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Ayesha Patrick, 42, remembers the scene well. It was late 2020, and she was getting ready for the day. Scales rained down from her skin onto the countertop as her daughter looked on from the bathroom doorway. Then the preteen posed a question her mom will never forget: "Is that going to happen to me?"

Plaque psoriasis isn't new to this New Jersey native and mother of two. In fact, Patrick and her twin sister were diagnosed with the skin condition as kids. To help them feel less embarrassed, their mom called the plaques in their hair and on their legs "growing dandruff" and "winter itch."

These skin and scalp symptoms were mostly manageable growing up. But psoriasis "ravaged" Patrick during the coronavirus pandemic. Plaques covered 80% of her body, and she lost much of the hair on the crown of her head.

Her dermatologist at the time, who was white, prescribed a treatment routine that wasn't a good fit. Patrick tried to explain why. But she felt misunderstood and that her concerns were dismissed.

"She wanted me to use this medication on my scalp every day," Patrick says. "But I'm a Black woman, and we don't wash our hair every day. That was a major challenge."

A lot has changed since the "chaotic flare" of the pandemic. Patrick now sees a doctor with lots of experience treating people of color. And, along with medication she puts on her skin, healthy lifestyle changes have helped her gain control of her plaque psoriasis.

That brings us back to that moment with her daughter. "When she asked me that question, it was part of what helped me make changes," Patrick says, "so she could continue to see that if I was OK, that she would be, too, if this ever happened to her."

Plaque psoriasis is a chronic inflammatory skin condition. It's found most often in people who have lighter skin and European ancestry. But the disease affects many skin tones and types.

Experts think plaque psoriasis is probably more common in white folks. But they generally believe that the true prevalence is underestimated in people of color. That typically includes those who identify as African, Asian, Black, East Indian, Hispanic or Latino, Native American, Pacific Islander, or a mixture of any of the above.

People with skin of color make up most of the world's population. Still, there's not a lot of research on psoriasis in these groups, although some studies have found that people who are Asian or Hispanic are more likely to have severe psoriasis, or disease that covers greater than 50% of their body surface area.

Julia Riley, MD, is an assistant professor of dermatology at Northwestern Feinberg School of Medicine and assistant director of the Northwestern Center for Ethnic Skin and Hair. She says there's some evidence that people of color may have more severe psoriasis, compared to white people.

"However, severe psoriasis can present in all populations," Riley says.

"However, severe psoriasis can present in all populations," Riley says.

According to statistics in the U.S., here's how psoriasis rates break down among racial and ethnic groups:

A mix of things come together to prevent proper psoriasis care in people of color.

First, you need a doctor to look at your skin to tell you if you have psoriasis and to give you the right treatment. But the U.S. has a long history of racial discrimination and inequality. This is known as systemic racism, and it limits access to health insurance and medical care for many people of color.

And for many cultural and historical reasons, certain racial and ethnic groups are more likely to mistrust the medical system and may be wary of or unfamiliar with certain treatments. "I do have a lot of psoriasis patients [of color] who are hesitant to try a biologic," Riley says.

Doctors are also less likely to recognize psoriasis right away in skin of color. Many suspect it only when they spot reddish or "salmon-pink" plaques. That's typically how the condition appears in lighter skin, but plaques may not look red at all in darker skin.

And for many cultural and historical reasons, certain racial and ethnic groups are more likely to mistrust the medical system and may be wary of or unfamiliar with certain treatments. "I do have a lot of psoriasis patients [of color] who are hesitant to try a biologic," Riley says.

Doctors are also less likely to recognize psoriasis right away in skin of color. Many suspect it only when they spot reddish or "salmon-pink" plaques. That's typically how the condition appears in lighter skin, but plaques may not look red at all in darker skin.

"In patients of color, plaques of psoriasis can appear more purple, gray, or brown in color," Riley says. "For that reason, it's more challenging to diagnose, because a dermatologist may not have seen those images in their textbooks."

The layer that sloughs off can also look quite different in darker skin.

"The scale on top can be kind of dull and gray, and maybe not even that noticeable," says Christine Ko, MD, a professor of dermatology and pathology with Yale Medicine and author of How to Improve Doctor-Patient Connection: Using Psychology to Optimize Healthcare Interactions.

If you're a Black woman, it's not uncommon to hear that you simply have very dry skin, "or you just have a lot of dandruff," Patrick says.

Psoriasis in people of color can also look like other skin conditions. And if your doctor thinks you have something else entirely, like lichen planus or ringworm, you may not get the correct treatment right away.

Most dermatologists know what psoriasis is, but some are more experienced in treating skin of color. According to Riley, looking specifically for someone who specializes in this area is one way to ensure that you're seeing someone who is comfortable treating your skin type.

Patrick tapped her Facebook community when she decided to switch dermatologists. Now she's in a supportive relationship where she feels understood. But things aren't better because she and this new doc share the same race.

"The practice works primarily with people of color," Patrick says, "so I'm comfortable in knowing that she's worked with many patients who look like me and have experienced similar issues as I have now."

You also have the right to ask why your doctor is or isn't prescribing certain treatments. And you should feel safe to suggest things like biologics if your provider doesn't bring the option up first. "That's called shared decision-making," Ko says. "It's not rude. And if it's taken as rude, that's a red flag."

It's also fine to find out if there's a different "vehicle" to treat your condition. For example, Riley says, you could get a topical steroid for the scalp in the form of a wash, oil, foam, or ointment. And be honest about the specifics of your hair care routine.

"When I'm treating someone with an issue in the scalp, I typically ask: Do they wash their hair every 2 weeks? Every 1 week? Every 3 weeks?" Riley says. "Based on their answer, we try to find a plan that works for them."

Psoriasis isn't only a skin disease; the inflammatory condition raises your odds of several other medical problems. You'll want to see your regular doctor for routine health screenings.

It's important to note that a lot of the conditions that happen alongside psoriasis — like obesity and metabolic syndrome — are already more common among people of color.

"That's even more of a reason for patients who are seeing dermatologists for their psoriasis to also see a primary care provider who can diagnose and manage those other conditions," Riley says.

Patrick decided to overhaul her nutrition and fitness routines to try to ease her flares. She feels better when she follows a gluten-free diet, limits sugary cocktails, and gets a daily dose of sunlight for extra vitamin D. She also fits in 20 minutes of cardio at least 3 days a week.

Her skin still has some hyperpigmentation. These dark areas show up after psoriasis heals and tend to stick around longer in darker skin. But she's no longer covered in plaques. And that constant burning she used to have on her scalp?

"I no longer feel that," Patrick says.

Her skin still has some hyperpigmentation. These dark areas show up after psoriasis heals and tend to stick around longer in darker skin. But she's no longer covered in plaques. And that constant burning she used to have on her scalp?

"I no longer feel that," Patrick says.

Caring for Your Health with Psoriasis

Patrick's plaques are under control these days. But she remembers spending an hour covering her body with topicals. Then she'd take extra time to pick an outfit to hide her arms and scalp. And how would she do her hair wrap? Would she wear a wig that day?

"When you're doing all those things," Patrick says, "your mind is like, 'Oh my God, this is too much.'"

The right psoriasis treatment plan can make a world of difference when it comes to your well-being. But people with psoriasis are generally more likely than those without the condition to have trouble with their mental health. That includes anxiety, depression, or even suicidal thoughts or behaviors.

Scientists think ongoing inflammation may change your body in ways that affect your mood and your skin. But life with a chronic skin condition can be overwhelming at times. And when you're stressed, you may feel that your flares get worse.

During her worst flare, Patrick admits she didn't really understand what was going on with her skin. And she couldn't find a lot of info online or helpful pictures of psoriasis in Black skin. She decided to change that and started her own support group.

The Sistas With Psoriasis Facebook group is 120 members strong and growing. It's a safe space for women of color to talk about lots of things: How do you get psoriasis medication without health insurance? Is nail-pitting a sign of psoriatic arthritis? What natural remedies ease plaque symptoms? Which foods are anti-inflammatory? What's it like to get light therapy or try biologics?

"I wanted to connect with other women who were asking the same questions or needed support," Patrick says. "All of us end up learning from each other because all of our walks are different."

On most days, Patrick feels blessed by her life. But lifestyle changes aren't enough to manage her psoriatic arthritis. And there are times when she gets worried about what comes next. But she trusts that her doctor has her best interests in mind, and she finds comfort in her community.

"When I talk to people who've dealt with way worse flare-ups than I have, and for longer, they tell me about how they had to go through tar baths and insane stuff," Patrick says. "I'm like, OK, I know that biologics seem scary, but it's not like it's the '40s."

On most days, Patrick feels blessed by her life. But lifestyle changes aren't enough to manage her psoriatic arthritis. And there are times when she gets worried about what comes next. But she trusts that her doctor has her best interests in mind, and she finds comfort in her community.

"When I talk to people who've dealt with way worse flare-ups than I have, and for longer, they tell me about how they had to go through tar baths and insane stuff," Patrick says. "I'm like, OK, I know that biologics seem scary, but it's not like it's the '40s."