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What is Genital Psoriasis?

Genital psoriasis is a common presentation in psoriasis patients, affecting up to 63% of adults with the condition at some point in their lives, with 2-5% experiencing symptoms exclusively in the genital area. This form of psoriasis significantly impacts the quality of life, often more severely than psoriasis in other body regions. Patients frequently struggle with intense itching, sexual difficulties, avoidance of intimate relationships, and feelings of shame.

What to Consider While Treating Genital Psoriasis

Genital skin is thin and sensitive. Careful use of topical treatments to avoid skin atrophy and irritations.
About 40% of genital psoriasis patients experience secondary infections, typically caused by Candida or Staphylococcus aureus.
Patients with psoriasis should be asked about genital involvement and its impact on their lives.
Topical corticosteroids are the first line of treatment.
Irritant topical treatment should be avoided.
Unresponsive cases should be biopsied to confirm diagnosis and to exclude malignancy.

Medical Treatment Options

Topical Treatment Options

During flares: Moderate-to-high potency corticosteroids (e.g., Betamethasone dipropionate 0.05%) for short-term use.
Maintenance therapy: Lower-potency steroids (e.g., Methylprednisolone aceponate 0.1% or Hydrocortisone acetate 1%).

Topical phosphodiesterase-4 inhibitors

Crisaborole 2% ointment, applied twice daily to the anogenital area for 4 weeks, demonstrated significant effectiveness in treating genital psoriasis.
Roflumilast 0.3% cream (Zoryve, Arcutis Biotherapeutics)
- FDA-approved for plaque psoriasis, including sensitive areas like the face and intertriginous regions.
- Once-daily roflumilast 0.3% cream showed good results within 6 weeks.
- Fewer side effects compared to corticosteroids and vitamin D analogues.

Tapinarof 1% cream (Vtama, Dermavant Sciences)

FDA-approved aryl hydrocarbon receptor (AHR) agonist.
A once-daily thin layer on the affected skin.
Associated side effects include folliculitis, contact dermatitis, and headache.

Calcineurin inhibitors

Tacrolimus 0.1% ointment applied twice daily.
May be used off-label for patients needing long-term maintenance.
Generally well tolerated with occasional side effects like mild pruritus or burning.

Topical vitamin D analogues

Less effective than calcineurin inhibitors and linked with more adverse effects.

Topical tar preparations

It works best in combination with topical corticosteroids to reduce irritation.
Limited use due to unpleasant odor.

Janus Kinase Inhibitors

Delgocitinib 0.25% ointment: under trial.

Oral Treatment Options

Methotrexate

7.5–10 mg per week.
Limited use due to side effects e.g severe nausea, vomiting, headache, urinary tract infections and insomnia.

Oral Dapsone (100 mg daily)

Mycophenolate mofetil(MMF)

Oral MMF 500 mg twice daily

Apremilast

Oral apremilast 30 mg twice daily.

Treatment of Recalcitrant Cases

Ixekizumab

Ixekizumab is a monoclonal IgG IL-17 inhibitor that significantly improves genital psoriasis symptoms, quality of life, and sexual well-being, with effects lasting up to 1 year.
Initial dose: 160 mg (administered as two 80 mg subcutaneous injections) at Week 0.
Subsequent doses: 80 mg at Weeks 2, 4, 6, 8, 10, and 12.
Maintenance dose: 80 mg every 4 weeks thereafter.
Common adverse events such as diarrhea, injection site reactions, nasopharyngitis, upper respiratory infections, and headaches.

Other biologics

Adalimumab.
Ustekinumab.
Secukinumab.

Phototherapy treatment For Genital Psoriasis

Phototherapy is not recommended due to the risk of skin cancers.

References

Adult genital psoriasis: An updated review for clinicians[link]
Ixekizumab improves disease severity, clinical symptoms and quality of life in patients with genital psoriasis: A 24-week real-life experience[link]
Genital Psoriasis: Impact on Quality of Life and Treatment Options[link]