More than skin deep: In patients with psoriasis, visible irritation (left) correlates to inflammation seen in scanning PET images of the skin itself (center, greatest inflammation in red) and of the arterial vessels (right).
Research shows minorities are less likely to seek care for the skin disease. Now there’s an effort to find out if in-home treatment can better serve patients.
Deadlier cancers. Fewer corrective surgeries for those who survive breast cancer. Higher rates, earlier onset, and faster progression of glaucoma. Specialists in every medical discipline are working to correct the harms of racial disparities in American health care. Still, the more anyone shines a light on those inequities, the grimmer the picture can appear. But in the world of dermatology, the literal act of shining a light could be part of the answer to reducing the treatment gap affecting racial minority patients with psoriasis.
That disparity is more troubling than a mere irritation. There is evidence to indicate that when African Americans get psoriasis—an inflammatory disease that causes raised, red patches of skin covered by silvery scales—their cases tend to be worse than in white patients. Moderate to severe cases of psoriasis carry an increased risk of heart attack, stroke, and premature death, a finding established by Penn Medicine dermatologist Joel M. Gelfand, MD, MSCE’03, in a 2006 landmark study.
Yet a recent Penn study found that a higher percentage of whites saw a dermatologist for their psoriasis than did non-Hispanic minorities, which include blacks, Asians, native Hawaiians and Pacific Islanders, and others, an average of 50.8 percent of whites compared to just 38.3 percent of the minorities. In addition, the study found whites also averaged approximately twice as many visits to any doctor for psoriasis. Researchers found whites averaged 2.69 visits per year, compared to 1.30 for non-Hispanic minorities. In total, this amounts to over 3 million fewer visits per year for psoriasis among non-Hispanic racial minorities compared with whites.
Junko Takeshita, MD, PhD, MSCE’15, and Joel M. Gelfand, MD, MSCE’03
“When you combine these results with the knowledge that minority patients tend to have more severe disease and a greater negative impact on their quality of life due to their skin disease, the data really highlight the racial gaps that exist in psoriasis care,” said the study’s senior author Junko Takeshita, MD, PhD, MSCE’15, an assistant professor of Dermatology and Epidemiology at Penn.
The causes of these disparities are varied and complex and are a focus of Takeshita’s ongoing research, but the fact remains that this is a clear problem that needs solving. So if patients, for whatever reason, aren’t seeking care, is there a way to bring the care to them?
One of the preferred treatments for psoriasis is phototherapy using ultraviolet B light. This type of phototherapy involves exposing the skin to ultraviolet light on a regular basis so ultraviolet B rays penetrate the skin and slow the growth of affected skin cells. It typically requires treatment in an office three times per week for 12 weeks, which is a substantial burden for patients, as it pulls time away from work and family obligations and adds to transportation costs.
“We know from interviews with patients that the inconvenience of these frequent visits is one major barrier to office-based phototherapy,” Takeshita said.
So what if patients could undergo phototherapy without visiting the office at all?
“Home-based phototherapy represents a more patient-centered approach, but there is a lack of data comparing its effectiveness to that of the office-based treatments,” said Gelfand, a professor of Dermatology and Epidemiology at Penn. “This has led to decisional uncertainty from patients, dermatologists, and insurers.”
Gelfand is hoping to fill in that data void. He recently received an $8.6 million contract from the Patient-Centered Outcomes Research Institute (PCORI) to study the effectiveness of home-based phototherapy. Gelfand will conduct a “pragmatic” trial in 1,050 patients called the LITE (Light Treatment Effectiveness) study. Pragmatic trials are designed to be much more reflective of real world clinical practice. The goal is for his research to not only literally shed light on whether home therapy is as good as office treatments, but also illuminate whether it can especially help minority patients with darker skin tones, thus helping to reduce the racial treatment gap. To find out, his study will have a unique design allowing him and his team to tackle the question head on.
“Historically, people of color are underrepresented in clinical trials and studies, but our research, through PCORI, will be the first ever to specifically and prospectively look at the effects of phototherapy on different skin types,” Gelfand said.
The study will evaluate if the therapy penetrates darker skin as well as it does light skin, if longer treatment times may be necessary for different groups, and what side effects, if any, exist from this treatment. Answering those questions can go a long way toward finding out if patients can self-administer this treatment at home instead of going to a clinic three times a week.
Gelfand credits the work of Takeshita, his former post-doctoral fellow, as a major factor in receiving the PCORI grant.
“This all starts with recognizing disparities in the first place, and Dr. Takeshita’s work in that area has been crucial in that regard,” Gelfand said.
“Ultimately, increasing awareness of these disparities is the first step in trying to provide equitable care and improve outcomes for everyone with this disease,” Takeshita said.
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