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Flaring Up Down Below with Psoriasis

About one in four people with psoriasis will experience genital psoriasis. Relief starts with having an honest conversation with your doctor.

For many of us, a doctor’s visit is right up there with taking the trash out on a cold, rainy night or sitting through your child’s favorite animated movie for the thousandth time. The waiting room is a drag, those paper gowns are never fun, and bringing up issues involving a sensitive area may make you feel uncomfortable or self-conscious.

This is especially true when it comes to psoriasis in the genital area. Just as psoriasis can appear on your elbows, hands and scalp, psoriasis pops up around the genitals, pubis, buttocks and upper thighs around 24 percent of the time.

Sometimes called inverse psoriasis, if it appears in the folds of the skin, the lesions characterized in genital psoriasis typically involve small, red round plaques. Genital psoriasis brings the same symptoms as non-genital psoriasis: itchiness, burning, pain and worsening lesions due to external triggers.

Treatments for genital psoriasis, like other types of psoriasis, include low-potency topical steroids for mild to moderate cases and systemics and biologics for more extreme cases. You can get genital psoriasis under control with proper treatment and careful monitoring. The biggest hurdle may be a reluctance to seek medical advice.

Speak Up (Even If You’re Embarrassed)

According to an August 2017 study published in the Journal of Drugs in Dermatology, 45.8 percent of psoriasis patients did not discuss their genital psoriasis with a health care provider. The top reason: embarrassment.

Dermatologist Abby S. Van Voorhees, M.D., chair emeritus of the NPF medical board and a co-author of the study, says that physicians have a hard time treating something they don’t know about – or can’t examine – due to a patient’s inability to speak up.

“I’ll ask patients if they have any psoriasis on the genitalia or on the rectum and then they will look at me a little sheepishly and say, ‘Actually, I do.’ I then say, ‘May I see it?’ They then usually hesitate and ask, ‘Well, do I really have to? I’m embarrassed.’ ”

Van Voorhees, professor and chair of dermatology at Eastern Virginia Medical School in Norfolk, says she often must convince patients that she does need to see their genital psoriasis so that she can properly diagnose it and prescribe the appropriate treatment.

The same level of hesitation in discussing the issue extends beyond face-to-face interactions with physicians. The NPF Patient Navigation Center, which provides personalized assistance to learn about treatment options and find health care providers, is very familiar with genital psoriasis inquiries – and how the conversation can be sensitive.

Mercy Rivera, a patient navigator, has noticed a pattern when it comes to calls about genital psoriasis. First, the majority of inquiries are from women – whether they are reaching out about a problem for themselves or a male partner. Second, it might take some coaxing to discuss potential genital issues.

“With some of the people that we talk to, it does take a while for them to open up to actually let us know that they have genital psoriasis,” says Rivera. “I think that for the most part, at least on the phone, people tend to shy away from saying that they have genital psoriasis.”

Rivera says that it’s usually well into the conversation, after the patient has discussed the severity of her symptoms and concerns, that she hints at possibly having genital psoriasis.

When in Doubt, Consult Your Dermatologist

Once the subject of genital psoriasis has been broached with a health care provider or a patient navigator, that’s not the last roadblock on the path to a diagnosis.

Rivera also comments that cases of misdiagnosis from gynecologists, while not the norm, may happen. “There have been cases of patients, specifically women, who aren’t diagnosed [for psoriasis], going to their gynecologist when an issue in the genitals occurs," says Rivera. “The gynecologist, especially those not familiar with psoriasis, sometimes is unsure of what is going on or might misdiagnose the issue as an STD.”

Rivera says that many of those contacting the Patient Navigation Center about genital issues are concerned that their condition may be related to a sexually transmitted disease based on conversations with their primary care provider or gynecologist. If you find yourself in a similar situation, Rivera says it might be worth asking your doctor for a skin biopsy to test for psoriasis, especially if you have an existing diagnosis for psoriasis. That will save you the headache and cost associated with bouncing from one provider to another until you receive the correct diagnosis.

As a practicing physician, Van Voorhees agrees that confusion can stem from doctors who might be working with a limited knowledge base when it comes to psoriasis.

“I think there’s a higher rate of misdiagnosis,” says Van Voorhees. “And I believe that to be true because primary care doctors, while they’ll usually always recognize psoriasis when it is on the elbows or knees, in the genital area it can be confused with yeast infections, fungal infections and sometimes eczema. That’s why it’s important to go to a dermatologist to find out what’s going on.”

Start Treatment

You’ve spoken up about your genital issues. You’ve seen a dermatologist and have been diagnosed with psoriasis. Now it’s time to start treatment.

In mild-to-moderate cases, a typical treatment recommendation is a topical steroid used for up to a month. According to the Journal of Drugs in Dermatology study, if issues continue after the initial month of treatment, health care providers may explore other options, including non-steroid-based topicals, emollients, tar-based products and antimicrobial therapy, and, in some cases, systemic therapy.

And for severe cases when other treatments are not working, systemics and biologics are options.

Watching out for triggers is also important when managing genital psoriasis. As with any other part of your skin, internal and external factors can exacerbate your psoriasis. However, genital psoriasis shares some unique considerations. “Just like all psoriasis, genital psoriasis gets triggered by harsh environments,” says Van Voorhees. “For example, some patients might get a gastroenteritis bug and they develop diarrhea, then their psoriasis might flare. The skin around the rectum might develop psoriasis.”

Along with administering treatment, Van Voorhees also educates her patients on the importance and use of barrier creams to limit the adverse effects of issues like diarrhea.

Don’t Be Shy

If you’ve been diagnosed with psoriasis, there’s a chance that your genitals will be affected at some point.

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