Why This Conversation Can't Wait
Neita and Miranti open the episode with a demographic reality that should reshape how every APP practices: Miranti notes it has been postulated that by 2045, more than 50% of the US population will be people of color. Both hosts frame this as a call to evolve, because so much of the training many clinicians received was built on a narrow reference point.
Miranti is candid that when she trained 25 years ago, dermatology textbooks were filled with 'pictures of old white guys,' leaving her to learn skin of color 'on the fly' through conferences and self-directed study. Neita, who trained in diverse Miami with strong supervising PAs, says even that experience didn't fully prepare her — she has spent her career putting in deliberate effort to diagnose these patients appropriately. Their shared point: the literature and research skew toward lighter skin tones, and that gap makes it harder for clinicians to recognize disease. As Miranti puts it, 'red does not always look red.'
Building a Room Where Patients Feel Understood
Neita observes that many of her patients specifically seek out a provider of color because they've felt overlooked or misunderstood elsewhere. But the hosts are emphatic that trust is not reserved for providers who share a patient's complexion. Miranti describes intentionally staffing her exam room with medical assistants who speak Spanish and have richer skin tones so patients feel included and comfortable enough to share more.
She recounts how patients will glance at her Black medical assistant for validation that 'this white blonde girl actually knows what she's talking about' — and she treats that as a feature, not an insult, giving the MA credit for it. The practical message for APPs who feel underqualified to discuss skin of color: you absolutely have the knowledge and the standing, but make the environment inclusive, and never hide behind the excuse that you 'haven't seen this yet.'
Acne and Psoriasis: Treat the Pigment, Treat Aggressively
Acne is often the first thing that brings skin of color patients through the door, Neita explains, and for many of them the post-inflammatory hyperpigmentation is as distressing — or more distressing — than the acne lesions themselves. Miranti relates from personal experience that a single pimple worries her less than the marks that linger for weeks or months. The hosts urge clinicians to name the PIH at the first visit, treat it as a front-of-mind priority rather than a secondary concern, and choose regimens that have been studied in deeper skin tones. Failing to address it early risks losing the patient's trust.
Both hosts stress treating acne aggressively given higher rates of keloids and hypertrophic scarring in this population — and Neita flags an uncomfortable truth: Black and Hispanic patients are less likely to be offered systemic therapies. You may be the first provider to bring up isotretinoin, spironolactone, or an antibiotic. Psoriasis follows a similar pattern. Miranti relies on texture, feeling for thickened, indurated plaques and looking for violaceous, dusky, or deeper brown tones instead of classic erythema, while asking about joint pain and cardiovascular comorbidities. Neita adds that scalp psoriasis is a more common presentation in Black patients, that Asian patients may present with an eczematous, psoriasiform picture that biopsy won't always clarify, and that even small BSA scalp disease can warrant earlier escalation to oral or biologic therapy — because asking a patient with textured hair to apply daily topicals to the scalp simply isn't realistic.
Atopic Dermatitis: Look Past the Erythema
The hosts are enthusiastic about the recent surge of AD trials that meaningfully recruited skin of color patients, and about the new non-steroidal topicals and biologics that have followed. Miranti reminds listeners that erythema is often muted in deeper skin tones, so clinicians should lean on visual and palpable clues and note the variety of presentations — hypopigmentation, hyperpigmentation, and violaceous tones.
Neita describes the phenotypes she watches for: more lichenification, papular variants, and follicular accentuation, especially in her pediatric patients whose follicles may look prominent even without obviously inflamed plaques. She points to higher transepidermal water loss and lower ceramide levels in Black patients as reasons AD tends to be itchier and more severe, and warns that muted erythema drives delayed diagnosis, undertreatment, and misery. The takeaway: diagnose early, treat early, and use the tools now available.
Scarring Alopecia: Don't Miss the Window
Hair loss is where Neita's passion runs deepest, and her warning is urgent: scarring alopecia in women of color is common and severe, and follicles are lost when it isn't caught early. Referencing a recent webinar, she notes these diagnoses are frequently missed in Black women because clinicians go clinical and skip the biopsy. Her fix is straightforward — do a proper history and a small 4-mm punch biopsy in an area of involved scalp that still has active follicles, and remember you may need multiple biopsies from different regions to capture the inflammatory cycle.
She emphasizes that patients can carry several diagnoses at once — she saw a patient that day with four concurrent hair conditions — so treating CCCA while ignoring coexisting androgenetic alopecia or traction alopecia will fall short. Miranti adds the practical courtesy of hiding biopsy sites away from the frontal hairline. On counseling, Neita's priorities for that first visit are giving the patient a specific diagnosis, explaining that chronic disease needs long-term therapy so patients don't disappear and return years later with far more loss, and being deeply sensitive to hairstyling. She describes a new patient in tears, unable to remove a glued-down wig, and reminds clinicians how much confidence is bound up in hair. Both hosts close by urging APPs to seek out the education — textbooks, conferences, and resources like VisualDx — and to treat every patient with empathy and a big heart during Alopecia Awareness Month and beyond.