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Jul 10
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Psoriasis and Psoriatic Arthritis in Patients With Skin of Color: Diagnostic Insights and Advancements in Treatment

By Sessions

psoriasis in skin of color

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.

Jul 02
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Forgotten Conditions in Skin of Color: Dissecting Cellulitis, Acne Keloidalis Nuchae, and More

By Sessions

acne keloidalis nuchae

At the 2025 Skin of Color Update, Prince Adotama, MD, FAAD, started his lecture with a discussion on acne keloidalis nuchae (AKN), a chronic inflammatory condition that leads to fibrotic papules, plaques and potentially keloidal nodules and plaques. This occurs most commonly in African Americans with a reported prevalence up to 13.6%. The pathogenesis of AKN is poorly understood but is thought to be initiated by a mechanically induced folliculitis that becomes extensive enough to result in scar formation. Similarly to pseudofolliculitis barbae (PFB), trauma and mechanical irritation could lead to a primary cicatricial alopecia.

Dr. Adotama also highlighted the role of metabolic syndrome in patients with AKN, citing multiple studies demonstrating a strong association between AKN and metabolic syndrome. It is important that physicians are aware of this possible comorbidity, and similar studies have shown increased risk of hypertension and hypothyroidism in patients with AKN.

Treatment for AKN includes topical and/or oral antimicrobials/antibiotics, as well as topical retinoids, topical steroids, and steroid injections. Laser hair removal (LHR) using diode and Nd:YAG and Alexandrite lasers can be helpful in the early papular stages. Surgical excision is recommended for keloidal plaques that are greater than 3 cm.

Additionally, unlike PFB, patients with AKN can utilize higher potency topical steroids. Dr. Adotama discussed that two weeks on and two weeks off for 8 weeks of topical clobetasol can be used, followed by betamethasone valerate for 4 weeks. This regimen did not yield any side effects of skin atrophy and showed a significant decrease in symptoms at 12 weeks. For patients that can tolerate intralesional steroids, using a strength as high as 40 mg/mL can be used in some cases if there is a keloidal component.

Dr. Adotama focused on an improved injection technique for AKN, where the clinician takes 5-10 mg/mL of triamcinolone and injects 0.1 mL aliquots into the deep dermis in 1 cm intervals until the entire area of involvement is completely treated (in contrast to injecting each individual lesion). This technique was published in the Journal of Dermatologic Surgery in July 2023, where Dr. Adotama presented a case of a 24-year-old man with Fitzpatrick skin type VI who had a six-year history of AKN. The patient had no prior treatments and after one round of deep dermal injections with triamcinolone 5 mg/mL (total volume of 1.4 mL) with topical clindamycin, the patient demonstrated significant improvement.

Dr. Adotama also reviewed the use of topical diclofenac sodium gel in the treatment of both AKN and dissecting cellulitis of the scalp (DCS). Although the mechanism of diclofenac sodium gel for either of these conditions is not fully described, the authors hypothesized that the diclofenac-related effects might result in an overall decrease in the neutrophilic and mixed-lymphocytic infiltrate in hair follicles of patients with DCS and AKN. Four patients were followed (3 with DCS and 1 with AKN) in this study. All 3 patients with DCS showed substantial improvement with diclofenac gel monotherapy, with most lesions resolving within a 3-month treatment period. A similar response was observed in the patient with AKN after 1-month of therapy.

For patients with a papular component, use of the long-pulsed Nd:YAG laser in conjunction with topical steroids has shown promising results in the treatment of AKN. Dr. Adotama highlighted a decrease in global assessment score on the treated side as compared to the control side, which although not statistically significant, did show clinical improvement. In a sub analysis that excluded patients with nodules and plaques, there was a statistically significant change between the treatment and control side, highlighting the importance of early treatment at the papular stage.

In patients who have more extensive disease, AKN lesions can be removed via a horizontal ellipse that includes the posterior hairline. Dr. Adotama highlighted the importance of this technique, as two of the six patients had a nonelliptic excision of the posterior aspect of the scalp that spared the posterior hairline and resulted in an inferior cosmetic outcome. A review from 2025 of surgical complications from AKN removal highlighted the low rate of complications, with an approximate 19% incidence of AKN recurrence after excision, an 11% incidence of hypertrophic scarring, and 3% incidence of infection.

Overall, Dr. Adotama provided three main topical treatment recommendations for patients with AKN:

  1. Retinoid: Vary strength depending on skin sensitivity and hyperpigmentation
  2. Steroid: Choose a mid-high potency
  3. Antimicrobial or antibiotic: Typically, benzoyl peroxide or clindamycin combination, although patients may require an oral antibiotic

In addition to topical treatments, injections are often necessary and Dr. Adotama recommended using the deep dermis technique with 5-10 mg/mL concentration for the papular variant.

Dissecting Cellulitis (DCS)

DCS is a neutrophilic alopecia with IL-1 playing an important role. Hidradenitis suppurativa (HS) is a comorbidity given its shared pathway, and one study found that more than half of patients with DCS presented with comorbidities related to follicular occlusion tetrad, with HS being the most frequent. Dr. Adotama also highlighted his study on long-term cardiovascular morbidity in DCS and found that DCS is associated with elevated risk of thrombotic and ischemic events similar to those reported in HS and moderate-to-severe psoriasis.

DCS most commonly presents in the second to third decade of life in African American men. It progresses through stages with the first stage marked by isolated nodules/abscesses and separated by normal skin without intercommunicating sinus tracts or scarring alopecia. As the disease progresses from stage II to III, it begins to demonstrate nodules and abscesses with intercommunicating sinus tracts, with the hallmark of stage III being scarring or permanent alopecia.

Treatment Options for Dissecting Cellulitis

Isotretinoin can be considered in refractory cases to topical therapy. Second-line therapy includes biologics, with TNF-alpha inhibitors having the highest efficacy (87% of patients demonstrated a sustained improvement). Additionally, dapsone can be used for stage II or III disease with or without isotretinoin. Surgery is also an option for patients and can be curative with 95% of patients in one study demonstrating sustained improvement.

Dr. Adotama discussed updated cases of patients who were trialed on a variety of biologics with improvement in DCS. One patient, a 26-year-old male with DCS, experienced significant clinical improvement following a short course of upadacitinib. The patient had tried and failed multiple other treatment modalities, however, following the initiation of upadacitinib, the patient had reduced pain and significant improvement in his quality of life. Apremilast was also utilized in a patient who had been recalcitrant to topical and systemic therapy (including isotretinoin, minocycline, Bactrim, and adalimumab). After 6 months of 30 mg twice-daily apremilast, the patient reported dramatic improvement in disease symptoms and reduction in flares with no notable side effects.

Dr. Adotama concluded his presentation with information on the Scarring Alopecia Foundation, a nonprofit organization dedicated to raising awareness, supporting research, and providing education about cicatricial (scarring) alopecias. Its mission includes offering resources to patients, connecting them with specialists, and funding scientific studies aimed at understanding and treating scarring hair loss disorders.

References:

Adotama, P., Grullon, K., Ali, S., & Okoye, G. A. (2023). How we do it: our method for triamcinolone injections of acne keloidalis nuchae. Dermatologic Surgery, 49(7), 713-714.

Alexis, A., Heath, C. R., & Halder, R. M. (2014). Folliculitis keloidalis nuchae and pseudofolliculitis barbae: are prevention and effective treatment within reach?. Dermatologic clinics, 32(2), 183-191.

Badaoui, A., Reygagne, P., Cavelier‐Balloy, B., Pinquier, L., Deschamps, L., Crickx, B., & Descamps, V. (2016). Dissecting cellulitis of the scalp: a retrospective study of 51 patients and review of literature. British Journal of Dermatology, 174(2), 421-423.

Bernard, J. W., Reddy, S., & Flowers, R. H. (2023). The successful use of oral apremilast for a case of dissecting cellulitis. JAAD Case Reports, 39, 122-124.

Callender, V. D., Young, C. M., Haverstock, C. L., Carroll, C. L., & Feldman, S. R. (2005). An open label study of clobetasol propionate 0.05% and betamethasone valerate 0.12% foams in the treatment of mild to moderate acne keloidalis. Cutis, 75(6), 317-321.

Gamissans, M., Romaní, J., López‐Llunell, C., Riera‐Martí, N., & Sin, M. (2022). Dissecting cellulitis of the scalp: A review on clinical characteristics and management options in a series of 14 patients. Dermatologic Therapy, 35(8).

Hinson, C., Sink, M., Odobescu, A., Sammer, D. M., & Zhang, A. Y. (2025). Surgical management of acne keloidalis nuchae: A systematic review of outcomes and techniques. Journal of Plastic, Reconstructive & Aesthetic Surgery, 104, 102-112.

Islam, Z., Toker, M., Gandhi, I. M., Sher, A., Campton, K., & Gandhi, I. (2024). Improvement of recalcitrant dissecting cellulitis of the scalp after a trial of upadacitinib. Cureus, 16(1).

Kridin, K., Solomon, A., Tzur-Bitan, D., Damiani, G., Comaneshter, D., & Cohen, A. D. (2020). Acne keloidalis nuchae and the metabolic syndrome: a population-based study. American Journal of Clinical Dermatology, 21(5), 733-739.

Lee, C. N., Chen, W., Hsu, C. K., Weng, T. T., Lee, J. Y. Y., & Yang, C. C. (2018). Dissecting folliculitis (dissecting cellulitis) of the scalp: a 66‐patient case series and proposal of classification. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 16(10), 1219-1226.

Maranda, E. L., Simmons, B. J., Nguyen, A. H., Lim, V. M., & Keri, J. E. (2016). Treatment of acne keloidalis nuchae: a systematic review of the literature. Dermatology and therapy, 6(3), 363-378.

Melo, D. F., Ramos, P. M., Machado, C. J., Anzai, A., Blanco, A., Mulinari-Brenner, F., … & Doche, I. (2022). Dissecting cellulitis in women: a retrospective multicenter study with 17 patients. International journal of dermatology, 61(11), e427-e430.

Michelen-Gómez, E. A., Chiesa Fuxench, Z. C., Cancel-Artau, K. J., Guerrero, A., Ibrahim, O., Santaliz-Ruiz, L. E., 4th, & Colon-Fontanez, F. (2023). Treatment of acne keloidalis nuchae and dissecting cellulitis of the scalp with diclofenac sodium gel: a case series. JAAD case reports, 42, 113–116. https://doi.org/10.1016/j.jdcr.2023.09.008

Ogunbiyi, A. (2016). Acne keloidalis nuchae: prevalence, impact, and management challenges. Clinical, Cosmetic and Investigational Dermatology, 483-489.

Patel, D., Thakker, S., Olagun-Samuel, C., Wang, D., Mitchell, J., & Adotama, P. (2025). Long-term cardiovascular morbidity in dissecting cellulitis: A propensity-matched TrinetX cohort study. Journal of the American Academy of Dermatology, 93(6), 1614-1616.

Saka, B., Teclessou, J. N., Akakpo, S. A., Pessinaba, S., Gnossike, P., Mahamadou, G., … & Pitché, P. (2020). Acne keloidalis nuchae and hypertension in black subjects: a case–control study. BMC Research Notes, 13(1), 431.

Shah, G. K. (2005). Efficacy of diode laser for treating acne keloidalis nuchae. Indian Journal of Dermatology, Venereology, and Leprology, 71(1), 31.

Sperling, L. C., Homoky, C., Pratt, L., & Sau, P. (2000). Acne keloidalis is a form of primary scarring alopecia. Archives of dermatology, 136(4), 479-484.

Thomas, J., & Aguh, C. (2021). Approach to treatment of refractory dissecting cellulitis of the scalp: a systematic review. Journal of Dermatological Treatment, 32(2), 144-149.

Valdman-Grinshpoun, Y., Kridin, K., Schonmann, Y., & Cohen, A. D. (2021). Acne keloidalis nuchae and thyroid diseases: a population-based cohort study. International journal of dermatology, 60(4), 466–470. https://doi.org/10.1111/ijd.15331 

This summary was prepared by Dr. Courtney Hanna, dermatology resident, who attended the session. The content reflects the resident’s notes and interpretations, may contain errors, and is provided for educational purposes only. It does not constitute official faculty endorsement and should not replace original sources or clinical judgment.

Jun 24
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How to Prevent and Manage Laser & Device Complications in Patients With Skin of Color

By Sessions

laser and device complications

Patients with skin of color are at a greater risk of complications when treated with lasers and devices. Next Steps in Derm, in partnership with Skin of Color Update, interviewed Dr. Arielle Kauvar, clinical professor of dermatology at the NYU Grossman School of Medicine, for her pearls on preventing and managing complications. Watch as Dr. Kauvar explains the different cooling methods used to prevent pigmentary alterations due to laser and device treatment. Find out how Dr. Kauvar conducts pre-procedure exams and why she says they are important. Plus hear how taking certain steps before treatment can prevent complications.

Further Reading

If you want to read more about using lasers and devices in patients with skin of color, check out the following articles published in the Journal of Drugs in Dermatology:

A Single-Center, Open-Label, Prospective Study of a 589/1319 nm Dual Wavelength Laser for the Treatment of Facial Hyperpigmentation

ABSTRACT

Background: Facial hyperpigmentation, characterized by the excessive production of melanin in the skin, is a prevalent dermatological concern affecting individuals of various ethnic backgrounds.

Aims: To evaluate the safety and efficacy of a multi-wavelength 589/1319 nm dual-pulse duration laser device for the treatment of hyperpigmentation

Patients/Methods: A total of 17 healthy women (mean [SD] age of 43.4 [11.6] with skin phototype II-IV) were enrolled in this prospective, single-center study. Eligible participants received up to 3 treatments spaced 3 to 5 weeks apart with 2 follow-up visits at 4 and 12 weeks after the final treatment. Assessments included investigator ratings of skin quality, global aesthetic improvement, and hyperpigmentation. Safety and tolerability were monitored throughout the study.

Results: Significant improvements in hyperpigmentation and skin quality were observed at the 2 follow-up visits from baseline in most patients per investigator assessments. Patient satisfaction was high, and treatments were safe with transient self-resolving side effects such as erythema.

Conclusions: Laser treatments using a dual-wavelength 589/1319nm device significantly improve facial hyperpigmentation in patients of various skin types.

Supplement Individual Article: Algorithm for Pre-/Post-Procedure Measures in Racial/Ethnic Populations Treated With Facial Lasers, Nonenergy Devices, or Injectables

ABSTRACT

Background: Cosmetic procedures with lasers, nonenergy devices, and injectables are increasing in popularity among patients with skin of color. Published algorithms address measures to reduce side effects related to aesthetic procedures; however, none focus on reducing adverse events in skin of color.

Methods: An expert panel of dermatologists and plastic surgeons conducted face-to-face and online meetings to develop an algorithm for measures before, during, and after using aesthetic devices (energy and nonenergy-based) and injectable treatments based on the best available evidence for skin of color. Published algorithms and literature searches for aesthetic procedures provided guidance for the current algorithm. A modified Delphi method was used to reach a consensus to apply outcomes of literature searches, along with expert opinion, resulting in the current algorithm.

Results: The four sections of the algorithm outline an approach to optimize outcomes with specific before, during, and after procedure considerations. Pre-procedural consultation includes the development of a specific treatment plan based on individual patient goals and risk profile (including history and signs that may predict a higher risk for pigmentary or scarring complications). Before the procedure, sun avoidance and sunscreen use are emphasized; herpes simplex virus 1 prophylaxis and bleaching agents are administered if indicated. During the procedure, skin cleansing products are addressed, along with judicious techniques to minimize unintended cutaneous injury or inflammation. Post-procedural sunscreen and gentle skincare that may include skin-lightening agents or formulations designed to prevent infection and promote optimum healing are advised.

Conclusions: The algorithm strives to optimize treatment outcomes for patients with skin of color by providing their physicians with guidance on measures before, during, and after office-based medical aesthetic procedures.

Did you enjoy this video interview? Find more here.

Jun 16
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Pigment-Specific Dermoscopy and AI: From the SOCU Poster Hall

By Medical Dermatology

pigment-specific dermoscopy and AI

The “diagnostic gap” remains a sobering reality in dermatology. In Black patients, 52% of melanomas are diagnosed at a late stage, compared to just 16% in White patients. In addition, traditional “classic” patterns often fail dermatologists when diagnosing conditions in Fitzpatrick skin types V and VI. A poster presented at Skin of Color Update explores how to bridge this gap through pigment-specific dermoscopy and AI.

The highlights:

  • The Bias Reality Check: “Off-the-shelf” AI tools can drop from 70% accuracy in lighter skin to as low as 17% accuracy for Fitzpatrick Type VI.
  • The Power of Integration: When AI is optimized for skin of color and paired with high-quality dermoscopy, diagnostic sensitivity can jump from 63.4% to 86.1%.
  • New Clinical Pearls: Learn why you must look for skin of color-specific features like eccrine pigmentation and central hyperpigmentation to improve your diagnostic yield.

AI isn’t here to replace your clinical nuance—it’s here to be the “second opinion” that helps catch the “can’t-miss” diagnoses.

Read a Next Steps in Derm interview with lead author Zahraa Rabeeah, MD, to learn how to enhance your practice today.

 

Jun 12
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The Role of JAK Inhibitors in Treating Patients With Skin of Color

By Sessions

JAK inhibitors

At the 2025 Skin of Color Update conference, Brett King, MD, PhD, FAAD, delivered a thought-provoking presentation focused on knowledge gaps in JAK inhibitor use among patients with skin of color. Moving away from a case-based approach, Dr. King emphasized the need for inclusive clinical data and nuanced understanding of the efficacy of JAK inhibitors across different patient populations.

The Expanding Landscape of JAK Inhibitors

Over the past decade, eight JAK inhibitors have received FDA approval across a wide range of indications from dermatologic diseases to hematologic malignancies. With over 50 cytokines signaling through the JAK-STAT pathway, it’s no surprise that these agents have revolutionized inflammatory skin disease management. Key cytokines driving dermatologic conditions include IL-4, IL-13, and IL-31 (atopic dermatitis and itch), IL-12 and IL-23 (psoriasis), and IFN-γ (alopecia areata, vitiligo, sarcoidosis, lichen planus, and granuloma annulare).

Atopic Dermatitis: Evidence Across Diverse Populations

Dr. King highlighted several post-hoc analyses of pivotal JAK inhibitor trials analyzing efficacy across racial and ethnic groups.

  • Abrocitinib trials included nearly 9% Black and 22% Asian participants and showed comparable improvements in IGA and itch scores across racial groups and Fitzpatrick skin types.
  • Upadacitinib studies demonstrated a dose-dependent difference: at 15 mg daily, Black patients achieved EASI90 at slightly lower rates than White patients, a gap that disappeared at the higher 30 mg daily dose.  Black patients also experienced a numerically lower itch reduction compared with Asian and White patients at 15 mg, with this difference also seen at the 30 mg daily dose.
  • Ruxolitinib cream analyses showed somewhat lower IGA success rates in Black patients (26.6%) versus Asian (51.3%) and White (45%) participants, though the differences were modest.

Overall, these findings affirm that JAK inhibitors are effective across populations but underscore the need for larger datasets to confirm consistency and optimize dosing strategies in skin of color. Dr. King also raised the question of whether some of the differences seen may be due to challenges with grading disease severity in Black patients with atopic dermatitis.

Vitiligo: Reassuring Efficacy in Patients with Skin of Color

  • In pooled phase 3 data of ruxolitinib cream for vitiligo, the proportion of Black and Asian participants was similar to that in atopic dermatitis studies. Interestingly, efficacy appeared numerically higher in Black patients, possibly due to easier visualization of repigmentation in darker skin.
  • Multiple oral JAK inhibitors are currently in development for vitiligo, which could expand treatment options further.

Alopecia Areata: Diagnostic Nuances in Black Patients

With three JAK inhibitors (ritlecitinib, baricitinib, and deuruxolitinib) now approved for alopecia areata (AA), Dr. King emphasized the complexity of diagnosing AA in patients of African descent. In an addendum to the BRAVE-AA1 trial, external expert reviewers assessed scalp photographs from 36 self-identified Black participants who were screened for enrollment in the study. Strikingly, 33% were determined to have central centrifugal cicatricial alopecia (CCCA) or traction alopecia rather than alopecia areata. This provocative dataset highlights the need for accurate diagnosis and culturally competent assessment in both research and clinical practice.

Hidradenitis Suppurativa and Sarcoidosis: Emerging Data

For hidradenitis suppurativa (HS), the phase 2 trial of povorcitinib included nearly 25% Black participants.  This is an encouraging step toward representation but is also likely a function of the high incidence of HS in these patients. While there are no subgroup analyses at this time, phase 3 trials of povorcitinib and deucravacitinib are underway.

In sarcoidosis, inhibition of type 1 immunity with tofacitinib has shown marked improvement in both cutaneous and systemic disease. Notably, 6 of 10 patients in this study were Black, making this an exciting finding for a condition that disproportionately affects patients with skin of color. Results from an open-label abrocitinib trial are expected soon.

Safety of JAK inhibitors

  • Common adverse events include upper respiratory infections, headache, nasopharyngitis, nausea, and acne.
  • Boxed warnings for JAK inhibitors include serious infection, mortality, malignancies, major cardiovascular events, and thrombosis. Dr. King highlighted the need for dermatologists to understand these boxed warnings in order to be comfortable using these medications. Many of these warnings come from older patients with rheumatoid arthritis treated with tofacitinib, and data from baricitinib and upadacitinib have shown the safety profile is better in patients with skin diseases versus other diseases.
  • JAK inhibitors should be used with caution in older or obese patients, current or past smokers, patients with a history of diabetes or past history of thrombotic events (stroke, deep venous thrombosis, pulmonary embolism).
  • These medications require baseline and period lab monitoring.

Summary

While JAK inhibitors are transforming dermatologic care, clinical trials should prioritize inclusive data collection and accurate disease recognition in patients with skin of color. Understanding diagnostic nuances, optimizing dosing, and interpreting clinical endpoints across diverse populations will be essential to ensure equitable and evidence-based use of these diverse and highly effective medications.

This information was presented at the 2025 Skin of Color Update conference by Brett King, MD, PhD, FAAD. The above highlights from this lecture were written and compiled by Riyad N.H. Seervai, MD, PhD. Visit Next Steps in Derm to watch a video interview with Dr. King about this topic.

Jun 02
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Vitiligo Treatment Breakthroughs: Optimizing Outcomes for Patients With Skin of Color

By Sessions

vitiligo treatment

At Skin of Color Update, Pearl E. Grimes, MD, FAAD, shared the latest breakthroughs in vitiligo treatment.

Vitiligo remains one of the most emotionally and therapeutically challenging conditions in dermatology. It’s a disease that patients cannot hide, making its impact deeply personal and public. Contrary to common misconceptions, vitiligo affects all racial groups equally, not just African Americans.

A recent international survey highlighted the profound psychological burden of vitiligo. Patients reported increased rates of anxiety, depression, eating disorders, and PTSD. The burden is especially high among African American patients, those with facial involvement, and those with more than 5% body surface area affected.

Dr. Grimes discussed factors that influence the success of repigmentation:

  • Body Site: The face and neck respond best to treatment, while the hands remain the most resistant.
  • Age: Children tend to have better outcomes.
  • Duration of Therapy: Patients should be counseled that treatment requires several months of commitment. Be patient!
  • Lesional White Hairs: Areas with white or gray hairs are less likely to respond.
  • Trichrome Lesions: These are more resistant to therapy.

Vitiligo management should focus on three main goals: reducing oxidative stress, modulating the immune response, and stimulating melanocyte growth. Dr. Grimes discussed multiple treatment approaches:

  • Oral Minipulse Dexamethasone: 2–4 mg for two consecutive days every week, typically for about six weeks.
  • Narrowband UVB (NB-UVB): Administered 2–3 times per week, effective for both stabilization and repigmentation.
  • Vitamin D: Deficiency is common, especially in African American patients and those with vitiligo. Dr. Grimes recommends screening and supplementing all patients.
  • Emerging Therapies: These include JAK inhibitors (alone or combined with NB-UVB), afamelanotide, aryl hydrocarbon receptor agonists, WNT pathway agonists, and even metformin.
  • Topical therapies: Both topical corticosteroids and calcineurin inhibitors are equally effective, with tacrolimus offering a favorable side-effect profile. Topical ruxolitinib can be considered a first-line agent. Dr. Grimes emphasized that patients may continue to see improvement beyond 24 weeks, so persistence is key!
  • At-home NB-UVB devices have been available for over 20 years and are effective alternatives to in-office treatments.

As far as new medications:

  • Ritlecitinib, Povorcitinib, Upadacitinib, Baricitinib: There is significant positive data to support the use of these oral JAK inhibitors.
  • Combination Therapy: Best results are seen when oral agents are combined with NB-UVB.
  • Afamelanotide + NB-UVB: This combination accelerates repigmentation compared to NB-UVB alone.

Dr. Grimes predicts that the future of vitiligo treatment will rely on combination therapies. For example, using JAK inhibitors to control inflammation and agents like afamelanotide to stimulate melanocyte growth.

Vitiligo management is rapidly evolving, with new therapies offering hope for better outcomes, especially for patients with skin of color. A personalized, persistent, and multi-modal approach is key to optimizing results.

This information was presented at the 2025 Skin of Color Update conference by Pearl E. Grimes, MD, FAAD.  The above highlights from this lecture were written and compiled by Jay Nguyen, DO.

May 27
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Pigmentary Impact of Acne: SOCU Video Interview

By Sessions

pigmentary impact of acne

“Our patients hate these marks. They hate them more than they hated their acne to begin with.”  — Hilary Baldwin, MD, FAAD

Don’t miss this insightful interview on the pigmentary impact of acne, conducted by Next Steps in Derm in partnership with Skin of Color Update. Dr. Baldwin reviews how her management of acne and post‑inflammatory pigmentary changes has evolved. She shares practical, clinic-ready guidance including:

  • Whether to take an acne‑first approach or treat acne and hyperpigmentation simultaneously
  • Why “scars” is often the wrong term for certain post‑acne pigmentary changes
  • How she safely incorporates new over‑the‑counter topicals into patients’ routines to address pigmentary alteration

If you treat acne in patients with skin of color (or anyone troubled by persistent pigmentation), join us in Chicago June 6 and 7 for the Pigmentary Disorders Exchange Symposium. Sessions will address the pigmentary sequelae of inflammatory skin conditions, including acne and atopic dermatitis, as well as the latest in the management of pigmentary conditions, including melasma and vitiligo.

May 15
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Unique Skin Conditions in Asian Patients: SOCU Session Summary

By Sessions

Asian skin dermatology

Here’s a summary of key clinical pearls from the Skin of Color Update lecture by Hye Jin (Leah) Chung, MD, MMSc, FAAD, on managing dermatologic conditions in Asian patients:

  • Asian skin: higher ceramide content but greater propensity for reactivity → prioritize efficacy while minimizing irritation and PIH.
  • Melasma: emphasize photoprotection (tinted sunscreens to block visible/blue light) and gentler topicals (azelaic acid, kojic acid, topical TXA) over irritant triple combinations or cysteamine.
  • Oral tranexamic acid (TXA): Dr. Chung’s protocol — 325 mg BID × 3 months, then 325 mg daily × 3 months, then 6‑month drug holiday. Obtain thorough history and baseline thrombophilia testing (protein C/S, factor V Leiden, lupus anticoagulant, anticardiolipin antibodies) before initiation.
  • Lasers and pigment: low‑fluence Q‑switched or picosecond Nd:YAG for subcellular photothermolysis; consider picosecond/Q‑switched for deep dermal pigment (ABNOM). 1927 nm can help PIH via controlled epidermal/papillary dermal coagulation.
  • Scars: CROSS with TCA for ice‑pick scars; consider ablative CO₂ for papular scars (or needle + electrosurgery where laser unavailable).
  • Device safety: favor microneedling, fractional RF microneedling, and fractional picosecond modalities; use high‑energy/low‑density settings if performing fractional ablative/nonablative treatments to reduce PIH risk.

The write-up was written by Jay Nguyen, DO, and posted to Next Steps in Derm.

May 07
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Atopic Dermatitis in Skin of Color: SOCU Video Interview

By Sessions

atopic dermatitis in skin of color

Next Steps in Derm, in partnership with Skin of Color Update, sat down with Raj J. Chovatiya, MD, PhD (associate professor, Rosalind Franklin University/Chicago Medical School), to discuss diagnosing and treating atopic dermatitis in patients with darker skin tones.

Watch to learn:

  • Practical tips Dr. Chovatiya shares with trainees for recognizing AD in skin of color
  • How differences in presentation can influence treatment choice
  • His patient-centered approach (“Patients aren’t textbooks!”)
  • How to interpret the latest AD research for clinical care

Whether you teach, consult, or see a diverse clinic population, this conversation will sharpen diagnostic skills and therapeutic decision‑making.

Apr 21
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Scarring Alopecias: SOCU Interview with Dr. Susan Taylor

By Medical Dermatology

scarring alopecias

Scarring alopecias require early, effective treatment to stop progression and prevent further permanent hair loss. In an interview with Next Steps in Derm, in partnership with Skin of Color Update, Susan C. Taylor, MD, FAAD, shares the latest research in the understanding of scarring alopecias and how that’s influencing the therapeutic pipeline. Dr. Taylor, the Bernett Johnson Endowed Professor of Dermatology at the University of Pennsylvania Perelman School of Medicine, outlines current and future treatments, including JAK inhibitors, metformin, and vitamin D.

For more on hair loss, join us on Saturday, June 27, for Hair and Scalp Disorders: The Rx Pad and Beyond, a virtual, one-day conference. The program provides a full-spectrum perspective on hair and scalp management, from diagnosis to therapeutics to nutrition and lifestyle factors. Led by co-chairs Adam Friedman, MD, and Amy McMichael, MD, every session emphasizes practical tools, decision-making, and real-world implementation. Register today!

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