Plaque psoriasis can affect patients of all skin tones and may present differently in different skin types. Historically, when plaque psoriasis was discussed in textbooks, curricula, and conferences, the images used were of patients with lighter skin tones. However, there is a beautifully diverse spectrum of skin tones, each of which can influence the clinical appearance of different skin conditions. For example, erythema alone can look different depending on skin tone and body location. If we are not purposefully inclusive when training clinicians to identify plaque psoriasis, we are compromising their ability to make the diagnosis in patients with different skin tones. This can translate into more biopsies for patients with plaque psoriasis who have melanin-rich skin, which has been documented.

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When the majority of our plaque psoriasis–related images are of patients with lighter skin tones, it also means that the public is not aware of how the condition can appear across demographics. There is an array of patient demographics that are not well represented when online search engines, such as Google Images, are queried for plaque psoriasis, among many other conditions. One of my residents conducted an experiment involving searching Google for images of dermatologic conditions to see how far they needed to scroll until they saw darker skin tone representation—and it was approximately 15 to 20 images down. A person’s inability to self-identify with a condition can affect our epidemiology data, as much of our original prevalence data on plaque psoriasis was self-reported by patients.

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It is also important to consider anatomical differences across different skin tones. For instance, the darker the skin tone, the more acidic it is. The thickness and composition of the stratum corneum can also vary. Patients with plaque psoriasis who have darker skin tones tend to have thicker, more prominent, confluent scales overlying the plaques compared with those who have lighter skin tones. Additionally, we see a predilection for sebopsoriasis in individuals with darker skin tones. These skin-related differences may also impact patient preferences for topical vehicles, especially based on body location, so we should not make assumptions about preferences. It is important to discuss the full range of treatment options and their vehicles with patients.

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Patients with darker skin tones have a greater potential for disfigurement due to plaque psoriasis. Any inflammatory condition can cause hypo- or hyperpigmentation, and plaque psoriasis can induce or inhibit melanogenesis, depending on the profile of the inflammation. This discoloration can be very hard to treat and may be more disabling than the disease itself. Psychosocial burden is a reason to be more aggressive with the treatment of plaque psoriasis in patients with darker skin tones in an attempt to prevent future injury beyond the psoriasis itself.

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A final challenge is the unmet need for more purposeful, inclusive clinical trials. When a phase 3 trial population is 80% White but the general population is not 80% White, how can we be assured that the results of the study are generalizable to all the patients we treat? Efforts are being made to fill these holes. The VISIBLE study, for example, purposefully recruited a patient population with darker skin tones to fill in the efficacy and safety generalization gaps with guselkumab. Overall, we do not currently have enough data to say that there are distinct differences in how these drugs work in patients with different skin tones. Ideally, the cohort of patients in clinical trials would accurately reflect the US population.