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Eczema and psoriasis are considered common "bread and butter" dermatologic diagnoses, but many patients, particularly patients of color, are not aware they have these diagnoses or how to treat them. There are several challenges that lead to delayed diagnosis and treatment in patients of color.
Why patients of color may not see a dermatologist?
First, many patients of color do not consider the dermatologist as a needed specialist. They may not realize that dermatologist can help manage conditions affecting the hair, skin, and nails in all skin types. This may be due to multiple factors, but lack of skin of color dermatologists is likely one of them. Patients want to feel comfortable knowing the person taking care of their skin understands it, so naturally they are reluctant when they don't see doctors in the specialty that look like them.
Another challenge is decreased visibility and representation of skin of color in images of eczema and psoriasis. Psoriasis advertisements rarely feature skin of color models, actors/actresses, and images of skin of color patients with psoriasis and eczema are sparse compared to those of Caucasian skin. A quick image glance from any search engine results easily demonstrates this point. Unfortunately, the inferred message, especially for psoriasis, is that these conditions do not occur in skin of color.
Are inflammatory skin conditions common in people of color?
Inflammatory skin conditions are not uncommon in skin of color. In fact, several studies have shown an increased prevalence of eczema in skin of color children compared to Caucasian children. It may be so common, that it becomes normal-ish, as in "normal dry skin," the phrase many of my patients have used to describe their eczema or seborrheic dermatitis (considered a form of eczema affecting the scalp due to yeast, commonly called dandruff). Also, because inflammation on Caucasian skin appears red or pink, it may be missed in skin of color by both patients and health care professionals because inflammation in skin of color may appear violaceous or hyperpigmented. This all results in further delays in diagnosis and appropriate management.
How eczema and psoriasis may impact life beyond the skin
Eczema can cause long term itch that is difficult to manage if patients are not receiving appropriate treatment. Itch is often worse at night, interrupting sleep. Sleep deprivation is associated with many short-term and long-term effects including lack of attention and poorer performance at school or work. Itch can also cause anxiety, social withdrawal, and decreased quality of life..
In addition to itch, in skin of color, inflammation commonly causes hyperpigmentation (darkening of skin) and/or hypopigmentation (lightening of skin). This is worsened by itch because scratching causing more significant dyspigmentation and skin changes. Dyspigmentation is a common reason skin of color patients seek care. It can have a significant impact on self-esteem and cause other psychosocial obstacles in skin of color patients.
How to manage eczema and psoriasis in skin of color.
One of the first steps in addressing these challenges is helping patients understand eczema and psoriasis are inflammatory diagnoses that can be managed. Before deciding on what needs to be done for treatment, I first have a conversation with patients about the behaviors that need to be un-done. For instance, fragrance is a known irritant for sensitive skin, but it is highly used in soaps, moisturizers, and laundry products. Natural products and even products marketed for babies may contain fragrances and other irritants. Patients need to understand that the products touching their skin may be worsening their condition. By simply choosing products that are mild, free of fragrance, or marketed as “free” and/or “clear” they are already on the journey to less inflammation.
Similarly, for seborrheic dermatitis or dandruff mentioned above, it is a common practice for some patients to grease the scalp with oils; however, this could lead to worsening dandruff because some oils may promote growth of the yeast that causes dandruff.
Scratching is another behavior that causes problems and needs to be un-done by properly addressing itch or avoiding the behavior. Scratching can become compulsive even if the itch is eventually under control. Not only does this cause dyspigmentation and thickening of the skin in eczema patients, but in psoriasis, the trauma from scratching can actually lead to worse psoriasis in that area.
A team-based approach to managing eczema and psoriasis is best. Inflammation in skin of color will look less “red” than classic textbook cases making it less likely to be detected as eczema or psoriasis. Patients may have a role in early diagnosis and management by simply understanding these conditions occur in skin of color, developing good skin care practices, and seeking care from a dermatologist.