Intimate relationships require mutual trust, caring and acceptance. Psoriasis, even when it does not affect the genitals, may lead to problems with self-esteem and sexual health, says dermatologist Lourdes Pérez Chada, M.D., MMSc, a psoriasis and psoriatic arthritis clinical research fellow at Brigham and Women’s Hospital in Boston, Massachusetts.
“The World Health Organization defines ‘sexual health’ as a state of physical, mental and social well-being in relation to sexuality. Studies show it is negatively affected in anywhere from 20 percent to 70 percent of people with psoriasis,” she says.
What follows are answers to common questions about psoriatic disease and intimacy.
How can psoriasis and psoriatic arthritis interfere with intimacy?
About 60 percent of those with chronic plaque-type psoriasis will develop genital psoriasis at some point. In addition, about 24 percent have skin-fold psoriasis, which typically affects the genitals. Symptoms of genital psoriasis include pain, stinging, and burning during and after sex. Sexual intercourse can also cause genital psoriasis to flare because of the Koebner phenomenon, in which even small traumas to the skin, including friction and rubbing, can exacerbate psoriasis.
In people with psoriatic arthritis, joint pain and fatigue that are hallmarks of the disease can mean pain and reduced mobility during sex. And, for people whose psoriasis does not affect the genitals or skin folds, the disease can cause emotional issues that make intimacy more difficult.
Those with more severe psoriasis have a higher risk of sexual dysfunction. This may be related to feelings of low self-esteem, embarrassment and unattractiveness, or to anxiety and depression often seen in people with psoriasis.
Does genital psoriasis affect intimacy differently in men and women?
Overall, women report more sexual distress than men; itching and less frequent intercourse are their biggest psoriasis-related sexual issues. Men tend to be more sexually active than women with the disease and complain most about stinging and burning. Both can feel reduced sexual desire or a need to limit or avoid sex. People may also find it hard to begin or even maintain a relationship with a partner.
Women with psoriasis tend to have a higher frequency of unprotected sex, while men with psoriasis start having sex at earlier ages than those without the disease. These behaviors may be linked to low self-esteem, which is common with psoriatic disease and often associated with self-destructive actions. It is critical to emphasize the importance of contraception and safe sex, particularly among young people who have psoriasis.
How can I improve my intimate relationship?
Appropriate, adequate treatment for psoriasis and psoriatic arthritis is essential. We know that improving the PASI score, a measure of psoriasis severity, by at least 75 percent is associated with a significant boost in sexual function.
For those with genital psoriasis, topical therapy is the first-line treatment. Topical steroids of mid- to low-potency are typically used short-term and with caution, as they can cause thinning of the skin and stretch marks — and the skin of the genitals is already thin and delicate. Instead, vitamin C derivatives and calcineurin (a protein that activates T-cells of the immune system) inhibitors can be used long-term. These agents can be used alone or in combination with topical steroids.
What are other treatment options for genital psoriasis?
If topicals aren’t effective, systemic medications, such as methotrexate and biologics, can be used. The first clinical trial testing a biologic for genital psoriasis found that 73 percent of patients treated with an IL-17A inhibitor achieved clear or almost clear genital skin after 12 weeks, with many experiencing significant improvement in the first week. By week 12, more than 70 percent of participants treated with the biologic said psoriasis was affecting their sex much less than before treatment.
Can lifestyle modification improve symptoms of genital psoriasis?
Friction, warmth and moisture can exacerbate genital psoriasis, so avoid wearing tight clothing and underwear. Wash affected areas with a mild cleanser, and avoid perfumed products and abrasive scrubs. Reapply medications after being intimate.
Men with genital psoriasis should consider using a lubricated condom during sex to help keep skin from inflaming.
My dermatologist has never asked me whether psoriasis affects my genitals, and I’m too embarrassed to bring it up. What should I do?
Studies show that dermatologists do not routinely evaluate genital psoriasis, often because physicians do not feel comfortable asking, and sometimes because they don’t realize they should be asking. If you’re suffering from genital or skin-fold psoriasis, and your physician is not asking about it, you should bring it up so he or she can help you treat it. Ask for help coping.
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