Psoriasis, a chronic immune-mediated skin condition that impacts millions of people, is well known for the thickened, flaky areas of skin called plaques, but there are many other symptoms of psoriasis. In some cases, skin tone impacts the appearance and symptoms associated with psoriasis. According to Dr. John “Jay” Wofford of U.S. Dermatology Partners North Dallas, “Pink to red plaques of skin with silvery scales are the textbook definition of a psoriasis lesion, but the longer I work with psoriasis patients, the greater the variation I see. Specifically, those with darker skin tones may have entirely different psoriasis features, so it’s essential to educate patients about the range of potential signs they should look out for to ensure they receive appropriate diagnosis and treatment.” In this blog, Dr. Wofford discusses various psoriasis effects on skin tones as well as treatment and management tips.
What Is Psoriasis?
So, exactly what is psoriasis? It’s a common inflammatory condition that impacts approximately 125 million people globally, including over 8 million in the U.S. While the impact of psoriasis on skin is the most noticeable, this condition is a systemic inflammatory condition driven by an overactive immune system. During psoriasis flares, the immune system triggers the rapid multiplication of skin cells. The common skin symptoms of psoriasis include:
- Patches of skin that are red, pink, purple, or brown, depending on skin tone.
- Scaling of skin that looks like silver, white, or gray patches.
- Dry or cracked skin.
- Changes in nail thickness.
In addition to these signs, individuals with psoriasis may also struggle with joint pain and inflammation, stiffness, and fatigue.
How Psoriasis Appears on Different Skin Tones
Dr. Wofford says, “A common challenge in dermatology practice is learning the different ways that skin conditions impact differing skin tones. With psoriasis, the appearance differs dramatically between skin tones. Knowing what to expect is essential to ensure individuals receive the correct diagnosis.” Below, Dr. Wofford outlines psoriasis presentations by skin tone to aid in early diagnosis and intervention.
On Lighter Skin Tones
Lighter skin tones exhibit the most recognized presentation of psoriasis, including pink or red plaques with silvery-white scaling. Skin redness, clinically referred to as erythema, is visible in early stages. Skin scaling and flaking may be more noticeable on lighter skin tones.
On Darker Skin Tones
Rather than pink or red, psoriasis plaques on darker skin tones often appear gray, purple, or dark brown. There is often redness and inflammation surrounding the plaques, but it may not be as obvious on darker skin tones. Scales may be darker gray or silver, blending into skin or simply appearing like dry patches. Psoriasis is less noticeable on darker skin tones.
Diagnostic Challenges
The differences in presentation, Dr. Wofford says, “may lead to diagnostic challenges, especially for dermatologists early in their careers and those who don’t have the opportunity to work with individuals with darker skin tones often. A psoriasis plaque can often be mistaken for a different condition in those with darker complexions. Specifically, psoriasis is frequently misdiagnosed as eczema or lichen planus in individuals with darker skin. It’s important to examine skin carefully and discuss other signs and symptoms to ensure accurate diagnosis and effective treatment planning.”
Why Psoriasis May Be Underdiagnosed in People of Color
According to the National Psoriasis Foundation, psoriasis is often undiagnosed or misdiagnosed in people of color. While those with fair skin are diagnosed more frequently, this doesn’t necessarily mean that fewer people with dark skin tones struggle with psoriasis. Some factors that contribute to reduced psoriasis diagnosis in people of color include:
- Biased clinical imagery – most dermatology textbooks and training materials depict psoriasis on light skin. As a result, many clinicians are less familiar with how psoriasis manifests in darker skin.
- Symptom misinterpretation – this issue can lead to long-term misdiagnosis, as dermatologists may mistake dark brown or purple plaques for fungal infections, eczema, or other conditions.
- Health disparities – due to socioeconomics, language barriers, and systemic biases in healthcare, people of color are less likely to see dermatologists regularly, limiting early diagnosis and intervention.
Consequences of Delayed Diagnosis
When it comes to consequences of delayed diagnosis, Dr. Wofford says, “Undiagnosed or misdiagnosed psoriasis in people of color increases risk of complications, including more severe symptoms and greater chances of developing psoriatic arthritis (due to delay of appropriate treatment). Additionally, the prolonged discomfort and lack of support may lead to depression or feelings of isolation. As a dermatologist, it’s important to be educated about these differences and ensure we provide our patients with the care they need.”
Post-Inflammatory Pigmentation: A Key Concern in Darker Skin
Psoriasis in people of any skin tone can be difficult to manage and cause discomfort, but there are additional concerns for those with darker skin tones. Specifically, post-inflammatory pigmentation changes are common as skin heals following psoriasis flares. Post-inflammatory pigmentation issues include lighter spots (hypopigmentation) or darker spots (hyperpigmentation). According to Dr. Wofford, “Pigmentation changes in those with lighter skin tones are often less noticeable and short-lived, whereas these changes in darker skin tones tend to be longer lasting and more noticeable.” To reduce risk for post-inflammatory pigmentation changes, keep the following tips in mind:
- Use sunscreen – the sun’s UV rays can worsen pigmentation issues. Daily use of broad-spectrum (protecting against UVA and UVB rays) sunscreen with SPF 30+ is essential, especially for healing skin.
- Apply topical healing treatments – skincare products with ingredients like niacinamide and vitamin C can help reduce the appearance of dark spots and keep skin a more uniform tone.
- See a dermatologist – a board-certified dermatologist who’s familiar with skin of color can recommend safe options for treating discoloration without causing further concerns or psoriasis flares.
Psoriasis Treatment for All Skin Tones
When it comes to psoriasis treatment, Dr. Wofford says, “There’s not a one-size-fits-all treatment for every psoriasis patient. It’s essential to work with a dermatologist to develop a care plan during active psoriasis flares as well as ongoing skincare plans for managing this condition. As a dermatologist, I always tailor treatment approaches to the individual’s needs and symptoms, which can be especially important for those with darker skin tones struggling with psoriasis.” Some commonly recommended psoriasis treatments include:
- Topical therapies – corticosteroids, vitamin D analogs, and exfoliating creams and ointments may be recommended to treat or prevent psoriasis flares.
- Oral medications – a variety of oral medications may be prescribed for short or long-term disease management.
- Biologics – these injectable medications target overactive parts of the immune system (e.g., IL-17, IL-23 inhibitors) that may lead to psoriasis flares.
- Phototherapy – light therapy can be beneficial, but it should be used with caution in patients with darker skin to prevent post-inflammatory hyperpigmentation.
Important Treatment Considerations for Skin of Color
For those with darker skin, Dr. Wofford recommends, “Talk to your dermatologist about how to tailor your treatment plan to avoid potential risks. If you’re concerned that treatments are causing new symptoms like changes in pigmentation, ask about alternatives.” A few common treatment considerations for psoriasis in darker skin tones include:
- When using topical steroids, avoid hypopigmentation by choosing a strength and application frequency tailored to your needs and skin tone.
- Monitor skin for scarring and long-lasting pigmentation issues. Let your dermatologist know about any changes in your skin’s appearance or texture after psoriasis plaques heal.
- Choose skincare products that support the skin barrier without causing irritation.
- When possible, work with a dermatologist trained in cultural competency and skin of color dermatology.
Conclusion: Improving Psoriasis Awareness for Every Skin Type
According to Dr. Wofford, “The key take away should simply be that psoriasis isn’t just a condition that impacts people with lighter colored skin. It impacts people with all skin tones. Misdiagnosis and misunderstanding of the differing presentations of psoriasis on varying skin colors often leads to inadequate treatment.”
Schedule a Dermatologic Consultation to Improve Psoriasis Management
If you’re struggling with psoriasis management or have symptoms that indicate psoriasis, it’s time to discuss your skincare options with a dermatologist. You can get started at a local U.S. Dermatology Partners practice by taking a few moments to fill out our online scheduling request form. We look forward to hearing from you.
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