The Importance of Access to Treatment

Historically, racial and ethnic minorities in the United States have lived with long-term disparities in both access to health care and the quality of care that they receive. These differences are improving thanks to laws like the Affordable Care Act. Still, some minority groups have higher rates of illness and death from many health conditions than white people. And they’re still more likely to face prejudice and other barriers to health care.

These differences in care also include treatment for plaque psoriasis, a skin disease that causes an itchy, scaly rash. Research shows racial minorities see a doctor less often for the condition than white people. Here’s a look at some reasons for these disparities and how the medical community can help.

What Are the Barriers to Psoriasis Care for People of Color?

The issue of insurance 

Walking into the doctor’s office is the first step in getting care for your psoriasis. But you may not be able to make this step without health insurance coverage. This is a problem that impacts racial and ethnic minorities more often in the U.S. For Americans under age 65, Asian Americans are just slightly more likely to be uninsured than white people, while Hispanics, American Indians, and Alaska Natives are more than 2.5 times more likely to have no coverage. The uninsured rate for Black Americans is almost 2 times that of whites.

Without coverage, access to health care remains out of reach for many people of color. 

Getting the right diagnosis

Once you’re able to see a doctor, the next step in treating psoriasis is getting a proper diagnosis. That’s not always easy for anyone – psoriasis is often mistaken for conditions like eczema or dry skin. 

But it’s doubly hard for people of color. During medical training, many doctors don’t learn how to spot psoriasis on nonwhite skin. While the condition tends to look bright red on lighter skin, it often appears purplish, brown, or reddish-brown on darker skin tones. Some people of color may also have thicker psoriasis plaques and more scaling across more areas of their bodies.

A biopsy (a study of a small skin sample under a microscope) helps doctors figure out if you have psoriasis. Dermatologists suggest the procedure when it’s hard to tell plaque psoriasis from other conditions. They say it can be especially useful for people of color.

Access to treatment

Once you have a psoriasis diagnosis, you and your doctor will work together to figure out the best treatment options. But for some, access to a doctor and treatment is another hurdle in getting care.

One issue is a lack of dermatologists in underserved communities. This can be an issue with a treatment like light therapy, which calls for visits to the dermatologist two or three times a week.

Meanwhile, if you’re a person of color in the U.S., finding a dermatologist of the same race or ethnicity can also be a challenge. 

While dermatologists of all backgrounds are qualified to treat skin of color, you may prefer care from a doctor who looks like you. In one study, Black people who visited skin-of-color clinics said dermatologists there had better training to address their concerns. They also felt the doctors showed them more respect and dignity and were more trustworthy.

Reena Ruparelia is a Toronto-based psoriasis advocate who has lived with the condition for nearly 30 years. She’s South Asian and has often visited older, white male dermatologists. Ruparelia says she felt intimidated by these doctors and uncomfortable asking questions. Today, her dermatologist is of the same background and gender.

“I feel like it’s much easier to speak with her because I can share my problems. She took time to listen, but also understood my unique situation. I know that she’s willing to find a treatment that supports me.”

Another barrier to care for people of color is undertreatment. Research shows Black people with psoriasis are less likely than white people to get biologics. These are treatments made from living organisms. You take them as a shot for moderate to severe psoriasis. But health insurance doesn’t always cover this type of treatment. Or your insurance company could require you to try another medicine first before covering it. 

How Can Doctors Improve Psoriasis Care for People of Color? 

Diversity in medical training and research

More inclusive medical training can help doctors better diagnose and treat people of color. There are now efforts to include a broader range of skin tones in educational courses, textbooks, and other resources. 

Lynn McKinley-Grant, MD, a board-certified dermatologist, professor of dermatology, and president of the Skin of Color Society, suggests students learn to diagnose skin diseases face-to-face with people from different racial and ethnic backgrounds. 

“If you’ve trained in the middle of Minnesota and you haven’t seen any brown skin, then there should be an effort to make sure people take a rotation or two in places where there are varying skin types,” she says.

There’s also a lack of diversity in psoriasis research. Studies show psoriasis treatments are safe and work well in people of all skin tones. The problem is researchers have mainly studied them in white people with the condition. One review found that 84% of people who join clinical trials for psoriasis are white. 

The dermatology community has started to recognize the need for more racial diversity in clinical trials. Researchers are making more of an effort to include a wider range of people in dermatology studies to understand how treatments affect different groups.

‘Let the patient educate you a little’

McKinley-Grant and other dermatologists stress the importance of doctors listening to people of color, both during diagnosis and treatment. 

“If a patient tells you, ‘This is where I itch,’ ‘This is what’s burning me,’ and the doctor can’t see it, and their training has been focused on one skin type, then they have to listen and trust what the patient is seeing,” McKinley-Grant says. “Let the patient educate you a little.”

Ruparelia says many health care professionals have compassion fatigue, brought on by a packed schedule.

“After you’ve seen 10 people who are complaining about their skin, maybe you’re tired of hearing it. But if there’s a way to listen to every patient like it’s the first time you’ve heard it – take time to look at their skin and really give them a chance to express what they’re experiencing – I think it would make a huge difference.”

The Skin of Color Society also encourages doctors to ask their patients which treatment they prefer. For instance, some people of color will want to avoid phototherapy because it causes temporary skin tanning. Black women with scalp psoriasis may have unique concerns about hair texture, how often they wash their hair, and hair styling. 

When both people of color and their doctors are aware of how psoriasis affects this group, they can better work together to find the best treatment. 

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How Treating Psoriatic Disease Has Changed

By Nilanjana Bose, MD, as told to Susan Bernstein

I am an adult rheumatologist, so I see patients who are 18 and above, with the whole gamut of rheumatologic conditions. Every patient I see is different. For patients with classic psoriatic disease, skin psoriasis symptoms often occur before their arthritis symptoms happen. These two conditions could even develop years apart for some people. But that’s not absolute. You can develop arthritis, or joint pain and swelling, first and then later develop psoriasis.

Patients typically first come to see us for their joint swelling. Usually, psoriatic arthritis causes a peripheral joint swelling. They’ll have swelling of your fingers and toes, which can look similar to rheumatoid arthritis (RA). We do an initial workup and examine their skin, too. If they have psoriasis, including nail pitting or psoriasis plaques, or if they have a family history of psoriasis or psoriatic arthritis, this may suggest that they may have psoriatic arthritis.

COVID: Hello, Telehealth

Once the pandemic hit last year, for the first couple of months, we had to go into retreat mode at our clinic. We really had to scramble to adapt. We moved quickly into using telehealth to treat our patients. We didn’t have some of the telehealth technology, but once we understood that there were resources out there, like telehealth portals and online platforms we could use, we started adopting them.

I think our patients also adapted to telehealth fairly quickly. There were some challenges with older folks. Some didn’t have internet access or found it harder to work out the logistics of telehealth. But for those patients, we were able to conduct regular telephone visits as well.

Telehealth came with its own challenges. We had to learn how to “examine” a patient over the internet. It’s not easy, and it’s not optimal for joint or skin conditions. But a telehealth visit is any day better than a patient missing their appointment altogether and not accessing medical care.

For follow-up visits, telehealth is easy and works well. You can check in with patients and see how they’re doing on their current medications. Some of my patients really prefer telehealth for the convenience. Again, it’s not optimal. We still encourage our psoriatic disease patients to come into the office. It can be tough to see everything using the camera.

Overall, telehealth has been a fun experience, but if a patient needs to be examined in person, I ask them to come in. We’re all still masked up, practicing social distancing, and taking every precaution. We are very committed to the whole aspect of infection control with our patients.

I’ve even seen new patients using telemedicine, especially during the worse phases of the COVID pandemic. If they were referred to me by another physician because they have psoriasis, I can do the initial consultation remotely, but I still try to have them come in. Just getting in and seeing a rheumatologist to begin your treatment is ultimately the most important step with psoriatic disease. You can establish a rapport with your doctor and get the information you need.

Biologics: Game Changer for Psoriatic Disease

Biologics have totally changed the way we manage this disease. Once you’re diagnosed with psoriatic arthritis, there are great treatment options out there. In the past, we had steroids, DMARDs (disease-modifying antirheumatic drugs), and TNF inhibitors, but now, we have IL-17 and IL-23 inhibitors, and JAK inhibitors, too.

Initially, we evaluate our new patients with lab tests and joint imaging and go over all of their symptoms. Some people will have milder psoriatic disease, and some will have more systemic symptoms. With younger patients, we may try to be more aggressive at controlling their disease, because they’re at greater risk for joint damage.

When we go over treatment options, it’s really a two-way, fluid discussion. I talk with my patients about all the risks and benefits of each treatment. If my patient is doing better after a few months, we talk about it and may re-assess the treatment plan.

It’s very rare to see people with psoriatic arthritis these days who develop chronic joint deformities. It may happen if someone was diagnosed a long time ago, before there were better treatment options, or if they were unable to access care before they came to us. The improvements are mainly due to advances in drug treatment, but also because people are more conscious of rheumatic diseases. They Google it. They just have more awareness of rheumatic conditions and that they need to see a rheumatologist.

We screen every patient. Some of them have a true inflammatory, psoriatic disease, while some do not. They may have osteoarthritis or fibromyalgia causing joint pain. Every patient deserves a thorough, complete examination. We want to diagnose these patients as early as possible to begin treatment to control their disease and prevent damage.

COVID and Other Infections: Take Extra Precautions

We were having this exact discussion with our patients before COVID, too. They are at higher risk for serious infections not just COVID, but also other types of pneumonia and other infections. We had already been encouraging these patients to wash their hands often, take commonsense precautions, avoid close contact with sick people, and to get all their vaccinations.

Once the COVID vaccines became available, I told them, “Please get vaccinated and keep wearing your mask.” People who are on a biologic to treat their psoriatic disease are by default more cautious. For new patients who were just starting their biologics, I advised them on how to take precautions to prevent infection. We told many of our psoriatic patients, “Stay home as much as you can right now, and avoid close contact with others.” Patients do listen to this advice because they trust us as their doctors.

Making Psoriatic Patients Feel Safer

Always have a backup plan with telehealth technology! Also, I have encouraged all of my patients to enroll in our online patient portal, so we can stay connected. They can send me messages, I can update their prescriptions, and we can share test result with them.

Technology is a beautiful thing. We need to use it to the fullest advantage in modern medical care. Technology can make it easier to stay in touch with patients with psoriatic disease, who need ongoing care. But some patients may not be used to telehealth, so they can experience some frustration at first. Be patient, take your time to learn to use these tools, and help your patients adapt. Don’t give up if something doesn’t work right at first.

Face-to-face interaction is still very important when you are working with patients with psoriatic arthritis. It can be difficult to form a new patient/doctor relationship without any in-person component.

After they’re diagnosed, some patients continue to see me virtually, and it seems like we are really able to get to know each other well. Telehealth is a safe, secure environment for patients. They’re in their home or office, or even in their car. Sometimes, when I’m talking with a psoriatic patient over telehealth, I see them taking notes. That’s good! Some people find that they’re less anxious when they’re in a telehealth appointment instead of being in their doctor’s office.

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