washing your hair every day is going to dry out your scalp, it’s going to potentially make things worse, it’s going to break your hair. So those are little nuances that I like patients to keep in mind.
I generally say it’s much better to just go see a dermatologist and have them diagnose it because there are nuances to treatment that maybe even over-the-counter stuff is not going to be able to address. But even for someone like me who sees a lot of skin of color and scalp psoriasis, sometimes I have to biopsy because it can be challenging and I don’t want to give the patient the wrong medication. So we have a conversation and I sometimes tell them, “Hey, we could start with this treatment, if that doesn’t work, we can biopsy, or I’m on the fence, do you want a biopsy today?” And through shared decision-making, we kind of come up with the best option for each patient.
Are there differences in treatment approaches for scalp psoriasis in people of color?
Definitely. So when it comes to individuals with Afro-textured hair, as I mentioned earlier, we don’t want to be giving them treatment regimens that require frequent hair washing because generally, medications are washing their hair once a week. So a regimen that’s going to be conducive to that usual hair care practice is going to be important because if I send them home with a regimen where they’re washing their hair every day, they’re not going to do it, they’re going to lose faith in me, and then they’re going to move on to the next expert and potentially have further delays in their treatment.
So I generally try to pick formulations that mesh well with an individual’s normal hair care routine. Oils are great for tightly coiled hair, foams, lotions, these are other favorites of mine. I try to avoid solutions and creams because these can be drying for the scalp and drying for the hair. I have a low threshold to consider systemic therapy because the reality is when you’re trying to get something into the scalp, topicals are just only going to do so much. And the multidimensional burden of plaque psoriasis goes beyond what we can see on the scalp. That itch that I talked about, the quality of life burden, you see all these flakes on your clothes. So I like to cool this down quickly and let my patients live their best lives. Going to a systemic agent early is another great option.
What advice do you have for people of color living with scalp psoriasis to manage the condition in their daily lives?
Well, I think the important thing is to consider those formulations that match their regimen. They do have anti-inflammatory oils that they sell over the counter that would be a great option for individuals with Afro-textured hair. But if the dandruff is becoming too much, I do think it’s important for them to seek out care because there are limited options over the counter that would really help them nip this in the bud.
Are there any upcoming developments or advancements in the treatment of scalp psoriasis that you find particularly promising for people of color?
Well, I think this study has been very revolutionary in terms of us not only understanding the response of patients with skin of color to the medicine Tremfya, which was studied, but also really understanding the challenges and barriers that they go through when it comes to access to care, response to treatment, as well as their individual treatment goals. Cultural competency was another big issue that came out in the study because a lot of clinicians, if they themselves are not of color, they may not know how to interact with the patient of color to make them feel safe and have them get on board with any sort of regimen.
So I think those are the benefits that really go beyond what was specifically studied in the trial, but the scalp psoriasis piece I think was huge. We’re still analyzing the data, there’s still so much more that we’re learning about individuals with skin of color and their impact from scalp psoriasis. Across the entire dermatology landscape, there are new formulations of medications that are being developed, topical medications that are meant to really help bridge this gap because historically, we’ve just created lessons that work for the scalp, not really taking into account that many of our patients with plaque psoriasis of the scalp are patients with skin of color. So now, I think pharma is doing a much better job of keeping in mind the formulation that’s going to work across all skin tones so each and every one of our patients can have access to the latest medications.
Historically, the problem we’ve had with clinical trials is we’ve had an underrepresentation of patients with skin of color. And the problem with that is if you get the results from the study, you can’t necessarily apply it to your real-world patients because there is a disproportionate number of patients who are Caucasian included, and you don’t have enough patients with skin of color to really help you know if this medication is going to work. So the movements toward including more diversity in our clinical trials and not just as a checkbox, but really putting in the effort to ensure patients with non-enriched skin are getting into these trials, we’re properly studying their response to treatment, I think we’re really going to help change the landscape so these newer drugs will be much better studied in these populations.
Is there anything else you would like people to know about scalp psoriasis?
I think we’ve covered the scalp psoriasis piece quite in detail. The only thing I would urge patients out there of skin of color who are dealing with plaque psoriasis, whether it’s on the scalp or on their body, is really talk to your clinicians, make your expectations known, and be an advocate for yourself. Because I think there are a lot of clinicians out there who want to help, they just don’t have the right tools. And don’t be quick to just write someone off and say, “Well, they don’t know what they’re talking about.” Engage them, really let them know what your goals are because you’re just as important, and your needs and your goals should be at the forefront of every single discussion.
And if they give you a treatment regimen that doesn’t really mesh with your day-to-day, just let them know, “This is not gonna work for me, what other options do we have?” I think finding a culturally competent clinician can be challenging, but I also want patients to really advocate for themselves so that if somebody’s on the fence, they can get them to include that shared decision-making a little bit more at the forefront when they’re talking about treatment options.