Many people who have psoriasis will experience the telltale sign of itchiness or burning. But for people with differing skin tones, that’s where the similarities may end.
The symptoms of psoriasis, a chronic inflammatory condition, can look different on people with differing skin tones. On lighter skin, plaque psoriasis can appear red; on darker skin, it can be purple or gray-ish.
Unfortunately, many people who’ve searched Doctor Google for psoriasis images on Black skin haven’t found very many answers — and, given this lack of representation, they can leave with possibly with more questions than they had before.
Here’s what you should know about psoriasis — including what it looks like, and why it can go underdiagnosed and undertreated in the Black community.
Psoriasis in the Black Skin: A Lack of Representation
The Internet is flooded with images of white people who have psoriasis, but there aren’t nearly as many pictures of Black people who have psoriasis. This often leads people to the conclusion that psoriasis mainly develops in people with lighter skin — which couldn’t be further from the truth.
In fact, about 1.9 percent of Black Americans have psoriasis, according to a study published in the March 2014 issue of the Journal of the American Academy of Dermatology. The same research found that 1.6 Hispanic Americans had psoriasis, and 3.6 percent of white Americans had psoriasis.
Despite these statistics, a whopping 93 percent of all main characters who were featured in TV commercials and advertisements about psoriasis, including treatments and products, over a two-week period in 2018 were white, according to a study published in September 2020 in the journal Cutis. Black and Asian main characters only represented about 6 percent and 1 percent. The findings of this study, conducted by Junko Takeshita, MD, PhD, and other researchers, are important because advertisements are a main source of health-related information for the public.
Ultimately, Black people who have psoriasis are less likely to see themselves represented in ads for psoriasis treatments, concluded the study authors — which may deter them from seeking treatment or suspect that those treatments aren’t an option for them. This is something that Corey L. Hartman, MD, a board-certified dermatologist and the founder of Skin Wellness Dermatology, has seen firsthand. Many Black patients are either shocked to learn they have the condition or reluctant to believe certain treatments will be effective for them, says Dr. Hartman.
How Psoriasis Appears on Darker Skin
Although the lesions on all skin types can be painful, itchy, and filled with pus, Hartman points out that psoriasis on white skin usually appears as thick plaques with a silver scale and are most commonly found on the arms, chest, legs, and shoulders.
This isn’t necessarily the case for Black patients or individuals with darker pigmented skin, however. People with more melanin in their skin may develop psoriasis lesions that appear violet, dark brown, or gray. “Since psoriasis looks different on Black skin — and there’s not enough education about what this looks like — it’s often misdiagnosed,” says Hartman.
Individuals with darker skin are also more likely to find psoriasis lesions on the scalp, elbows, knees, torso, buttocks, and even nails; the areas affected can also vary in size, although it’s not exactly known why. In the case of scalp psoriasis, people should work with their dermatologist to create a hair care regimen that works for their specific type of hair.
The after-effects of psoriasis also differ among individuals with heavier pigmented skin. Depending on the severity of the outbreak, Hartman says that lesions from psoriasis can leave spots of discoloration or post-inflammatory dyspigmentation for months after a flare-up resolves. Dermatologists caution Black patients not to confuse this with active psoriasis, and recommend against using topical steroid treatments on the inflamed areas.
Other research published in November 2014 in The Journal of Clinical and Aesthetic Dermatology, shows that Black people who have psoriasis also typically have more severe breakouts compared to white people. Because of this, Hartman tells his patients of color to pay attention to any changes in their skin and consult with a dermatologist if they notice any symptoms. This way, they can be treated before the condition worsens.
Treating Psoriasis on Black Skin
While psoriasis medications can help control outbreaks in many people, Black people are often undertreated. Compared to white people, they’re not only less likely to be treated with biologics (a newer type of medication that “quiets” the immune-system), according to a study published in December 2015 in The Journal of Investigative Dermatology, but they sometimes receive only topical medications or no treatment at all, according to the National Psoriasis Foundation.
Black people who have psoriasis were also less familiar with biologics as a treatment option compared to white people, according to a study published in February 2019 in the Journal of Investigative Dermatology, despite the fact these medications are highly effective at treating the skin condition, regardless of a person’s pigmentation.
Dr. Hartman points out that undertreatment among Black patients is not due to a lack of concern or care for their health. Disparities such as a lack of access to quality medical care and healthcare insurance in the Black community have been well documented and contribute significantly to Black patients with psoriasis not being treated adequately.
Other research published by Dr. Takeshita has shown that dermatologists are less confident about diagnosing psoriasis in people with darker skin than those with lighter skin.
Contrary to what has been displayed in the media, psoriasis can affect people of any race. And a growing number of providers agree that we need more diverse representation and information for Black people with psoriasis.