Psoriasis in Darker Skin: Presentation and Management

00:01 So now we'll have a look at how psoriasis presents in various skin types.

00:07 In light skin, one sees well-defined salmon colored plaque with thick, silvery scales, and this may be associated with pruritis.

00:18 However, in dark skin there is no salmon patch to be seen.

00:23 All you see are hypopigmented papules and plaques, and erythema is absolutely not conspicuous.

00:34 So we do not see the salmon patch in patients with dark skin.

00:39 One can also have a problem with prominent and persistent post-inflammatory hyperpigmentation or hyperpigmentation, which affects the patient, just like active psoriasis.

00:54 Psoriasis tends to involve the following areas the elbows, knees, scalp, the umbilical area, and the gluteal cleft.

01:03 So what are the different clinical types of psoriasis? We have guttate psoriasis , pustular psoriasis which is not so common, inverse psoriasis or flexural psoriasis, nail psoriasis, and of course systemic manifestations or comorbidities.

01:20 Guttate psoriasis refers to small, pinhead sized papules which become flaky and may have silver scales, and we refer to this as guttate psoriasis as guttate means drop like lesions, and in the light skin you can see the drop like lesions of guttate, psoriasis and the salmon colored patches.

01:40 Again, in dark skin you see gray and lesions that may look dusky because the erythema is not conspicuous. Psoriasis is also found on the trunk and proximal extremities.

01:54 And there's a strong association with streptococcal infections in this particular type of psoriasis called guttate psoriasis. The second type is pustular psoriasis, where 1st May present with painful patches of plaques and primarily involves the palms and the soles. I haven't seen pustular psoriasis.

02:15 I think in my experience as a dermatologist, I've probably seen maybe two cases of pustular psoriasis, so we don't see much of it in patients with skin of color.

02:26 The inverse or intertriginous psoriasis or flexural psoriasis.

02:30 One gets lesions in the inguinal area, perennial, genital, intergluteal, auxiliary lesions, and they tend to be also a erythematous if it's in a white patient. Or they may have a lichen Audio in black patients.

02:46 One can also get, in females, inframammary lesions.

02:54 So it's called inverse due to the fact that there's reverse of the typical presentation of psoriasis.

03:00 Sometimes it is confused with fungal or bacterial infection, as well as Candida, and in children it can be easily confused with napkin rash when it occurs on over the groin. So we've spoken about the other types of psoriasis, including guttate, inverse psoriasis, pustular psoriasis.

03:20 Now we want to talk about nail psoriasis.

03:22 And remember a patient can just present with nail involvement with with no other cutaneous signs.

03:28 So nail psoriasis is an entity on its own.

03:33 What are the features of nail psoriasis.

03:35 One is pitting, which is typical leukonychia, white nails, red spots on the lunula, crumbling under the subungual plate, you may also get the oil drop sign, but these features may be seen in other conditions as well. For example in lichen planus and eczema like alopecia areata.

03:59 However, the oil drop sign seems to be unique to psoriasis.

04:06 And let's talk about systemic manifestations of psoriasis.

04:08 Psoriatic arthritis is another manifestation of psoriasis.

04:13 It can present up to 30% of patients with psoriasis.

04:18 One gets distal arthritis, particularly of the distal interphalangeal joints.

04:25 You can also get associated spondyloarthropathy.

04:30 Some of the comorbidities of psoriasis that have been described include the metabolic syndrome, cardiovascular diseases, atherosclerosis, depression, and fatty liver. The diagnosis of psoriasis is based on history and physical examination.

04:49 And of course, when not sure, the patient can be offered a biopsy which shows the typical features of psoriasis on histology as you can see on this H&E Slide.

05:03 The differential diagnosis includes seborrheic dermatitis, where once is fine, greasy scale, which is typically evident in non-indigenous locations. Involvement of areas such as the eyebrows, nasolabial folds, and sometimes behind the ears, is typical of seborrheic dermatitis.

05:24 Another differential is lichen simplex chronicus, and changes in this condition occur due to excessive scratching of the skin, and it may occur behind the neck, on the feet, and on the hands.

05:42 Atopic dermatitis is another differential, but the absence of thick, coarse scales and sharp raised and well-defined borders is typical of a atopic dermatitis.

05:56 Nummular eczema is another differential, as well as superficial fungal infections, which we have discussed in detail.

06:08 So how do we approach the treatment of psoriasis? The management really depends on the severity of the disease, what age of the patient you are dealing with, what are some of the relevant comorbidities and patients preference, including the cost and convenience of the treatment that we are offering? For mild to moderate disease topical corticosteroids are used, particularly in the flexural areas, vitamin D analogs, for example the calcipotriene and calcitriol, topical retinoids, e.g. for example tazarotene and systemic retinoids, are also used for some patients with moderate disease. For example, the vitamin A tablets, methotrexate, cyclosporine, and the biologic agents and phototherapy.

07:05 Adjuvant therapy includes use of emollients, particularly those with urea and salicylic acid, as they help as keratolytic to remove the thick scales of psoriasis.

07:16 But these need to be used in combination with other topical or systemic treatment for psoriasis.

07:24 I cannot overemphasize the importance of lifestyle modification.

07:29 . Stress reduction is crucial.

07:32 We know sometimes we all go under stress and it's difficult to control it.

07:37 But there are things that you can try and manage and control.

07:40 For example, smoking and alcohol cessation is recommended in patients with psoriasis as well as weight loss, as these have been shown scientifically to impact on the progress and severity of psoriasis.

07:55 So as we wrap up psoriasis, let's once again take a look at the key differences between clinical manifestations of psoriasis in people with different skin falter types.

08:06 As mentioned, patients with light skin, they have a well-defined salmon-colored plaques.

08:12 They make thick and silvery scales.

08:15 And patients with dark skin, we do not see the salmon patch.

08:18 You get hypopigmented papules and plaques, and sometimes they may look dusky or like not.

08:24 And the erythema is less easily perceived in patients with dark skin.

08:30 The presentation also may be a little different, with some patients presenting with follicular lesions than the patches. And it's also important to remember that black patients, beyond treating the psoriasis itself, one has to also address the issue of post-inflammatory hyperpigmentation, which is the result of the heal delusions of psoriasis. And this affects black patients as much as their active lesions themselves.

08:58 So just treating the active psoriasis and not giving attention to the post-inflammatory hyperpigmentation is not serving the patient well.