How Psoriasis Affects Black Skin

Many people who have psoriasis will experience the telltale sign of itchiness or burning. But for people with differing skin tones, that’s where the similarities may end.

The symptoms of psoriasis, a chronic inflammatory condition, can look different on people with differing skin tones. On lighter skin, plaque psoriasis can appear red; on darker skin, it can be purple or grayish. It often goes underdiagnosed and undertreated in the Black community, so it’s important to know what signs to look for.

Pinpointing psoriasis on darker or Black skin can be different than spotting it on lighter skin for several reasons.

Color

The appearance of psoriasis can vary based on the level of melanin, or the pigment that colors our skin. For Black patients or those with darker pigmented skin, lesions may be violet, dark brown, or gray, according to Corey L. Hartman, MD, a board-certified dermatologist and the founder of Skin Wellness Dermatology. On lighter skin, psoriasis appears as thick plaques with a silver scale.

“Since psoriasis looks different on Black skin — and there's not enough education about what this looks like — it's often misdiagnosed,” Dr. Hartman says.

Location

If you have scalp psoriasis, work with your dermatologist to create a hair-care regimen that works for your specific type of hair.

Effects

The aftereffects of psoriasis also differ among individuals with heavily pigmented skin. Depending on the severity of the outbreak, Hartman says that lesions from psoriasis can leave spots of discoloration or post-inflammatory dyspigmentation for months after a flare-up resolves. Dermatologists caution Black patients not to confuse this with active psoriasis, and they do not recommend using topical steroid treatments on non-inflamed, hyperpigmented areas.

Severity

• Plaque psoriasis: This gets its name from raised patches on the skin called plaques. “In lighter skin tones the raised patches may appear red or have silver scales,” Hartman says. “In Black skin, plaque psoriasis will also appear as raised skin and can range in tone, including light to dark brown, purple, or gray. Silver or ashy scales may also appear on the psoriasis plaques on Black skin.”
• Inverse psoriasis: This type of psoriasis may look like a shiny, smooth patch and is most common in skin folds and where skin rubs together, such as under the arms or on the upper thighs. “On Black skin, inverse psoriasis might look darker than surrounding skin and can present in a variety of brown, red, and purple tones,” Hartman says.
• Guttate psoriasis: This psoriasis may look like small scaly circles or teardrops, often found on the arms, legs, stomach, or back. “Guttate psoriasis on lighter skin may have a red, scaly appearance,” Hartman says. “It can be harder to see on darker skin tones as they can look brown, a similar color to the patient’s natural skin tone. You may see hyperpigmentation around the lesions on darker skin tones, which can help with diagnosis.”
• Pustular psoriasis: This psoriasis will be inflamed and often filled with pus. Although they are red on lighter skin, this type of psoriasis on Black skin may look darker brown or purple, Hartman says.
• Erythrodermic psoriasis: “Erythrodermic psoriasis appears as a rash, often itchy and uncomfortable, across a majority of the body,” Hartman says. It looks pink or red on lighter skin, he says, and may resemble a burn on darker skin.

• Skin-care regimen
• Stress level
• Joint tenderness or pain
• Medication
• Itching or burning in affected areas
• Family history of psoriasis

Hartman says that doctors often can confirm psoriasis visually. They may send a small patch of skin for laboratory review, too.

From there, your doctor can determine if you have psoriasis and what kind.

What Can Psoriasis Be Mistaken For?

• Eczema: The term covers a variety of skin inflammations; eczema appears as an itchy, irritated rash.
• Rosacea: This chronic inflammatory condition causes redness or bumps on the face or head, but rosacea sometimes can appear on the back, chest, and other parts of the body.
• Seborrheic dermatitis: This form of dermatitis presents as scaly skin. On the scalp, it’s often known as dandruff, though it can appear on other oily spots of the body.

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Part of the reason for misdiagnosis has been that darker skin tones have not been represented as much in psoriasis research, Hartman says.

“This can lead to a knowledge gap among the medical community on how to properly assess and treat these patients,” he says.

Topical Treatments

• Corticosteroids are drugs available as oils, lotions, gels, shampoos, and other common topical ointments. They’re commonly recommended for mild to moderate psoriasis treatment.
• Vitamin D analogs are synthetic forms of vitamin D that slow down skin growth.
• Retinoids are gels or creams you can apply to slow the development of thick, scaly plaques.
• Calcineurin inhibitors can help calm psoriasis rashes and scales, especially in sensitive areas.
• Salicylic acid is available over the counter and in prescription doses to reduce the scaling of scalp psoriasis.
• Coal tar reduces itching, swelling, and inflammation and is available over the counter or by prescription.
• Anthralin can reduce psoriasis scales.

Light Therapy

• Sunlight may help with psoriasis symptoms, but speak with your doctor for more information on how to use natural light as a treatment safely.
• Narrowband ultraviolet (UV) light can help treat psoriasis that has not responded to topical treatments.
• Psoralen plus ultraviolet A (PUVA) is a similar but more aggressive form of UV light-therapy treatment. It might have more intense side effects.
• Excimer lasers are strong UVB lights that directly target problem areas.

Underrepresentation in Treatment

Hartman says that undertreatment among Black patients can result from additional factors. Disparities such as a lack of access to quality medical care and healthcare insurance, as well as racial inequities in the Black community, may contribute to Black patients with psoriasis not receiving adequate treatment.

The internet is flooded with images of white people who have psoriasis, but there aren’t nearly as many pictures of psoriasis on Black skin. This often leads people to the conclusion that psoriasis only develops in people with lighter skin, which couldn’t be further from the truth.

Ultimately, Black people who have psoriasis are less likely to see themselves represented in ads for psoriasis treatments, the study authors concluded — which may deter them from seeking treatment or suspect that those treatments aren’t an option for them.

This is something that Hartman has seen firsthand in his practice. Many Black patients are shocked to learn they have the condition or reluctant to believe certain treatments will be effective for them, he says. The good news, Hartman says, is that the knowledge gap in the medical community for treating psoriasis has narrowed, with board-certified dermatologists learning more about how to diagnose and treat psoriasis on all skin tones.

• Psoriasis symptoms are similar for most people. In darker or Black skin, patches will likely appear purplish or gray, rather than red.
• About 1.5 percent of Black adults in the United States have psoriasis, but they are less likely than white adults to receive treatment.
• Your doctor usually diagnoses psoriasis after a physical examination, but psoriasis sometimes can be mistaken for other conditions. Talk to your healthcare provider about your concerns and questions.
• Psoriasis treatments include topical ointments, light therapy, or, in severe cases, biologics.