What I Wish I Knew About Managing Psoriasis in Different Populations

Psoriasis is a skin condition that causes the body to make new skin cells at a faster rate than usual—in a matter of days rather than weeks. In the most common type of psoriasis, plaque psoriasis, the build-up of these cells on the skin leads to the creation of thick, scaly, itchy patches of skin. But while 7.5 million people in the U.S. have psoriasis, the condition is often misunderstood and even misdiagnosed.

There are a few reasons for this, Frank Wang, MD, associate professor of dermatology at the University of Michigan, told Health. A major issue, according to Dr. Wang, is that medical schools only have “limited amounts of time for dermatology education” for students before the students decide on a specialty. 

For those who enter dermatology as a specialty, there is an additional three years of training during post-medical school residency. But for many doctors who don’t go on to become dermatologists and get that extra training, often all of what they learn about skin disorders is crammed into that small amount of time during medical school.

 With that, it’s hard to go over the ins and outs of what conditions like psoriasis can look like across all skin types. 

 While Dr. Wang went on to specialize in dermatology and get those extra years of skin-specific training, he said there are a few things he wished he had learned in medical school about managing patients with psoriasis who fall into different populations, such as those with darker skin tones, those who are older, and those with drier skin. 

How much time do you have in medical school to learn about how psoriasis shows up in patients with different skin tones?

Frank Wang, MD: In general, there’s very limited amounts of time for dermatology exposure, training, and education in medical schools. When I was in medical school, I had three to five days of dermatology education. For the average medical student at University of Michigan, they get around five to six days of formal dermatology training.

You can imagine with that limited amount of time, there’s even more limited time for education in the presentations of disorders in skin of color.

What do you wish you had learned in medical school about the presentation or treatment of psoriasis in patients with different skin tones?

Dr. Wang: I personally was not exposed to much dermatology in medical school, let alone dermatology in patients with skin of color. Some of the things I now know that I wish I had known before was that how psoriasis looks is different in darker skin tones than lighter skin tones. The redness and inflammation can be harder to detect in darker skin, whereas it may appear bright red in lighter skin. Psoriasis may have a dull red or even a darkish brown color to it in darker skin.

What do you wish you had known about the impact on quality of life on patients with psoriasis who have darker skin tones?

Dr. Wang: Psoriasis in general impacts quality of life. But particularly for people with darker skin, it can leave behind a darker or lighter area. That kind of discoloration can last a really long time—months, even years. That's very upsetting to many patients with darker skin, and it really impacts their quality of life. Those are just some of the clinical features that I wish I knew more about before.

What do you wish you had known about finding the right psoriasis treatment for people of different ages?

Dr. Wang: In general, we tend to see less psoriasis in children—it's just not as common in children. The greatest onset is between the ages of 20 and 30. 

With that in mind, for most of the medications we have available for psoriasis—the older medications, newer agents, and biologics—we tend to have more experience with their use in adults. Generally, older patients have more medical problems. Some of the agents we use to treat psoriasis we don't necessarily want to use if the patient has congestive heart failure, lupus, or some other medical problems. This I learned more in practice and beyond than in school.

What do you wish you had learned earlier about how psoriasis can impact people with different skin types?

Dr. Wang: The drier your skin is, the more likely it is your psoriasis will be worse. If a patient has psoriasis and they're not doing basic moisturizing of skin, that tends to worsen psoriasis. 

That can be compounded when it's wintertime—the air is cold and dry. All that dryness from the weather will worsen psoriasis. It can be a little trickier to treat during this time of weather. It can certainly lead to a flare-up. If someone’s skin is dry and they are not moisturizing, psoriasis will flare up. 

Dry skin in general is going to make psoriasis worse.

What do you wish you had learned about how else psoriasis can impact a person’s life?  

Dr. Wang: With such minimal exposure to dermatology as a medical student, we didn’t cover how psoriasis can impact a patient’s quality of life. I now teach medical students and, knowing that we have limited time, I’m more interested in making sure they know that psoriasis exists. 

But I also want them to know that it's more than skin deep. Psoriasis impacts a patient's quality of life, their ability to do normal things, and maybe even have a job. You can imagine how difficult it is to have psoriasis if you're an actor or are in the public eye. 

I want students to know psoriasis can influence internal problems as well, like cardiac disease and arthritis—that’s something that I mostly learned about after medical school.