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Sensitive Site, Serious Impact: Diagnosing and Treating Genital and Inverse Psoriasis

By Danielle Spatholt, MSBS, PA-C

Abstract

Psoriasis that involves the genitalia and intertriginous folds is an often-overlooked and underreported dermatologic concern. Clinicians should be aware of the signs and symptoms of genital and inverse psoriasis, including erythematous macerated plaques and patches that may not include the classic scale of plaque psoriasis. They should also understand the significant negative impact that even a small area of psoriasis can make on a patient’s life. While the symptoms of itching, burning, fissuring, and pain are significantly burdensome, inverse and genital psoriasis can influence the patient’s mental and sexual health as well.

 

 

Introduction

Psoriasis is a chronic, immune-mediated skin condition with a variety of subtypes. Any area of skin on a patient’s body can be affected by psoriasis, including the genital and intertriginous areas. Similar to the classic plaque-type psoriasis, inverse and genital psoriasis presents with sharply demarcated plaques or erythematous or hyperpigmented patches. Of note, inverse psoriasis and intertriginous psoriasis are synonymous terms, but intertriginous psoriasis is distinct from genital psoriasis. Genital psoriasis involves the scrotal, vulvar, and perianal area, not necessarily the skin folds in the groin area.

Due to the intertriginous nature of these types of psoriasis, they can also be macerated without scale. The Koebner phenomenon exacerbates this disease, as the friction of the skin folds and sweating worsen symptoms. The literature estimates that inverse-type psoriasis affects between 21–30% of all psoriatic patients.1 At any point during their psoriatic disease, up to 63% of patients report genital involvement.2 Inverse and genital psoriasis have serious negative impacts on a patient’s quality of life.2,3 Skin lesions can become painful, itchy, and even fissure in intertriginous areas. Patients report feeling embarrassed and concerned about how their skin lesions may be interpreted by their sexual partner. They may not report genital involvement to their healthcare provider, and not all providers will ask or examine this area, leading to underreporting or untreated disease. In a study by Larsabal et al., 18% of men and 16% of women reported dyspareunia associated with genital or inverse psoriasis.3 The instantaneous incidence of genital psoriasis was 43%.3 This detail may not be captured without a comprehensive history from the dermatology provider. Routinely asking psoriasis patients about genital involvement can help better recognize and treat patients with psoriasis of these special sites and will positively impact large numbers of patients.

Clinical Recognition and Presentation

Providers should keep inverse psoriasis in their differential anytime an erythematous or hyperpigmented plaque with maceration is present in an intertriginous area. Patients may notice pain, burning, skin fissures, itching, and skin irritation from sweat with genital or inverse psoriasis. Scale may be present, but due to the moist conditions on the skin-on-skin areas, this type of psoriasis commonly lacks the typical micaceous or hyperkeratotic scale present in psoriasis vulgaris. The axillary, inguinal, inframammary, intergluteal, and genital skin of the penis, vulva or perineum, or scrotum can be affected.

Differential Diagnosis

Inverse and genital psoriasis can mimic other infectious intertriginous skin conditions such as tinea cruris, erythrasma, candidiasis, intertrigo, and seborrheic dermatitis. For tinea cruris, a potassium hydroxide (KOH) prep can be helpful to differentiate between psoriasis and tinea because a KOH prep will be positive for hyphae with tinea cruris. Additionally, look for the leading scale, which is typical of tinea infections. Erythrasma can be diagnosed with a Wood’s lamp examination and will show bright red coral fluorescence. Candidiasis can present with satellite vesicles or pustules at the periphery.

Inflammatory dermatoses such as morphea and lichen sclerosus may present with indurated, sclerotic, and shiny skin. Contact dermatitis will often present with a geometric pattern and a history of a contact allergen such as a scented deodorant, lotion, or body wash. Atopic dermatitis, particularly in young children, often spares the diaper area, while inverse and genital psoriasis will not spare this area. Lichen planus can present with or without scale in the genital area but generally will have more purple, flat, and topped papules.

Neoplastic skin disease, such as extramammary Paget’s disease and Bowen’s disease, will often present as a solitary erythematous plaque that slowly grows. These do not respond to topical treatment as expected with other described dermatoses. Skin biopsy is helpful and sometimes necessary in differentiating between these varied entities. Dermatology providers should always remember to widen their differential and consider a skin biopsy if a patient’s condition is worsening or not improving despite treatment.

Diagnostic Approach

In a study by Larsabal et al., all patients knew they had genital lesions/rash but only 40% had a genital skin exam by a dermatologist.3 This highlights the importance of offering a full skin exam, including a genital exam, regularly to patients with psoriasis. Developing a trusting relationship with patients can take time, but it is important to their care. I often ask, “Do you have any psoriasis in the underwear area?” or after they have shown me all their flared psoriasis areas, I will ask if there is anywhere else I should look. This opens the conversation and allows patients to talk about their inverse and genital psoriasis in a way that is comfortable to them. Along with taking this patient-centered approach to exam, it’s important to listen to patients when they are experiencing symptoms or not improving. Because so many skin conditions can affect the genital region, biopsy should be considered and offered to the patient if the diagnosis is unclear or they are not making progress with treatment. Patients with genital or inverse psoriasis are also at risk for psoriatic arthritis (PsA) and mental health disorders. In the Larsabal et al. study, 13% of patients with genital psoriasis had a PsA diagnosis.3 Patients with perianal and intergluteal psoriasis are also more likely to experience PsA.4 Patients with genital psoriasis are more likely to have scalp, external auditory meatus, and nail psoriasis.3 They also found that patients with genital psoriasis had impaired quality of life and sexual health, especially women.3

Treatment Strategies

Inverse and genital psoriasis affect areas with thinner skin, so patients will need a specialized approach to treatment. The National Psoriasis Foundation (NPF) recommends low-to-medium-potency topical steroids for short-term use for genital and inverse psoriasis.5 Due to potential steroid side effects such as atrophy and striae, clinicians should closely monitor patients who are using topical steroids more than one month in intertriginous areas. Tapinarof (Vtama, Organon) and roflumilast .3% cream and foam (Zoryve, Arcutis) are both U.S. Food and Drug Administration (FDA) approved for psoriasis. Roflumilast .3% cream is the first topical to ever be approved for use in intertriginous areas. These can be part of a long-term maintenance steroid-sparing regimen.

For maintenance treatment, clinicians may consider off-label use of vitamin D analogues and calcineurin inhibitors such as calcipotriene, tacrolimus, and pimecrolimus.5 Patients should be warned that these can burn or sting on genital and intertriginous areas. According to Kalb et al., 20% of patients using calcipotriene reported irritation while using it in skin-fold areas.5

Patients with genital or inverse psoriasis should be offered systemic treatment if they fail topical therapies, experience side effects, or if topical application to the amount of their skin affected would be burdensome due to the large amount of affected skin. Oral agents such as apremilast (Otezla, Amgen), which is approved in ages 6 and up, and deucravacitinib (Sotyktu, Bristol Myers Squibb) in adults may be considered when topical treatment is not appropriate. Biologics such as tumor necrosis factor-α inhibitors, interleukin (IL)-17, and IL-23 inhibitors are also options for patients suffering from genital or inverse psoriasis. Larsabal et al.’s study noted 23% of patients with genital psoriasis were on biologic treatment.3 The Joint American Academy of Dermatology (AAD)-NPF guidelines highlight the significant benefit of biologic treatment on patients’ mental health, particularly when compared to traditional systemic treatment and phototherapy.6 These therapies are approved for plaque psoriasis, but many do have specific data showing success in genital psoriasis.

Patient education for inverse and genital psoriasis should include non-prescription emollients such as petrolatum ointment, zinc oxide barrier creams, friction-reducing gels, and powders. For patients who want to avoid talc, corn starch powder is a natural, gluten-free, and vegan alternative. Patients can try wearing cotton, loose-fitting clothing in the areas affected by inverse and genital psoriasis. Counseling patients on the use of soaps and cleansers without fragrance
is important as well.

Patient Education and Follow-Up

Due to the impact that genital and inverse psoriasis has on patients’ mental and sexual health, providers should ask patients about all areas affected by psoriasis and their impact on quality of life. The Joint AAD-NPF guidelines on psoriasis care state that psoriatic patients are 1.5 times more likely to experience depression than patients without psoriasis.6 Additionally, they have a two-to-three-times higher risk of anxiety.6 Consider referring patients to a mental health professional if they are showing signs of depression or anxiety.6 While skin is our main focus as dermatology providers, sexual health and mental health are part of the overall well-being of our patients and may be extremely important to the patient’s goals of their care. As dermatology PAs and NPs, we can help normalize this discussion and reduce feelings of embarrassment or awkwardness for our patients.

Patients with any type of psoriasis should be educated on the chronic nature of this condition. Patients may see their skin visibly clear and feel they are “cured” and stop treatment. Providers should educate patients that there is no cure for psoriasis at this time, and stopping treatment may result in recurrence of their skin disease. With some biologics, in particular, re-capturing that same efficacy after an extended time off therapy may be difficult and can result in flares. Patients should be educated on the risks of oral steroid use in psoriasis, particularly if prescribed pulse dosing or a quick burst of steroids without tapering.

Providers should understand the Dermatology Life Quality Index (DLQI) is an outcome measure that helps clinicians understand the impact of a dermatologic condition on patients’ lives.6 It is a 10-item validated questionnaire completed by the patient. It should take only a few minutes to complete and can be done in the exam room before the official visit begins. Higher scores demonstrate a larger negative effect on the patient’s quality of life. Patients with genital psoriasis have worse DLQI scores than those without.6 As clinicians, we tend to focus on the appearance of the skin, but symptoms such as itch, burning, and pain can only be appreciated by talking to the patient and using measures such as the DLQI.

Conclusion

Genital and inverse psoriasis are underrecognized but common manifestations of psoriasis that have negative consequences on the patient’s physical appearance and psychological and sexual health. More than half of patients with psoriasis experience genital or intertriginous involvement during the course of their disease.2 Clinicians should be asking about these areas and completely examining patients affected by psoriasis. Genital and inverse psoriasis is treatable with topical, oral, or biologic options. Dermatology PAs and NPs should familiarize themselves with these unique subtypes of psoriasis and should work to normalize this discussion for patients and themselves. Treatment decisions should also include the patient’s goals for their skin and overall well-being.

REFERENCES

  1. Merola JF, Li T, Li WQ, Cho E, Qureshi AA. Prevalence of psoriasis phenotypes among men and women in the USA. Clin Exp Dermatol. 2016;41(5):486–489. https://pubmed.ncbi.nlm.nih.gov/26890045/
  2. Meeuwis KAP, Potts Bleakman A, van de Kerkhof PCM, et al. Prevalence of genital psoriasis in patients with psoriasis. J Dermatolog Treat. 2018;29(8):754–760. https://pubmed.ncbi.nlm.nih.gov/29565190/
  3. Larsabal M, Ly S, Sbidian E, et al. GENIPSO: a French prospective study assessing instantaneous prevalence, clinical features and impact on quality of life of genital psoriasis among patients consulting for psoriasis. Br J Dermatol. 2019;180(3):647–656. https://pubmed.ncbi.nlm.nih.gov/30188572/
  4. Wilson FC, Icen M, Crowson CS, McEvoy MT, Gabriel SE, Kremers HM. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum. 2009;61(2):233–239. https://pubmed.ncbi.nlm.nih.gov/19177544/
  5. Kalb RE, Bagel J, Korman NJ, et al. Treatment of intertriginous psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol. 2009;60(1):120–124. https://pubmed.ncbi.nlm.nih.gov/19103363/
  6. Elmets CA, Leonardi CL, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073–1113. https://pubmed.ncbi.nlm.nih.gov/30772097/

 

ABOUT THE AUTHORS
Danielle Spatholt, MSBS, PA-C is a Dermatology Physician Assistant at Dermatology Partners of DOCS Dermatology in Strongsville and Avon, OH.

DISCLOSURES
Danielle Spatholt, MSBS, PA-C, reports no relevant financial disclosures.

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