Announcer:
Welcome to CME on ReachMD. This activity, entitled “PsignPosts: Addressing Health Disparities in Psoriatic Arthritis” is provided by Prova Education.
Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.
Dr. Mencia:
For many people with psoriasis or psoriatic arthritis, the disparities that exist within our healthcare system present real barriers to accessing the highest levels of care.
This is CME on ReachMD, and I'm Dr. William Mencia. I am here with Dr. Andrew Alexis, and we will be discussing the diagnosis and treatment of psoriasis and psoriatic arthritis in people with skin of color.
Dr. Alexis, welcome to the program.
Dr. Alexis:
Thank you so much.
Dr. Mencia:
Let's dive right in. Dr. Alexis, people with skin of color often experience long delays in the diagnosis of their psoriasis and/or psoriatic arthritis. As a dermatologist, what insights can you share with our learners as to why this occurs? And more importantly, what should we be doing differently to overcome it?
Dr. Alexis:
I think that's a great question. And the answer is that it's really multifactorial. Part of it has to do with a lower index of suspicion for having the diagnosis of psoriasis, so a lower index of suspicion among healthcare providers and perhaps even among patients since there's low public awareness of psoriasis among many communities of color.
What contributes to some of this lower index of suspicion is that older literature suggests that psoriasis is not very common among populations with skin of color, especially those of African descent, such as African Americans. Newer literature has challenged that, and we see that psoriasis is far more common than previously reported in African American communities and other communities of color.
Another factor is challenges with the diagnosis that some healthcare providers have because of the varying morphologies of psoriasis in the context of richly pigmented skin.
Dr. Mencia:
And, Dr. Alexis, what can you tell us about some of the systemic issues that we face within our healthcare system?
Dr. Alexis:
In addition to the factors that I mentioned, there are also systemic factors that contribute to delays in diagnosis and less access to therapies for psoriasis and psoriatic arthritis that disproportionately affect patients of color.
Some of these factors include the type of insurance that patients may have, or the absence of insurance. Some of the insurance plans may not be accepted by many providers in one's community, requiring patients to travel great distances, maybe to the medical center to be seen at a hospital-based clinic as opposed to a traditional private practice. So these are just some examples of the systemic factors. I think the limited insurance formulary of many of the plans that folks below a certain socioeconomic level typically have are limited. And so this reduces access to some of the leading therapies for psoriasis and psoriatic arthritis. And we see this phenomenon disproportionately affect patients of color in the United States.
Dr. Mencia:
You really defined well for us the term “social determinants of health.” You know, it's important that we ask our patients what their specific barriers are, what specific barriers they're facing, so that when we make our recommendations and we're determining a treatment plan, we can do so in a way that makes it accessible to them.
So with that, Dr. Alexis, let's move on to treatment. Could you walk us through your approach to the management of psoriasis? Specifically, what factors do you consider when you're developing an initial or a subsequent treatment plan? And also, how do you assess for, monitor, and treat psoriatic arthritis?
Dr. Alexis:
So the first question I ask myself when faced with a patient that has psoriasis is whether or not this patient would be suitable for topical therapy or systemic therapy. And in order to make that decision, I have to take into account a number of factors. I've got to take into account how much of the body is involved with the psoriasis. Does the patient have signs or symptoms of psoriatic arthritis? How much of an impact is the psoriasis or psoriatic arthritis having on that patient? And all of this feeds into treatment decisions. But a key differentiator is whether or not the patient has joint symptoms or signs that would suggest psoriatic arthritis, because as soon as that is determined, that the patient may also have psoriatic arthritis, well, then that puts us down a path of agents that can treat both the skin and the joints. And thankfully, we do have a range of agents that can do that well, including our TNF inhibitors, IL-17 antagonists, and more recently, the IL-23 antagonists.
Dr. Mencia:
For those just tuning in, you're listening to CME on ReachMD. I'm Dr. William Mencia, and here with me today is Dr. Andrew Alexis. Our discussion focuses on healthcare disparities in the diagnosis and treatment of psoriasis and psoriatic arthritis and people with skin of color.
Dr. Alexis, what are your thoughts on how to establish and strengthen a collaborative care model between the dermatologist and the rheumatologist for patients with suspected or diagnosed psoriatic arthritis? And regarding the theme of social determinants of health, what factors do you see that might limit the benefits of a collaborative team approach?
Dr. Alexis:
Well, I think the collaboration between dermatologists and rheumatologists is very important in the overall management of psoriatic disease. I think the dermatologist’s role is we have a potential to be in the frontline of making early diagnoses of psoriatic arthritis. Patients present to us with the skin involvement, but when faced with that patient with skin involvement, if we just take an extra step – and it's critical that we take this extra step because it dictates what the best, most appropriate therapy would be for that patient – but taking an extra step to assess for any signs or symptoms of joint involvement.
And there are some very helpful tools that have been published. Dr. Joe Merola's mnemonic of PSA for pain, joint pains, and S for stiffness or swelling of sausage digits, A for axial disease. So keeping that mnemonic in mind to just briefly screen the patient for any of those features. Using a screening tool that patients can complete, such as the PEST screening tool. So we in the frontlines as dermatologists can offer these quick assessments to determine whether or not this patient might have psoriatic arthritis.
If we suspect the patient has psoriatic arthritis, it's at that point that I would recommend a referral to the rheumatologist so that we can co-manage that patient. We can get started on therapy that would treat both joints and skin, but for ongoing management and confirmation of the diagnosis, having the rheumatologist expertise would be key.
With respect to your question about how social determinants of health could impact this, well, it's going to vary widely depending on where we practice. Some of us might practice in areas where we have access to joint clinics, clinics that have derms and rheumatologists together, psoriasis, psoriatic arthritis clinic, but the majority of us will not have that at our disposal and would have to manage in more of a community setting.
So taking the extra step of sort of identifying rheumatologists in our community that we can partner with, that we know would be open to referrals from us to help co-manage psoriatic arthritis, is one extra step to make it easier for patients who may have to travel great distances to come and may have issues related to taking time off work, etc., for multiple appointments. And so when you have a relationship with a colleague in the specialty we're co-managing, in this case rheumatology, we can find ways to make it streamlined and easier for the patient when there's an open line of communication.
Dr. Mencia:
Dr. Alexis, what role do radiographs play in your decision-making?
Dr. Alexis:
In terms of the role of radiographs, as a dermatologist, that's a little bit outside of our expertise. And that's where I depend on the expertise of a rheumatologist who I would be co-managing the patients with.
Dr. Mencia:
Thank you for that, Dr. Alexis. And that certainly speaks to the importance of that collaborative care model that we were speaking about earlier.
I'd like to shift gears with you a little bit now. And you're currently at the Weill Cornell Medical Center, but I understand that you've also had a lot of involvement with the Skin of Color Society, where you currently serve on its scientific committee. Would you tell our audience more about the society and some of the programs that the society has implemented to help address disparities in care for individuals with psoriasis and/or psoriatic arthritis?
Dr. Alexis:
Certainly. I'd be happy to. Now the Skin of Color Society is an international professional society that has as its mission to advance and promote awareness of issues that are of concern within dermatology for patients with skin of color. It was started back in 2004 and has grown considerably over those years.
There are a tremendous number of resources that the society has. There's patient education materials available on the website; there are materials for healthcare providers as far as educating healthcare providers about nuances of common dermatologic disorders in skin of color, including psoriasis. It hosts an annual scientific symposium, which I have had the privilege of being the co-chair of the scientific committee. And one of my charges is helping to organize this annual scientific symposium, where there are numerous lectures that are very educational for our community.
One of the things that we're most proud of with the society is its mentorship programs. It's also very active in promoting diversity within the specialty of dermatology. And in broad strokes, one of the areas that has helped contribute to this are its various mentorship and observership programs available for trainees at various levels.
Dr. Mencia:
Thank you, Dr. Alexis. That sounds like a valuable set of resources and programs that the Skin of Color Society is making available.
Before we conclude, is there anything else that you want our listeners to know that we haven't already touched upon in today's discussion?
Dr. Alexis:
Yes, I'd like to leave listeners with the message that, number one, psoriasis and psoriatic arthritis are by no means rare or even uncommon among patients with skin of color. In fact, it's often under-detected or detected late in the course of the disease. And some ways that we can help to reduce this issue of late diagnosis and underdiagnosis is to utilize resources that will help to better train our eyes to detect the morphology of psoriasis in the context of richly pigmented skin. When it comes to psoriatic arthritis, proactively asking our patients and assessing our patients using some of the very helpful tools that have been made available, including the PSA mnemonic and the PEST screening tool, are efficient and effective ways to help us in earlier detection of psoriatic arthritis.
And lastly, we want to consider for every individual patient their own specific social determinants of health and take that into consideration when it comes to how we proceed with our treatment recommendations.
Dr. Mencia:
Well, this has certainly been a fascinating conversation, Dr. Alexis. But before we wrap up, I was wondering if there is a key takeaway that you would like to leave our audience with before we conclude?
Dr. Alexis:
Absolutely. So one key takeaway I'd like everyone to remember is that to keep psoriatic arthritis in mind for every psoriasis patient, screening for psoriatic arthritis in every patient, and having an index of suspicion for the diagnosis of psoriasis when faced with any papulosquamous eruption, even if the morphology doesn't necessarily fit the types of morphologies that are typically seen in lighter pigmented individuals and shown in textbooks. So if we better train our eye to detect the broader range of presentations in skin of color and make a point of asking and assessing for psoriatic arthritis, partnering with rheumatologists for the management, the co-management of psoriatic arthritis, and lastly, taking into consideration social determinants of health for each individual patient, we can contribute to greater outcomes for our patients who suffer from psoriasis and psoriatic arthritis.
Dr. Mencia:
Well said, Dr. Alexis. And I would just add, to emphasize that last point that you made, that everyone can play a role in improving access to care, certainly in addressing those social determinants of health that impede a patient's ability to receive the care that they deserve. All we have to do is ask. Ask the right questions and then take those responses under consideration when designing our treatment plans.
Well, unfortunately, that's all the time we have today. So I want to thank our audience for listening. And a special thank you to Dr. Andrew Alexis for joining me and for sharing all of your valuable insights with our audience. It was great speaking with you today, sir.
Dr. Alexis:
It's a pleasure. Thank you.
Announcer:
You have been listening to CME on ReachMD. This activity is provided by Prova Education.
To receive your free CME credit, or to download this activity, go to ReachMD.com/Prova. Thank you for listening.
In support of improving patient care, Global Learning Collaborative (GLC) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Facebook Comments