Derm-it Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-it Trotter! Don't Swear About Skincare.
The Diversity Gap in Psoriasis Care
Psoriasis doesn’t look the same on every skin tone. In this episode, we break down how psoriasis appears on darker skin, lighter skin and mixed tones, why inflammation may look purple, brown or gray instead of red, and why these differences can delay diagnosis. We explore the limits of the Fitzpatrick scale, how ancestry shapes skin response, and what patients with melanin-rich skin should know about treatment, light therapy and pigment changes.
With dermatologist Dr. Mona Shariari, we explain how to recognize psoriasis on different skin tones, what symptoms to watch for, and how to advocate for accurate care. If you’ve ever wondered what psoriasis really looks like on brown or Black skin—or why your symptoms don’t match online photos—this episode brings clarity, science and practical guidance.
This episode is sponsored by Eli Lilly. We’re grateful for their support in helping us highlight the importance of accurate, inclusive dermatology education and expand conversations that improve care for every skin tone.
This podcast is sponsored by Eli Lilly. Dermatologists like myself, we I really care deeply about seeing, respecting, and treating old skin tones because when we disregard it, that's when we our patients might end up with not the best outcome. I challenge you to put the worst dryasys or AD in Google and see how far you have to scroll to see any other shade other than white bear Caucasian.
SPEAKER_01:I think hopefully we're seeing a movement in the direction to be more inclusive. And I think that's definitely happening within clinical trials and dermatology to try to make sure we are looking at how everyone reacts potentially differently.
SPEAKER_02:And if you're on the patient side of it, you're gonna think, you know what?
SPEAKER_00:That's probably not what I have because Welcome to Dermit Trotter, Don't Swear About Skin Care, where host Dr. Shannon C. Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
SPEAKER_01:Welcome to the Derbitrotter Don't Swear About Skin Care podcast. Today we are going to tackle a very unique topic that's been hot in the dermatology literature, but then also for a lot of you listeners out there, you've been asking me questions about skin tone and what does that mean for certain skin conditions and how do you care for your skin? So we're going to really get into that topic a bit more so that we have a greater understanding of what it means. I have a special guest here with me today, Dr. Mona Sharriari. She's a board-certified dermatologist, an associate clinical professor of dermatology at Yale University, and in practice with Central Connecticut Dermatology. And she's an expert in psoriasis and also has a great clinical interest in darker skin tones and diversity of skin tones. So welcome to the podcast.
SPEAKER_02:Well, thank you so much for having me, Shannon.
SPEAKER_01:Well, I know this is something that we've seen, you know, as dermatologists sort of taking center stage. And I think it's been long overdue. But also in clinical practice, I have patients coming in saying, what exactly do you mean by tone of my skin? Or what is this whole skin tone diversity concept that's sort of starting, especially I think, you know, for dermatologists. So how do you explain that when somebody asks that question?
SPEAKER_02:Well, it's interesting because sometimes when that concept of skin tone comes out, when I'm doing a skin check, my goal is to understand what is your risk of skin cancer. And a lot of times patients are taken aback. But when we're talking about skin tone, we're really talking about fairest porcelain to the deepest ebony and really everything in between. And really thinking about that skin tone diversity is just acknowledging that the spectrum's not only vast, but culturally, socially, and in this case medically significant, because that's what it comes down to in our day-to-day clinical practice. But it really does help shape individuals' identity, certain beauty standards, the way diseases show up on the skin, which is why dermatologists like myself, we I really care deeply about seeing, respecting, and treating all skin tones and acknowledging it. Because I think sometimes when we disregard it, that's when we our patients might end up with not the best outcomes.
SPEAKER_01:Yeah, and I like that too, because you talk about just you know more than the medical piece. Because I think, you know, some of the folks listening, especially dermatologists, might be thinking I'm just trying to figure out how this like interplays medically, but it's much more complex than that, as you just talked about, and how people identify and then those kind of social and cultural implications, which I think you know, some of our patients are aware of, or you know, historically, you know, they've struggled with you know changes in tone, or maybe they've had a skin condition that you know somebody didn't really recognize at first because it looked different just based on their skin tone. And I know kind of getting into the academic nitty-gritty, you know, can can you talk a little bit why do we see this variation? Because a lot of people are like, you know, why do we have this vast variety of skin tones that you see just in humans? You know, what is there a reason for this? And you know, maybe even evolutionary.
SPEAKER_02:Yeah, so this is one of my favorite biology meets anthropology stories. So really at the root are the melanocytes, the cells that are making that pigment in our skin. And when they produce a lot of pigment, we're gonna get darker skin tones. And then when we don't have as much pigment, we're gonna get the lighter skin tones. But really, evolution has fine-tuned what our melanocytes do. Near the equator, where that UV radiation is intense, darker skin developed as that protective armor against those intense UVA and UVB rays. Near the poles, the lighter pigment allowed for the UVB-induced synthesis of vitamin D. And if you look at in between the poles, you had that gradient with tanning really protecting individuals against those spikes in UVA, UVB. And the way I like to think of it is our skin is literally a living history book of where our ancestors came from. And it's funny because sometimes when I see my patients with atopic dermatitis who have an ancestry that takes them close to the equator, well, when they see me up in Connecticut, which is a much higher latitude, they end up with dry skin and all these other sequelae. And I tell the parents, you know what, your child's skin was meant to be closer to the equator. If you take them where their ancestors were, you're probably not gonna have this atopic dermatitis.
SPEAKER_01:Right. Well, and and and I love that you go into that because I think people don't understand it truly as a function of biology and where we all kind of originated from and sort of how that changed over time and how our skin adapted to those changes. I think that's just fascinating. You know, if you just look back the historical biological context and then over-evolution. And then you're right, once you put us in a different environment, you know, I, you know, have heritage kind of more northern European. And I always tease my husband, he is Hispanic and has Italian ancestry. And we always talk about how our skin tolerates different things, you know. And I said, you know, I don't have many shades of tan. I basically get red and maybe a slight hint of color, where he just laughs the whole time because he just gets this nice golden shade and pretty dark. And since he's actually moved to the States, big variation, you know, you can see that. And I think that connection is really important for people to understand where it comes down to biology and how it may impact skin disease. Now, we've gotten a little technical, I know, on the derm side, and we even talk about, you know, scales or Fitzpatrick type. And I think some of you, I was even talking to some colleagues, they're like, I don't even, I've never even heard of the monk skin tone. I know these Fitzpatrick types, and I was gonna have you talk more about them, you know, from the standpoint of, yeah, what does it mean maybe on the dermatology side? But for patients, isn't it important they kind of know where they fit within sort of these you know parameters that we've created as dermatologists?
SPEAKER_02:Yeah, exactly. So we'll go into the Fitzpatrick skin scale in a little bit more detail, but that that's what a lot of us are used to. And those of us who see a lot of patients with skin of color, we've realized the limitations of that scale. And it's funny because several years ago, they put international skin of color experts in a room to see if we come up with a better scale that was more all-encompassing. And guess what? We couldn't come up with anything better than what we currently had with Fitzpatrick Scale. But the Monk scale is actually a really interesting um scale that you mentioned. It's relatively new. It came out in 2023, and it's a more modern, inclusive way of categorizing skin tones that was made in partnership with Google. And actually, it wasn't designed to be used in clinical practice, it was designed with the goal of improving machine learning, artificial intelligence, um, rather than specifically for skin pigmentation quantification. And it uses 10 shades to capture the real world diversity that we see in skin tones. And the way I like to think about it is if you're doing a Google search for a physician in the year 2025, you want to see the heterogeneity of the types of physicians you would see in clinical practice. So now Google can actually use this monk scale behind the scenes to give you different types of quote-unquote physicians that you see in that search. So I think it's really interesting to be able to use it that way. And um I think that it's also over time gonna help improve the diversity that we see across a lot of public images, searches. Because what I find challenging when I see patients with skin of color is when they're trying to diagnose their own skin conditions, they go online and maybe they research psoriasis, they research atopic dermatitis. I challenge you to put the word psoriasis or AD in Google and see how far you have to scroll to see any other shade other than white fair Caucasian. And if you're on the patient side of it, you're gonna think, you know what? That's probably not what I have because my skin and my um disease is not represented in these photos. And then all of this leads to delays in diagnosis, misdiagnosis, under treatment. So I do think the Monk Scale, even though not perfect, it does offer us another way to be able to better categorize the diversity of tones that we see every day.
SPEAKER_01:It's kind of funny too, because you know, the collaboration with Google and knowing about that, you know, we're always teasing about the challenges with Dr. Google. I think this is uh one of the times where there could be a nice benefit of a collaboration. And you're exactly right. All patients come in that have darker skin, they'll say, you know, I believe you have psoriasis, you have eczema, and they'll say, No, I looked it up. I looked it up. I I don't look like that. And it's true in the room, I'll have an iPad and I will Google images and try to find an image that may match their skin tone. And it is an extreme challenge. So the fact that this is an effort that's being worked on to be more representative of the different skin tones and how skin disease can present, I think that's fantastic. And I have to give, you know, kind of credence a little bit to Google there, right? But this type of thing could definitely be beneficial for our patients.
SPEAKER_02:Absolutely. And I actually think as a specialty, the AAD is doing a really nice job of improving the skin of color presence in their databases. I'm actually part of the physician education committee of the skin of color society, and we're working with the AAD to see if we can just increase the diverse presentations of various common and even uncommon skin diseases within that database. Because if residents are trained on the various ways a disease can present, then when they're in attending, they can um actually diagnose those conditions correctly, initiate treatment more effectively. Because the reality is just like you and your husband, your children are not gonna be that classic fits one, um, fits four. Everyone is now a mix, and I like to call it a spectrum of different skin colors that we're gonna be seeing in clinical practice. So we do need to get better at understanding what um disease is gonna look like across the spectrum of skin tones.
SPEAKER_01:Yeah, and the training is very important, as you mentioned too, because depending upon where you train demographically, what part of the country or region where your clinic might be, who happens to walk through, your training could be very one-sided. So that's amazing that AD is helping to work on that to expose, you know, future dermatologists to that so they can help our patients, because you never know where you might land for your career. And so your career where you're practicing can have a very different spectrum of skin tones than maybe where you even train. So to help us all be better prepared for that is pretty amazing. Now, I was gonna touch a little bit upon that Fitzpatrick piece that you mentioned, because I know we still traditionally do use it, you know, for you know, sometimes people are looking at for light therapy. Maybe somebody comes in and deciding how they're gonna approach a patient and utilizing it more of a an assessment tool. You know, I think for patients who are like, I don't even know who Fitzpatrick was or what a Fitzpatrick type would mean. Do you mind kind of talking about that, maybe the limitations and maybe also where there still might be a use for it too?
SPEAKER_02:Absolutely. So um it I remember when I was residency, I would have a patient that I would see come out of the room and say, this is a 59-year-old female with Fitzpatrick skin type 2. But when you think about the Fitzpatrick skin typing scale itself, it was a study back in the 70s and first developed, and it was to accurately dose phototherapy for patients that needed UVA or UVB therapy for their skin disease. We just wanted to make sure that the dose of phototherapy wouldn't cause burning or harm to the patient, which was a very altruistic reason for it to be developed. And interestingly, it was actually first developed for lighter skin tones. So FITS 1 through 4 was what that initial scale included. And then we later realized we need to expand it to include some of our more melanin-rich patients. That's where FITS five and six um were added to the mix. But as somebody who sees a lot of patients with skin of color, four, five, six is really not enough to categorize the heterogeneity of patients that I see in everyday clinical practice. But when we think of the different six categories that we have, type one is the category that always burns and never tans. Think of the person who has red hair, pale skin. Type two is somebody who burns easily, tans minimally. Type three is someone who burns and also sometimes burns, but tans uniformly. And then type four rarely burns and tans easily. That's where I fall in. And then type five, they rarely burn, they're deeply pigmented, and type six never burns, and they're they tend to be profoundly pigmented. And it's really incorrect of us to walk into a room and just decide based on the color of the individual what that Fitzpatrick type is. Because the way you should really do it is use a colorometer, which is just a device that you put um on the inner surface of the arm, which is an area where sun isn't present, just to get a better gauge of what that individual's um skin tone may be. Now, I mentioned that I'm type four, and that's how I categorize myself based on how my skin reacts to the sun. But when I use the colorimeter, I actually came back as a type three. So it's really interesting for me as a dermatologist. Now I'm conflicted. Like, which category do I really fall into? Um, but I think that if Dr. Fitzpatrick knew how this scale was being used in day-to-day clinical practice, he'd roll over in his grave because that was not the intention really when we first started out. But I do think it's something. It gives us an idea of what is this individual's skin tone? Do we need to be more concerned about the behavior when we put them in front of phototherapy if we're doing laser on them? But as I mentioned, it is far from ideal. And one of the reasons why I don't love some of our studies, look, clinical trials that are looking at skin of color is because they gradate patients and put them into these categories of skin of color based on having, say, type four, five, six skin. But the reality is you could be skin of color based on your racial and ethnic identity and maybe have skin type two. Now you're going to be excluded from a trial, even though your body and your skin's behavior when it's exposed to laser or light may be a little bit different than somebody who's a true type two Caucasian person.
SPEAKER_01:It's very interesting to point that out because I don't think a lot of people would think of that, you know, right off the bat, you know, whether it be the patient or sometimes even as the clinician, I think a lot of times that there's a disconnect there. So that's a really important thing that you highlight. And mentioning the clinical trials, you know, when we have inflammatory disease, in particular psoriasis, I know, which is kind of a passion of yours, atopic dermatitis. When we're thinking about, you know, skin tone, Fitzpatrick types, I mean, we kind of talk more about how, you know, they obviously impact, you know, with Fitzpatrick, you know, your risk, you know, of burning or likelihood of tanning, you know, looking at the skin tone better representation. How does it all kind of get put together when you're looking at just different skin conditions and how they might actually look different, or maybe even the pathophysiology have some differences based on diversity of skin tones?
SPEAKER_02:Yeah, so I think the clinical presentation is probably one of the main places where having melanin to your skin is going to differ. Because when we think of psoriasis, for example, to use your um uh previous example, we think of erythematous plaques with silvery scale. And when you look up erythema, you're thinking red and pink. Those are the colors that we're used to. You Google it, that's what you see. But when we're dealing with melanin-rich skin, even someone who has type four skin, you uh aren't necessarily seeing those shades of red. It might be dark brown, it might be violet, it might even be gray. And that's where it's really important for us to understand that the erythema doesn't always look that classic red or pink that we're used to in a textbook. And the reason why it's important to identify this, one is you want to identify the disease correctly, but two, erythema is also used to assess disease severity in plaxoriasis. So if you're not seeing those high levels of erythema, you may now underassess and then under-treat somebody's um condition. So it's really important for us to really broaden our color palette when we're examining patients with melanin-rich skin with the darker skin tones. Now, the Fitzpatrick skin type comes into play when I'm doing phototherapy for my patients with um darker skin tone, because some patients may not want a systemic agent, topicals may not be sufficient. And I do indicate the Fitzpatrick type, but because phototherapy really wasn't studied in patients with, say, type five and type six skin, we're at a loss as to what is that perfect dose, what is the perfect time underneath the light to get a desired effect. So it's not a perfect model. That's all I can say.
SPEAKER_01:No, and that and that's really good because I think for patients, they might have an assumption too, oh, this has been looked at and thoroughly studied. And even as the dermatologist, I think historically going back, you look at those demographics and makeups of our clinical trials, and there obviously is an imbalance there where we don't often have, you know, patients with diverse skin tones included, and you know, trying to make a that translation into the real world that, oh, it's definitely going to work the same, we're gonna have the same outcomes really isn't fair. And it sort of puts it back, I think, on the dermatologist like yourself. You're trying to figure out based on your clinical experience and what you're estimating without those studies to back you up on what might actually be beneficial for the patient. So I think hopefully we're seeing a movement in the direction to be more inclusive. And I think that's definitely happening within clinical trials and dermatology to try to make sure we are looking at how everyone reacts potentially differently based on their skin tone. And you know, back in the day too, you know, they would talk about how they studied cardiovascular disease or heart attacks in women versus men. A lot of these studies were done, you know, just if you look at gender and Caucasian men, and they found over time, well, women present differently now too. They may not have the classic, you know, radiating pain and on the left side or elephant pressure on the chest and all the things that we've learned. I think we're becoming just more educated in how you know people are very different and how we present with certain things. And it's important to understand that so we can recognize it, obviously, and then treat it more effectively as well, and making patients aware of that too, and making them feel more included in the process.
SPEAKER_02:Yeah, it's so interesting you mentioned women and the differences because actually it wasn't until the 90s that women were included in clinical trials. Before that, the assumption was that women are just like men, but with different sex workers. And I think it was an aha moment when we realized actually, like you said, there are different diseases that present differently, different therapies that can um be a little bit more challenging in one gender versus another. But to your point, I think that's where the skin of color piece becomes very relevant in our clinical trial design because our trials are supposed to be a small population that represent the larger group. So we can take the results from that small group and apply it to everyday clinical practice. But if you have one group that's being overrepresented and one group that's being underrepresented, not only are you not able to get very accurate results on the efficacy and safety of a therapeutic, but also you don't understand what are other barriers to a skin of color patient getting the care they need. Because many of our patients' mistrust in the healthcare system is huge. If I'm giving my Caucasian patient an injectable as an option versus my skin of color patient an injectable as an option, it's a very different conversation because patients who um who are used to hearing about being practiced on and being used as mice, so to speak, in different trials back in the day. Like we did not do a good job with our skin of color patients, say 50, 60 years ago. And that's why a lot of our rules and regulations for patient protection were created for clinical trials. But that inherent distrust in the medical system is there. Cultural confidence. Like when you go into a room, somebody from a certain racial and ethnic background, you have to deal with that individual's preferences and their preconceived notions a little bit differently than somebody who may come from the same background as you. And I always say what you think you know about someone and that individual's background may not apply to the person sitting in front of you. So again, I always check my notions at the door and try to walk in the room with a clean slate because those are all the ways that we can ensure we're delivering that more inclusive care to our patients beyond just therapy selection.
SPEAKER_01:And that's that's great advice because I think people do we all have our own assumptions, inherent biases and experience clinically that can really influence how we practice or approach a patient. And you're right, leaving that at the door and just trying to look at the person and their condition and have them help educate us and walk through, you know, what's important to them, their values, and then trying to get a better understanding that definitely important to build that relationship. And as you said, I think we'll result, you know, in better treatment and trust for that patient if we build that rapport and kind of walk in their shoes, so to say, you know, so to say, although we can't, you know, really walk in everyone's shoes, everyone has different experiences, but to be more aware of that and really strive to do better, I think is so important. And especially when we're treating patients, you know, in skin and the very thing that we deal with and seeing all these variations in skin tone as well. And I know we talked a little bit about presentation. I was gonna comment a little bit about, because I think people just assume, oh, it might look different. In the last few minutes, we have can you talk a little bit about what data might be showing or research showing that actually there's some physiological differences, potentially psoriasis or atopic dermatitis that we might see in various skin tones as well.
SPEAKER_02:Yeah, actually, um there's a lot of data um on the horizon. We uh one of the studies that was done by uh Johnson and Johnson, looking specifically at patients with skin of color who were being treated for their plaxoriasis with gazelchumab, aka trymphya, did find some biomarker differences in our patients in terms of how their body responded to therapy, some of the comorbidities that they dealt with. But we actually have more data, I would say, on the atopic dermatitis side, because we are seeing differences in terms of just the genetic makeup. We always think of phylagrine loss of function mutations being the common thing in AD, but it's common in Caucasians. When you look actually at African Americans, we see uncommon phagrine variants that are gonna be linked to more persistent symptoms. Also, transepidermal water loss is more of an issue in our patients with skin of color than our Caucasian patients. This is why picking the right moisturizer in somebody with melanin-rich skin is gonna be a very different conversation than someone who has Caucasian skin. And a lot of people, if you're telling them, you know what, that moisturizer that's your mother and your grandmother and great grandmother youth is not gonna be okay for your skin, it's a tough belt to swallow. So again, that cultural competence when you're having those conversations is gonna be very key. And there's different presentations when it comes to AD, whether you're looking at the morphological presentations with numbular eczema or extensor surface involvement, scalp involvement, um, all of those being uh different in individuals with skin of color. So there are a lot of uh genetic as well as just clinical endotypic and phenotypic presentations that differ in our patients with skin of color versus our patients who are from Caucasian backgrounds. And being aware of that can help us better diagnose. And I tend to biopsy my skin of color patients more because they don't read the textbook. And I want to ensure I know what I'm treating before I start on a therapeutic journey.
SPEAKER_01:I would totally agree with you. I feel like I do biopsy more because definitely there's presentations that and the heterogeneity that exists out there. And especially I would say, although I know for time today we won't talk about it for skin cancer, which is a whole nother, you know, topic in our patients with diverse skin tones as well, because I do feel like often it's missed or underdiagnosed, or there's also perceptions, both I think on the dermatologist or clinician side as well as sometimes even on the patient side that with darker skin types, I'm not as susceptible to have skin cancer as well. And we could talk about kind of the differences there. I know for time we don't have it, but I think that's really important that people approach, you know, the individual patient, look at it, and if we're suspicious of something, that we treat it like anything else, you know, regardless of kind of how the patient comes in. But keeping in mind with various skin tones, things can look quite differently, as you mentioned. Well, I want to thank you so much for coming on the podcast today. This is a topic that I know a lot of our listeners are asking questions about and understanding just, you know, is there really science behind this and why do we see this vast array of skin tones and the implications it has for dermatology, diagnosis of skin conditions, treatment potentially as well. And your insights are very helpful, I think, to kind of provide a clearer picture on how we can actually move forward to include this, you know, as the dermatologist, but also on the patient to understand how their skin might behave differently as well.
SPEAKER_02:Yeah, no, thank you so much for having me. I just one last thought I want to leave our audience with is it's really the skin is the most visible organ. That's why I think there's a lot of psychological impact when someone has skin disease, because you can see it. But the benefit is when things get better, you can also see it. And it's really where medicine meets identity. So for our patients, understanding diversity means being seen, both literally and figuratively. So as clinicians, it's really our job to ensure we are taking care of the whole patient, not just having tunnel vision to one disease process, so it can really optimize outcomes.
SPEAKER_01:I love that. That perfectly said, perfectly said, and a great way to end our conversation today. Well, thanks again for coming on the podcast. You know, for our listeners out there, if they want to find out more about you, how can they locate you?
SPEAKER_02:So they can follow me on Instagram, Persian Skin Doc, and um LinkedIn as well, as well as um just taking a look at my profile on my practice page, centralctderm.com. And thank you so much, Shannon, for having me. I had a great time.
SPEAKER_01:Well, it was a it was a pleasure, Mona. We'll have to do it again sometime. And thank you all for listening and stay tuned for the next episode of Dermot Trotter. Don't swear about skincare.
SPEAKER_00:Thanks for listening to Dermot Trotter. For more about skincare, visit dermittrotter.com. Don't forget to subscribe, leave a review, and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.
