KEY ISSUES IN SKIN OF COLOR

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1 KEY ISSUES IN SKIN OF COLOR Amy McMichael, MD Professor and Chair Department of Dermatology Wake Forest Baptist Medical Center Winston-Salem, NC Real World for Residents 2017 SC Derm DISCLOSURE/CONFLICTS OF INTEREST Investigator Allergan Intendis Procter & Gamble Samumed Casseopia Concert Alcaris Incyte Consultant Johnson & Johnson Procter & Gamble Allergan Bayer Galderma Incyte Samumed Aclaris Anacor Pfizer Nutrafol Bioniz Allmirall 2 1

2 Diseases that are more common in skin of color Diseases that look different in skin of color Diseases that act differently in skin of color

3 SKIN OF COLOR People of color can be categorized as having skin of Fitzpatrick type IV through VI 1,2 People with skin of color come from a wide variety of ethnic backgrounds, including: African American/Black Asian/Pacific Islander Hispanic Native American People with skin of color make up the majority of the world s population and represent the fastest-growing segment of the US population 3 US population projections for the year 2050 suggest that non-caucasians will make up 47% of the total population 2 1. Fitzpatrick TB. Arch Dermatol. 1988;124(6): Taylor SC, et al. J Am Acad Dermatol. 2002;46:S98- S US Census Projections. 5 CHARACTERISTICS OF DISEASE IN THE US Previous studies show that patients of color suffer disproportionately from several dermatologic disorders less common in Caucasians Taylor SC. Cutis 2003;71: Grimes PE. Dermatol Clin 2000;18: Taylor SC. Skin Pharmacol Appl Skin Physiol 1999;12:

4 NATIONAL AMBULATORY MEDICAL CARE SURVEY (NAMCS) DATABASE STUDY Study to characterize top conditions seen in ambulatory care practice using a nationally representative sample from the NAMCS NAMCS data collected in the years Data stratified by race and ethnicity (NAMCS categories of White, Black or African American, Asian or Pacific Islander, American Indian or Alaska Native, and more than one race reported ) 7 TOP DIAGNOSES IN AFRICAN AMERICAN PATIENT VISITS TO DERMATOLOGISTS Davis SA, et al. J Drugs Dermatol 2012 Diagnosis ICD-9 Code No. of Visits % of Visits Acne ,720, % Unspec. dermatitis Seb dermatitis ,640, % ,990, % Atopic derm ,590, % Dyschromia ,290, % Psoriasis , % Alopecia , % Keloid scar , % Viral warts , % Sebaceous cyst , % 8 4

5 TOP DIAGNOSES IN AFRICAN AMERICAN PATIENT VISITS TO DERMATOLOGISTS Diagnosis ICD-9 Code No. of Visits % of Visits Acne ,720, % Unspec. dermatitis Seb dermatitis ,640, % ,990, % Atopic derm ,590, % Dyschromia ,290, % Psoriasis , % Alopecia , % Keloid scar , % Viral warts , % Sebaceous cyst , % 9 ACNE Disease that may act differently in skin of color 10 5

6 Electronic web-based survey of 208 women 51.4% white and 48.6% non-white years of age with >25 facial lesions Acne neg affected quality of life in both groups More white than non-white troubled by acne Non-whites Focused on post-inflammatory hyperpigmentation 70% felt race/ethnicity required targeted attention 2/3 desired acne treatment designed to meet needs of their skin 1 Callender, Alexis et al. JCAD. 2014;7(7): ACNE VULGARIS IS A COMMON CONDITION IN SKIN OF COLOR Acne vulgaris is estimated to affect million Americans 1 Several epidemiologic studies of individuals with skin of color indicate that: Prevalence of acne is similar among all races but may be higher in skin of color 2,6 Single US Pediatric Diagnosis 3 (Schachner L, 1983) Single UK Practice Referrals 4 (Child FJ, 1999) Single US Institution Diagnosis 5 (Alexis AF, 2007) Global Prevalence 6 (Perkins AC, 2010) Black 49.3% Black 51% Black 28.4% African American 37% Caucasian 50.7% White 41% White 21.0% Asian 30% Asian or Arabic 8% Caucasian 24% Hispanic 33% Continental Indian 23% 1. White GM. J Am Acad Dermatol. 1998;39(2 Pt 3):S34-S Halder RM, et al. Dermatol Clin. 2003;21(4): , vii. 3. Schachner L. Pediatr Dermatol. 1983;1(2): Child FJ, et al. Br J Dermatol. 1999;141(3): Alexis AF, et al. Cutis. 2007;80(5): Perkins AC, et al. J Eur Acad Dermatol Venereol

7 ACNE EPIDEMIOLOGY Largest, most comprehensive study of different ethnicities Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian, and African American women. 1 2,895 women, ages 10-70, graded for acne lesions, scars, dyspigmentation, sebum excretion and pore size 384 African American 520 Asian 1295 Caucasian 258 Hispanic 438 Continental Indian 1. Perkins AC et al JEADV TYPICAL PATHOLOGIC CONSIDERATIONS IN ACNE Open comedo Closed comedo Papule Pustule Inflamed Nodule 14 7

8 Inflammation Is Present Throughout the Stages of Acne Pathogenesis Historical perspective has focused on the proliferation of P acnes nurtured by overproduction of sebum as a major stimulus for secondary (and later-stage) inflammation in acne 1 Recent evidence supports the hypothesis that inflammation is present even when acne is not clinically visible 2 Initiation of inflammatory events may occur as early as microcomedo formation or comedogenesis, prior to hyperproliferative changes 2 1. Harper JC, et al. Adv Dermatol. 2003;19: Jeremy AH, et al. J Invest Dermatol. 2003;121(1): A Large Proportion of Inflammatory Lesions Arises From Normal Skin In a study of serial photographs of skin of acne patients, 28% of inflammatory lesions (inflammatory papules, pustules, and nodules) arose from normal skin 1 Comedones were not detected at the lesion sites at timepoints preceding the appearance of the inflammatory lesions These data support a model of acne pathogenesis in which the initiation of inflammatory events occurs early in the pathogenic process and prior to clinical detection of the acne lesion Some events involved in comedo formation may not be necessary for inflammatory lesion development 1. Do TT, et al. J Am Acad Dermatol. 2008;58(4):

9 INFLAMMATION IN ACNE: SKIN OF COLOR Halder et al took biopsies from 30 African American women and found 1 : Marked inflammation was present in all lesion types, including mild comedones Comedones ruptured early and often reformed These histologic findings may explain why mild to moderate acne in skin-of-color individuals results in postinflammatory hyperpigmentation (PIH) 2,3 1. Halder RM, et al. J Invest Dermatol 1996;106: Shah SK, et al. J Dermatolog Treat. 2010;21(3): Callender VD. Dermatol Ther. 2004;17(2): CLINICAL PRESENTATION OF ACNE IN SKIN OF COLOR 18 9

10 DIFFERENCES IN ACNE SUBTYPES EXIST AMONG ETHNIC GROUPS Most ethnic groups manifest comedonal versus inflammatory acne equally; however: Asians are more prone to inflammatory acne (20% vs 10%; P <.01) 1 Caucasians are more prone to comedonal acne (14% vs 10%; P <.01) 1 Mild acne is more prevalent in Hispanics (34%) and Caucasians (31%) than other ethnic groups 1 70% Inflammatory Lesions Comedonal Lesions Mild Acne 60% 50% 27% 34% 40% 30% 20% 18% 26% 10% 31% 14% 15% 22% 11% 10% 0% 19% 20% African American (n=384) Asian (n=519) 10% Caucasian (n=1194) 18% Hispanic (n=258) 12% Continental Indian (n=438) 1. Perkins AC, et al. J Eur Acad Dermatol Venereol (9) PIH AND KELOIDAL SCARRING ARE COMMON SEQUELAE OF ACNE IN SOC Skin-of-color patients are more likely to experience certain sequelae from acne 1-3 Dyspigmentation (hyperpigmentation and hypopigmentation) Scarring Among skin-of-color patients, African Americans and Hispanics are most likely to experience these sequelae 1 70% 60% 50% 40% 65% Hyperpigmentation Hypopigmentation Atrophic Scarring Hypertrophic Scarring 48% 30% 20% 10% 0% 15% 28% 6% African American (n=384) 18% 25% 22% 10% 7% 6% 1% 2% 2% 2% 3% 1% 1% 1% 1% Asian (n=519) Caucasian (n=1194) Hispanic (n=258) Continental Indian (n=438) 1. Perkins AC, et al. J Eur Acad Dermatol Venereol Davis EC, et al. J Clin Aesthet Dermatol. 2010;3(4): Shah SK, et al. J Dermatolog Treat. 2010;21(3):

11 CULTURAL PRACTICES MAY AFFECT THE CLINICAL PRESENTATION OF ACNE 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% African American (n=239) Skin Care Practices 4 Moisturizer Sunscreen Hispanic (n=55) Asian & Other (n=19) Astringent Oil-free Foundation Cultural practices with skin and hair care products are associated with certain presentations of acne 1-3 Pomade acne consists of closely packed, closed comedones and small papules along the hairline of African Americans and Hispanics, resulting from the use of hair products 1-3 Acne cosmetica refers to comedones that arise from excessive use of cosmetic products 2,4 Makeup is often used by skin-ofcolor patients to cover PIH 1. Cole PD, et al. Semin Plast Surg. 2009;23(3): Davis EC, et al. J Clin Aesthet Dermatol. 2010;3(4): Halder RM, et al. Dermatol Clin. 2003;21(4): , vii. 4. Taylor SC, et al. J Am Acad Dermatol. 2002;46:S98-S

12 TOPICAL RETINOIDS IN ACNE First choice for early and aggressive acne therapy in patients of color Targets acne pathogenic factors Reverse abnormal desquamation 1 Promotes drainage of comedones 1 Inhibit formation of new comedones 1 Hastens improvement of PIH 2 May cause dryness that will need to be managed 1 Kuenali S et al. Retinoids. In Jorizzo JL, Rapini RP, Bolognia JL, eds.dermatology. 2 nd ed. Elsevier Mosby, Bulengo-Ransby S, et al. NEJM Pooled analysis of 2 pivotal phase 3 studies Monotherapy with once-daily dapsone gel, 7.5% was effective, safe, and well tolerated for treatment of moderate acne in patients with lighter (I III) and darker (IV VI) skin phototypes Slightly later onset of improvement noted in the subgroup with darker skin phototypes

13 25 TREATMENT WITH TOPICAL RETINOIDS To maximize effects and minimize irritation Wash face with gentle cleanser and wait minutes Apply small amount all over face;can use with moisturizer Start with lower concentration Proper selection of vehicle (gels for very oily skin) Avoid drying cleansing agents (alcohol, harsh soaps, scrubs) Can use hydrocortisone 1% early in treatment 26 13

14 ACNE: COMBINATION TOPICALS Several studies suggest that combination topicals can be very efficacious in skin of color Minimal irritancy noted in these studies as well BPO 5%/Clindamycin 1% + tretinoin or adapalene 1 Adapalene-benzoyl peroxide 2,3 1 Taylor ST. Cutis 2007 Jul;80(Suppl): Callender VD et al. JCAD 2010;3(8): Alexis et al. JDD 2014;13(2): NCMS database study of 35 million acne visits from Isotretinoin prescribed in 5.8 million visits (17%) Black patients were less likely than white patients to be prescribed isotretinoin with cost being a factor Women less likely than men to be prescribed isotretinoin Fleischer AB Jr, Simpson JK, McMichael A, Feldman SR. JAAD 2003;49(4):

15 ACNE - OTHER CONSIDERATIONS Over the counter products that patients do not discuss Must ask about all washes, moisturizers, treatments, practices Ask about spot treating Ask about frequency of use of the medication Discuss exercise and perspiration Discuss hormonal balance (metabolic syndrome, polycystic ovarian syndrome) Consider Spironolactone for presumed PCOS and to avoid long term oral antibiotics 29 OTHER MEDICAL THERAPIES Chemical peels Effective for acne and PIH in skin of color 1-4 Caution should be exercised because skin-of-color patients may develop transient PIH 1,2 Laser- and light-based therapies Effective as adjunctive therapy for acne 1,5-7 Further studies in skin of color need to be conducted to evaluate laser- and light-based therapies for the treatment of PIH 5 1. Davis EC, et al. J Clin Aesthet Dermatol. 2010;3(4): Shah SK, et al. J Dermatolog Treat. 2010;21(3): Garg VK, et al. Dermatol Surg. 2009;35(1): Grimes PE, et al. Dermatol Surg. 1999;25(1): Davis EC, et al. J Clin Aesthet Dermatol. 2010;3(7): Yeung CK, et al. Dermatol Surg. 2009;35(4): Rojanamatin J, et al. Dermatol Surg. 2006;32(8):

16 Disease that is more common in skin of color patients Post-inflammatory hyperpigmentation 31 POSTINFLAMMATORY HYPERPIGMENTATION IN SOC ACNE PATIENTS PIH presents clinically as patches of hyperpigmented macules PIH can be diffuse or localized 1 PIH can occur with or without secondary excoriation of the acne lesion 1 Discoloration from PIH can last significantly longer than the acne lesions themselves 1 Epidermal hyperpigmentation can last up to 6-12 months 2 Dermal hyperpigmentation can last for years 2 The high prevalence of PIH in skin of color is thought to result from increased lability of melanocytes in darkly pigmented skin 3,4 1. Callender VD. Dermatol Ther. 2004;17(2): Lacz NL, et al. Int J Dermatol. 2004;43(5): Grimes PE, et al. Dermatol Clin. 1988;6(2): Coley MK, et al. Semin Cutan Med Surg. 2009;28(2):

17 Treat acne or other primary disease first Do not start bleaching agent at first visit If needed, use combination bleaching agents, since these will work more reliably Prefer triple combination therapy Chemical peels and microdermabrasion can help REMEMBER SUNSCREEN!! Prefer physical blocks over chemical

18 Epidermal melasma most common; most treatable form 70% to 94% of cases Hyperpigmented macules of brown color Pigmentation intensified under Wood s light Dermal melasma less common; difficult to treat Hyperpigmented macules of blue-gray color Pigmentation not intensified under Wood s light No treatment to date Mixed melasma Vascular component of melasma 35 Study of 102 women, quality of life instrument was administered to melasma patients High correlations in quality of life domains between the MELQOL and the SKINDEX-16, the DLQI, and skin discoloration evaluation Social life, recreation and leisure, and emotional well being are most affected life domains 36 18

19 Use of broad-spectrum sunscreens (SPF>30) Monotherapy or combination therapy with pharmacological agents Phenolic hypopigmenting agents, such as hydroquinone Non-phenolic hypopigmenting agents, such as tretinoin, glycolic acid Topical corticosteroids Other modalities Laser treatment, chemical peels,?microneedling

20 39 Oral tranexamic acid (TA) is a synthetic derivative of the amino acid lysine that works as a anti-fibrinolytic agent TA works via the inhibition of ultraviolet-induced plasmin activity in keratinocytes TA competitively inhibiting the activation of plasminogen activator (PA) through reversible interactions with its lysine-binding sites inhibiting PA from converting plasminogen to plasmin Typical dose is 250 mg twice daily Duration of treatment varies among studies (3-9 months) Screen out patients with history of: thromboembolism, stroke, heart disease Few side effects noted in most studies: mild GI upset, palpitations, oligomenorrhea, urticarial rash Lee HC, et al. JAAD 2016;75: Zhang L et al. Biomed Res Int. 2018; 2018:

21 73 women enrolled with 1 or more of the following: acne, hypopigmentation, lentigines, melasma, vascular proliferation, rosacea, or other facial scars Skindex-16 used to measure HRQOL;FNE for fear of negative evaluation Significant improvement seen in women with disfiguring facial pigmentary disorders while using corrective cosmetics 33% improvement in Skindex-16 p<0.001, Reductions in FNE by 11% p,0.001 Worry over skin discoloration reduced 47% p< Before After 42 21

22 43 Disease that acts differently in skin of color

23 45 Massive ear keloids are larger than the size of corresponding ear. Tirgan M 2017 [version 2; referees: 2 approved with reservations] F1000Research 2017, 5:2517 (doi: /f1000research ) 46 23

24 KELOIDAL SCARRING IN SKIN OF COLOR Keloidal scars are most often observed on the chest, back, and jawline of skin-of-color individuals 4 Keloidal scar tissue occurs ~ 5 to 16 times more frequently in patients with skin of color than in Caucasian patients 1,2 Keloidal scarring is more permanent and disfiguring than primary disease itself, and may have a greater impact on quality of life 4 1. Kelly AP. Semin Cutan Med Surg. 2009;28(2): Kelly AP. Cosmetic Derm. 2003;16: Mameros AG, et al. Arch Dermatol. 2001;137(11): Callender VD. Dermatol Ther. 2004;17(2): For keloidal scarring Intralesional kenalog over time, isotretinoin, lasergenesis, multiple fractionated CO2 laser treatments, surgery followed by radiation Cryosurgery with intralesional kenalog For anetoderma scarring Lasergenesis (Nd:Yag laser) For rolling scars Subscision followed by filler injections Microneedling Ice pick scars Tough to treat, can try Lasergenesis, microneedling, toothpick with TCA 60-90% 48 24

25 49 Successful keloid removal with contact cryotherapy for small primary and secondary (left column,... Tirgan M 2017 [version 2; referees: 2 approved with reservations] F1000Research 2017, 5:2517 (doi: /f1000research ) 50 25

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27 TOP DIAGNOSES IN AFRICAN AMERICAN PATIENT VISITS TO DERMATOLOGISTS Diagnosis ICD-9 Code No. of Visits % of Visits Acne ,720, % Unspec. dermatitis ,640, % Seb dermatitis ,990, % Atopic derm ,590, % Dyschromia ,290, % Psoriasis , % Alopecia , % Keloid scar , % Viral warts , % Sebaceous cyst , % 53 Study by Gelfand et al performed population-based study to determine prevalence of psoriasis in African American patients- Gelfand et al, JAAD 2005;52:23-6 Total sample included 27,220 individuals, of which 21,921 were Caucasian and 2443 were African American Prevalence of psoriasis was 2.5% in Caucasian patients and 1.3% in African American patients 57% reduction in prevalence of psoriasis in African American patients compared to Caucasian 54 27

28 African Americans more likely to have 3-10 palms of psoriasis than Caucasians African Americans less likely to have 1-2 palms of skin involvement No difference in treatment satisfaction or degree to which psoriasis affects daily life Psoriasis not rare in this population and carries substantial burden in both groups 55 In the USA, the overall prevalence of psoriasis is estimated to be 3.7% based on data from the National Health and Nutrition Examination Surveys in and The rate is highest in white individuals (3.7%), followed by black (2.0%) and Hispanic individuals/others (1.6%) These estimates are slightly higher than a prior population-based study of 27,220 people, which found a prevalence of 2.5% in white patients and 1.3% in black patients Rachakonda TD, et alj Am Acad Dermatol. 2014;70(3): Helmick CG et al. Am J Prev Med. 2014;47(1):

29 799,607 beneficiaries Treatments used for moderate-to-severe psoriasis (phototherapy, oral systemic, or biologic therapies) were received by 27.3% of the total psoriasis sample, of whom 37.2% used biologics Patients without a Medicare Part D low-income subsidy (LIS) had 70% lower odds of having received biologics than those with LIS (odds ratio 0.30; 95% confidence interval, ) The odds of having received biologics were 69% lower among black patients compared with white patients (0.31; ) Takeshita J, Gelfand JM, Li P, Pinto L, Yu X, Rao P, Viswanathan HN, Doshi JA. J Invest Dermatol Dec;135(12): As with adults, the prevalence of psoriasis in black children appears to be significantly lower than in white children, with 0.06 vs. 0.29% of children affected, respectively Potential impact of under-reporting and selection bias in estimates of psoriasis prevalence in ethnic minorities Non-white individuals are more likely to have undiagnosed psoriasis than white individuals (in part owing to barriers to care and decreased healthcare utilization in these groups), which suggests that the prevalence of psoriasis in black and Hispanic individuals may be underestimated Wu JJ et al. J Acad Dermatol. 2011;65(5):

30 In Africa, clinic-based investigations have demonstrated a wide variation in the prevalence of psoriasis between different countries, with higher rates seen in eastern than western Sub-Saharan Africa Psoriasis has been reported to affect % of individuals in Kenya, Uganda, and Tanzania (Eastern Africa) vs % in Ghana, Nigeria, Senegal, and Mali (Western Africa) Differences attributed to genetic differences between Bantu-speaking Africans, who predominantly populate eastern, central, and southern Africa, and non-bantuspeaking groups in western Africa African Americans are more closely related to non-bantu-speaking (West) Africans, which may explain the relatively lower prevalence of psoriasis in this group Kaufman BP, Alexis AF. Am J Clin Dermatol Jun;19(3): patients enrolled, 104 from the VAMC Patients were primarily male (78.4 %), with a mean age of 56.7 years 39% were African-Americans Psoriatic arthritis was less frequent in African-Americans compared to Caucasians (30 vs %, respectively, p < 0.001) African-Americans had more severe skin involvement [Psoriasis Area and Severity Index 8.4 (10.0) vs. Caucasians 5.5 (6.4), p = 0.06] African Americans had greater psychological impact and impaired quality of life. Use of biologic therapies was greater in Caucasian patients (46.2 vs % in African-Americans, p < )

31 Several studies suggest that erythema is more challenging to detect in skin of color Inflammation that typically manifests as pink or red lesions in lighter skin may appear violaceous or hyperpigmented in darker skin types In such cases, active psoriatic lesions may be mistaken for post-inflammatory hyperpigmentation, especially when thickening and/or scaling is minimal Resolution of psoriasis lesions in darker skin types is associated with a higher rate of dyspigmentation (both hyper- and hypo-pigmentation), which may be equally or even more bothersome to patients than the original psoriasis itself dermatologists/psoriasis experts surveyed 66% (19/29) of respondents reported clinical differences in African Americans (including dyspigmentation, thicker plaques, less erythema) Treatment was not surprising and mirrored how all patients are treated. McMichael AJ et al, JDD, 2012;11(4):

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35 69 Current therapies for psoriasis are considered to be safe and effective for use in diverse ethnic groups, although the majority of clinical trials have been performed in white individuals Recent systematic review investigating the diversity of dermatology clinical trials found that psoriasis studies enrolled the lowest number of non-white participants, with 84.3% of total participants being white* Phase III pivotal trials for biologic treatments have enrolled % white participants The dermatology community has begun to recognize the paucity of ethnic minorities in clinical trials, there is now a greater drive to include a more racially diverse population in pivotal studies to broaden the applicability of the results to non-white ethnic groups *Charrow A, et al. Diversity in dermatology clinical trials. JAMA Dermatol. 2017;153(2):

36 Avoid delay in diagnosis by biopsying early if no response to eczema treatment Usual treatments of topicals steroids, Vit D derivatives, phototherapy Narrow band UVB or Excimer laser for localized lesions Move to Methotrexate early For appropriate patients, consider acitretin Biologics on therapeutic ladder Discuss the thickness and hyperpigmentation and need to minimize manipulation 71 Scalp treatment Need to carefully choose vehicle for treatment for compatibility of hair type Address the frontal scalp component Post-inflammatory hyperpigmentation (PIH) Often patients are unhappy with treatment outcome because PIH remains Encouragement to wait for PIH improvement

37 Brodalumab with robust skin clearance efficacy in the treatment of moderate-tosevere plaque psoriasis Comparable across subgroups defined by race or ethnicity No notable patterns in AE reporting or patient-reported outcomes (ie, DLQI, WLQ, PSI) were observed in patients with skin of color when compared with those in white patients Compared with other biologics used to treat moderate-to-severe psoriasis, brodalumab may be unique in its association with comparable efficacy, safety, and patient-reported outcomes across diverse racial subgroups including black, Asian, white, and Hispanic/Latino patients Brodalumab 210 mg Q2W Brodalumab 210 mg Q2W Black Asian White Hispanic /Latino (n=132) (n=36) (n=39) (n=1116) Age, mean (SD), y 45.7 (13.6) 42.0 (12.9) 45.2 (12.9) 42.8 (11.9) Male, n (%) 20 (55.6) 36 (92.3) 759 (68.0) 93 (70.5) Weight, mean (SD), kg 92.5 (24.4) 84.2 (21.9) 90.9 (23.2) 89.2 (21.1) BMI, mean (SD), kg/m (8.4) 29.3 (6.0) 30.4 (7.3) 31.4 (6.6) Duration of psoriasis, mean (SD), y 12.6 (10.2) 13.8 (9.6) 18.9 (12.3) 12.8 (10.2) Psoriatic arthritis, n (%) 7 (19.4) 4 (10.3) 222 (19.9) 19 (14.4) BSA, mean (SD), % 29.9 (19.9) 25.9 (17.7) 27.2 (16.9) 27.8 (19.1) PASI score, mean (SD) 23.0 (9.7) 19.4 (7.2) 20.3 (8.3) 20.1 (7.6) spga score, n (%) (36.1) 20 (55.6) 15 (38.5) 20 (51.3) 637 (57.1) 425 (38.1) 87 (65.9) 41 (31.1) 5 3 (8.3) 4 (10.3) 54 (4.8) 4 (3.0) PSI score, mean (SD) 19.6 (7.4) 18.5 (7.5) 18.6 (7.0) 20.5 (7.2) DLQI score, mean (SD) 16.4 (7.8) 15.1 (7.2) 14.4 (7.1) 15.6 (7.1)

38 Early recognition/biopsy of psoriasis in African American patients Begin genetics research in diverse populations Remember the importance of increasing our knowledge of treatment outcomes in African American patients Consider patient expectations for psoriasis and pigment Aggressive treatment 75 Remember the importance of acne for women, especially African American women Consider patient expectations Aggressive treatment Address post-inflammatory hyperpigmentation Reset patient expectations for therapy Need to devise optimal management of psoriasis in African American patients Continuous therapy paradigm needs to include those with thicker, excoriated, or more symptomatic disease Criteria for determining severity may need to be reexamined for dark-complexioned patients 76 38