prospective study, the VISIBLE trial, assessing the safety and efficacy of guselkumab across diverse skin tones (discussed below) are beginning to bridge this gap.
The VISIBLE Study
The VISIBLE trial aimed to study the safety and efficacy of guselkumab as well as evaluate psoriasis and treatment outcomes in skin of color patients across all skin tones using a combination of objective and patient reported parameters. This study was highly inclusive and included any patient that identified as non-white. As a result, it enrolled a racially and ethnically diverse cohort, encompassing the full spectrum of Fitzpatrick skin types (including Central American, Cuban, and Middle Eastern participants). This underscores the importance of inclusive trial designs that go beyond the basic definitions of certain racial/ethnic groups or Fitzpatrick skin types in a “skin of color” cohort. It also highlighted the power of polarized imaging to help differentiate erythema from hyperpigmentation to appropriately assess disease activity and severity, which ultimately guides treatment decisions. Comorbidities such as hypertension and diabetes were common in this cohort but found to be undiagnosed or poorly controlled in a majority of patients, underscoring the importance of comprehensive care and involvement of primary care for optimal management of psoriatic comorbidities.
In this study, clinically meaningful improvement (PASI 90) was achieved by 75% of patients at 1 year. There was complete scalp clearance in 60% of patients by week 48. PsA was present in 30% of the study patients, with most of these patients being diagnosed during the study itself. Clinically meaningful improvements in joint symptoms and quality of life were seen in about 60% of patients.
Interestingly, pigmentary alteration had a greater impact on quality of life than disease activity (measured by PASI score) in patients with skin of color. Dr. Shahriari emphasized the importance of acknowledging this and counseling patients about post-inflammatory pigment changes, and setting the expectation that this can take months to years to improve despite adequate control of psoriasis and/or PsA. Treatments for this include topical skin lightening agents, chemical peels, and having a low threshold to consider systemic therapy. Prevention is almost always easier than treatment.
Real-World Case
Dr. Shahriari shared the case of a 29-year-old Hispanic man with psoriasis involving 20% body surface area who was previously diagnosed with eczema and tinea. He presented with severe plaque psoriasis, joint pain and dactylitis, and required a cane to walk. After initiating biologic therapy, he achieved significant improvement (PASI90) at 16 weeks and no longer needed his cane after 6 months. His quality of life improved dramatically, and he was able to return to full-time work and lose 40 lbs. in weight. He did experience persistent dyspigmentation and still considered this bothersome: a reminder that PIH, while not captured in PASI scores, significantly impacts patients with skin of color.
Summary and Clinical Pearls
- Broaden your color palette: Erythema may appear violet, gray, or brown.
- Assess severity accurately: PIH and scarring can mask activity.
- Do not undertreat: Topical, oral, biologic, and phototherapy options exist for all skin types.
- Psoriasis and PsA have many faces and are often underdiagnosed in patients with skin of color.
- Avoid undertreatment, with a lower threshold for systemic therapy in patients with severe disease or joint symptoms.
- Skin of color patients are particularly bothered by post-inflammatory pigment alterations. Set realistic expectations about this, initiate early treatment, and consider therapies directly aimed at this.
- Understanding population-specific practices (e.g., hair care), and treatment preferences and barriers is part of providing culturally competent dermatologic care in patients with skin of color.
This information was presented at the 2025 Skin of Color Update conference by Mona Shahriari, MD, FAAD. The above highlights from this lecture were written and compiled by Riyad N.H. Seervai, MD, PhD.
