Examining Health Care Disparities in Psoriasis and Other Skin Diseases

A review published in the journal Dermatologic Clinics explored health care system factors, social determinants of health, and cultural or societal differences contributing to racial and ethnic disparities in dermatology care.¹ The research suggests that these factors can increase the burden of disease on minority patients with skin diseases such as psoriasis.

“Health disparities are complex and multifactorial and are often linked to social and economic disadvantage,” wrote the researchers. "They originate from dynamic interactions of genetic, biological, environmental, social, economic, and health system–related factors.”

As the economic burden of skin diseases increases, researchers look to racial disparities that may be contributing to the prevalence of these diseases. In the United States, the economic burden of health disparities is projected to increase from $126 billion in 2020 to $353 billion in 2050, according to prior research.²

In this review, researchers investigated racial and ethnic disparities among patients with skin diseases such as psoriasis, acne, melanoma, hidradenitis suppurativa (HS), and atopic dermatitis to pinpoint possible social determinants of health and provide better strategies to alleviate barriers to care access.

An estimated 7.55 million adults living in the United States live with psoriasis, which has higher prevalence among White individuals (3.6%) compared with Asian (2.5%), Hispanic (1.9%) and Black (1.5%) individuals. Plaque psoriasis has been found to be the most common subtype across all racial groups. However, studies have also found that Asian patients have higher odds of psoriasis and erythrodermic psoriasis, as well as a lower prevalence of inverse psoriasis compared with White individuals.

When looking at health care system factors, Black patients were less likely to receive biologic treatment or effective medications for their psoriasis compared with White patients. The authors cited one study that found 8.3% of Black patients received a disease-modifying antirheumatic drug (DMARD) for their psoriasis, and 28% received a biologic therapy. In comparison, 13.3% of White individuals received a DMARD and 46.2% received a biologic therapy for their psoriasis.

Additionally, under current health care system reimbursement models, it is difficult for many Medicaid patients to have their dermatologic visits covered by their insurance policy. A 2016 study demonstrated significantly higher odds of hospitalization for psoriasis among Black, Hispanic, and Asian individuals, with odds radios (ORs) of 1.28 (P = .02), 1.65 (P < .0001), and 2.08 (P < .0001), respectively.

The same study also found higher rates of hospitalization for psoriasis among Medicare recipients (OR, 1.42; P < .0001), Medicaid recipients (OR, 1.61; P < .0001), and uninsured patients (OR, 3.81; P < .0001) compared with privately insured patients.

When comparing economic factors, low SES patients with psoriasis had a consistently lower quality of life and lower work productivity compared with high SES individuals without psoriasis. Additionally, non-White patients reported high costs of care as a significant barrier to seeking and receiving treatment.

Regarding educational factors, poor health literacy was associated with poorer health outcomes. Patients of lower SES and education attainment levels with severe psoriasis had seen fewer physicians and were less likely to frequently receive a systemic treatment than those with severe psoriasis from higher SES and educational attainment levels.

Lastly, when evaluating for cultural/societal factors, Hispanic and Black patients with psoriasis reported experiencing more provider-related bias, stereotyping, misdiagnosis, and delayed diagnosis compared with White patients.

Overall, the review shows how health inequalities disproportionately affect minority populations seeking dermatology care vs White patients seeking care. The researchers believe that further studies will help physicians and providers develop more effective and inclusive strategies for future interventions.

“As policies and strategies aimed at eliminating health care disparities are advocated for, one must be mindful of the individual level and system-level contributors,” concluded the researchers. “Additional studies are needed to unravel the cultural, economic, and biologic complexities that contribute to the observed inequities in outcomes among patients with skin disease.”

References

1. Brown SG, Cobb CBC, Harvey VM. Racial and ethnic health disparities in dermatology. Dermatologic Clinics. 2023;41(2):325-333. doi:10.1016/j.det.2022.10.003

2. Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving health equity: a guide for health care organizations. Institute for Healthcare Improvement; 2016. Accessed March 24, 2023. https://www.ihi.org/resources/Pages/IHIWhitePapers/Achieving-Health-Equity.aspx.