What is genital psoriasis?
As the term suggests, genital psoriasis (GenPs) is psoriasis in the genital area. Sometimes this can be the only area affected. Genital psoriasis affects approximately 63% of people with psoriasis at least once in their lifetime. The presentation will vary according to the site involved and may range from plaques on the external genitalia to fissures in between the buttocks. Usually, genital psoriasis does not resemble the thick, red, scaly plaques seen in other areas. It appears as bright red, shiny patches of skin, often with no scale on top. The reason for this is that the affected sites are usually covered, which helps the lesions to retain moisture and therefore appear redder and less scaly.
All age groups may be affected by genital psoriasis, including babies. Involvement of the genital area in this age group is often described as nappy psoriasis, which may appear very red and can be alarming to parents, who need reassuring that this is usually not a painful condition.
- The pubic region – a common site of genital psoriasis, which can be treated in the same way as scalp psoriasis, but be aware that the skin in this area is likely to be more sensitive than on the scalp.
- Upper thighs – psoriasis on the upper thighs is likely to appear as small round patches, which are red and scaly. Any psoriasis between the thighs can become more easily irritated by the friction caused by thighs rubbing together when you’re moving. Reducing the friction between your legs will relieve sweatiness and irritation. Liberal use of emollients will help with this particular problem.
- Skin folds between thigh and groin – psoriasis in this area will normally appear nonscaly and reddish white in the creases between the thigh and groin, and may become sore with cracks forming. Over weight or sporting people may be susceptible to thrush in the skin folds, which can be mistaken for psoriasis. Like genital psoriasis, it can cause the same irritation from friction of the skin, so a correct diagnosis is essential for proper treatment.
- Psoriasis of the vulva – commonly appears to be smooth, non-scaly and red. The liberal use of emollients will help reduce any irritation in this area, which would otherwise increase the risk of secondary bacterial or fungal infection. The typical sites of involvement are the creases at the top of the legs and the hair-bearing pubic region. The mucosal membranes at the entrance to the vagina are not involved.
- In men – the appearance of psoriasis may consist of small red patches on the glans (tip of the penis) or shaft, and the affected skin may appear to be shiny. Scale is not usually present. Circumcised and uncircumcised penises can be affected.
- The anus – psoriasis on the anus and surrounding areas will normally appear to be red, non-scaly and can become itchy, weepy and sore. Secondary infections, both bacterial and fungal, may occur due to skin splitting and can be uncomfortable or painful.
- Buttocks – psoriasis in the buttock folds may appear as red and non-scaly or red with very heavy scaling. The skin in this area is not as fragile as that of the groin. See Psoriasis and Sensitive Areas for more information.
What causes genital psoriasis?
Psoriasis is an inflammatory condition that affects the genital region. There is no identifiable cause for the condition in this area and it is important to stress that it cannot be transmitted through sexual contact. There is no correlation with pregnancy or the menopause.
Why does genital psoriasis sometimes require specific treatments?
The fact that skin in the genital region tends to be covered up (sometimes referred to as occluded skin) means that any treatment is more easily and thoroughly absorbed, which makes it more effective. This more powerful effect means that potent topical steroids must be used under strict medical direction to avoid skin thinning and stretch mark formation. Perfumed products should also be avoided to reduce the risk of both irritant and allergic contact dermatitis, either of which will make the psoriasis even harder to treat.
What treatments may or may not be used in genital psoriasis?
Psoriasis in the genital region is very difficult to control. While it is easy to relieve the symptoms of itch and discomfort, treating the lesions effectively is more challenging. When treating genital psoriasis it is important to keep the affected areas moisturised. When using moisturisers, any irritation that occurs may be due to your sensitivity to some of the ingredients.
Below is a summary of topical treatments, some of which may be recommended for your particular circumstances. Others are unsuitable for use in the genital area. If you develop genital psoriasis, you should discuss it with your doctor, who will be able to advise you on suitable treatments.
Emollients – are an important part of the daily care of psoriasis on all parts of the body, including the genitalia. They help to make the skin more comfortable. There is also a range of topical treatments available - creams and ointments – that your doctor can prescribe. See Emollients and Psoriasis.
Topical vitamin D creams and ointments – are effective in treating psoriasis and the newer types are less likely to cause irritation. However, some do have the potential to irritate sensitive areas such as the genitalia. Some doctors recommend cautious use of vitamin D analogue creams and ointments on genital skin. Topical steroid creams – may be recommended for sensitive areas. However, care should be taken with their use as the potential for increased absorption may lead to side effects such as skin thinning. For this reason, low strength topical steroids are favoured for use in the genital area. It is also important that topical steroids are not used for long periods of time or without close supervision from your doctor. Prolonged use of high-potency steroids can also cause stretch marks and you may become resistant to these medications, making them less effective in the long term.
Treatment should never be stopped abruptly as this may trigger a rebound flare of your psoriasis.
Topical steroids may also be combined with antifungal and antibacterial agents because infections with yeasts and bacteria in warm, moist skin creases such as the groin are more common.
Dithranol and vitamin A – derivatives (retinoids) are not usually recommended for use in skin flexures because of their tendency to cause irritation.
Coal tar preparations – are not usually recommended in genital areas because they can cause irritation, especially to areas such as the penis, the scrotum, the vulva or cracked skin.
Calcineurin inhibitors – (tacrolimus and pimecrolimus) are effective in treating genital psoriasis and do not have the side effect of thinning the skin that limits the use of topical steroids. They do, however, often cause an uncomfortable burning sensation when applied and can reactivate sexual transmitted infections such as herpes and viral warts.
UV light treatment – is not usually recommended for genital psoriasis due to an increased risk
of skin cancer in this area . Men with psoriasis undergoing UV light treatment are specifically advised to cover the genital area during treatment to reduce the risk of cancer. See Psoriasis and phototherapy.
Systemic therapies – such as dapsone and methotrexate can work well for people with genital lesions and should be considered for people with debilitating quality of life impairment.
Biologics – A recent study has shown ixekizumab to have high efficacy specifically for genital psoriasis, with rapid improvement seen as early as 1 week into treatment. See Treatments for Psoriasis for more details.
Remember: it is also advisable to get any rash that appears on the genitals checked, as there are other conditions that can affect these areas. Never assume that because you have psoriasis all rashes that appear will be due to psoriasis.
If your partner is worried, you can show him or her leaflets on psoriasis, ask your doctor to explain the problem, or even attend a genitourinary clinic together for a joint check-up. Treatment at genitourinary medicine (GUM) clinics is free and confidential; you can also make an appointment yourself without a referral. At certain times, some clinics also operate as drop-in centres, where you can turn up without needing to make an appointment. You can find location, telephone number and clinic times by phoning your local hospital.
Coping with genital psoriasis
Skin diseases can be difficult to cope with and a skin disease that affects the genitals can be doubly so. You may find it embarrassing and stressful to discuss genital psoriasis with a doctor or nurse.
Try to remember there is nothing to be embarrassed about. Overcoming your natural reluctance to discuss these matters, and learning how to be up-front with your doctor and loved ones, can make coping with psoriasis much easier.
Honesty and openness are key factors in coming to terms with your situation. If your partner knows how genital psoriasis is affecting you, he or she will be better able to support you emotionally and physically. Equally, your doctor will be in a better position to help you. See Psychological aspects of psoriasis for further guidance.
Remember: your healthcare professional wants to help you, so let them know how you are feeling, and don’t forget that professionals are used to dealing with such sensitive areas and issues as part of their daily work. They have seen it all before!
During a flare, should I refrain from sexual intercourse?
Not necessarily, but a flare may be exacerbated (made worse) by sex, due to friction causing a Koebner reaction (a condition where injury can cause psoriasis) and it may be painful.
Genital psoriasis can cause irritation and discomfort during sexual intercourse, which can affect sexual relations with your partner. Effective medication will help to relieve this problem.
Men may find it difficult to have an erection because their penile skin may be painful, tender, have cracks or bleed. This can lead to tensions within a sexual relationship, so talking to your partner and being in an understanding relationship can help defuse any emotional complications.
Using a condom during intercourse may reduce any discomfort, as the condom will act as a barrier to avoid skin-to-skin and fluid-to-skin contact, which cuts down on irritation. After intercourse, cleansing the area and reapplying the medications or emollients as directed by your doctor will also aid recovery.
What should I do if I have genital psoriasis?
Genital psoriasis may also affect the surrounding area in the groin. It rarely appears in the vagina. If you develop psoriasis of the genitalia, you should always consult your doctor. Do not be embarrassed.
Genital psoriasis can sometimes look similar to a fungal or bacterial infection, or even contact dermatitis, so your doctor may need to check the diagnosis with a laboratory test before starting any treatment. The delicate skin in the genital area may mean you need a weaker psoriasis treatment than elsewhere on your body. You should bear in mind that you may be susceptible to irritation and allergic reactions from any substance applied to the skin. Sensitisation most commonly occurs from perfumes and preservatives in over-the-counter wash products and topical local anaesthetics. It is important to keep personal hygiene as uncomplicated as possible and avoid fragranced products.
It is also important to remember that your psoriasis is not due to an infection and is not catching. So, when you are in a loving relationship with a partner who knows about your psoriasis, it should not interfere with your sex life. If you are with a new partner, take the time to explain your condition before you become intimate, to reduce stress and needless worry for you both.
This article is adapted from the Genital psoriasis leaflet.
Always consult your doctor or healthcare provider.