Psoriasis in Sensitive Areas

Psoriasis is a chronic autoimmune inflammatory skin condition that affects more than 6.9 million people in the United States.¹ Like cardiovascular conditions, cancer, and depression, psoriasis can have a severe impact on quality of life (QOL, discussed more fully later in the article).² There is currently no cure for psoriasis, but several treatment options are available for its symptoms that may help improve patients’ QOL, particularly when sensitive areas are involved (Figure 1).

Figure 1. Plaque psoriasis is the most common type of psoriasis, usually appearing on flexor surfaces.

TREATMENT OPTIONS

Multiple factors determine treatment choice. These include disease severity, comorbidities, and patient response and tolerance. Treatment in sensitive areas can be challenging because of the thinness and delicacy of the skin and its increased absorption of topical agents. Although 2021 National Psoriasis Foundation and American Academy of Dermatology guidelines discussed the use of topical corticosteroids as the most common agents for psoriasis treatment, more recently approved treatments show promising results. These novel agents warrant the consideration of new approaches to the treatment and management of psoriasis in sensitive areas.³

In June 2022, the FDA approved tapinarof 1% cream (Vtama, Dermavant Sciences) for the treatment of psoriasis through the modulation of T helper 17 cytokines. A maximal-use trial on the safety and tolerability of tapinarof found that treatment was well tolerated in sensitive areas with no irritation.⁴

The FDA also recently approved roflumilast 0.3% cream (Zoryve, Arcutis Biotherapeutics), a phosphodiesterase type 4 inhibitor, for the treatment of plaque psoriasis, including sensitive areas, in individuals 12 years of age and older. In a phase 2b, double-blind clinical trial, 73% of patients treated with roflumilast showed improvements in intertriginous areas within 6 weeks.⁵

Low- to midpotency topical corticosteroids and topical vitamin D analogs such as calcipotriene cream 0.005% (Dovonex, Leo Laboratories Ltd) and calcitriol are still used for psoriasis treatment, but this has become less common. Calcipotriene is especially useful for the treatment of psoriasis on the scalp and nails because the cream is designed to slow epidermal proliferation, remove scales, and flatten lesions. Side effects include burning and skin irritation.⁶ Calcitriol can also help control proliferative skin cells in sensitive areas, although irritation and burning may occur. For this reason, providers may start with alternative agents before considering calcitriol. Calcinuria and itching may occur with the use of calcitriol, and the drug should be discontinued if calcium metabolism is affected.⁶ A 2003 study found that calcitriol was more favorable than calcipotriene in sensitive areas because the former was less likely to irritate the skin.⁷

The use of topical calcineurin inhibitors such as tacrolimus or pimecrolimus is off label.⁸

Long-term (> 4 weeks) management of genital and inverse psoriasis with topical corticosteroids may be appropriate when the agents are used on an interval basis and in moderation. Adverse effects should be monitored.⁹

Delgocitinib ointment 0.25% (Corectim, Japan Tobacco Inc and Torii Pharmaceutical Co, Ltd) is being studied for the treatment of inverse psoriasis. This janus kinase inhibitor was developed for the treatment of atopic dermatitis. A randomized, double-blind, phase 2a proof-of-concept trial of delgocitinib in 69 patients with mild to moderate inverse psoriasis is ongoing. Treatment involves the application of 30 mg/g twice daily for 6 weeks. The primary outcome is the psoriasis area and severity index score after 6 weeks of treatment.¹⁰

Systemic and biologic therapies have also been shown to be effective for the treatment of psoriasis in sensitive areas.⁹ Ixekizumab is an interleukin-17 inhibitor with FDA-approved efficacy data for its use in genital areas. The drug has shown promise for providing symptomatic improvement of moderate to severe genital psoriasis and improving patients’ QOL with minimal adverse effects.¹¹ Systemic therapies, including methotrexate and cyclosporine, may be used to treat moderate to severe or refractory genital psoriasis, but these agents are associated with significant adverse effects and therefore must be administered cautiously.⁹

Apremilast (Otezla, Amgen Inc) is an oral phosphodiesterase type 4 inhibitor that was approved in 2022 for the treatment of mild psoriasis after the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial demonstrated efficacy for psoriasis treatment with an established safety profile.¹² The drug is beneficial in treating patients with psoriatic arthritis and is indicated for individuals who are candidates for phototherapy or systemic therapy.¹² It has a recommended dose titration with an optimal dose of 30 mg twice daily or once daily in patients with renal failure. Diarrhea, nausea, upper respiratory infections, headache, weight loss, and drug interactions are among the potential side effects.¹² A phase 3 trial (DISCREET) was concluded in December 2022 and studied the efficacy and safety of apremilast in patients with moderate to severe genital psoriasis. Initial findings indicate that apremilast met the primary endpoint of statistically significant improvement in modified static Physician’s Global Assessment of Genitalia (sPGA-G) responses within 16 weeks compared to placebo.¹³

QOL AND OTHER SPECIFIC AREAS

The impact on QOL can be significantly worse for people with lesions in sensitive areas, where the skin is thinner (eg, face, mouth, and nose) or where two skin surfaces are in contact (eg, the axilla, the area under the breast, and the genitals).¹⁴ Approximately 63% of adult patients with psoriasis have lesions in the genital area, and 2% to 5% of patients have lesions confined solely to the genital region.^15,16

Psychosocial Effects

In addition to somatic symptoms such as itching, soreness, swelling, physical disability, and pain, psoriasis has multiple psychosocial effects. These include social stigma, reduced self-efficacy and confidence, anxiety, depression, suicidal ideation, and disruption of interpersonal relationships and professional fulfillment.¹⁷ Patients with psoriasis report experiencing worsening anxiety and depression triggered by flares, becoming increasingly housebound, feeling sexually impaired or undesirable, and engaging in the use of substances such as cigarettes, alcohol, and illicit drugs. The involvement of sensitive areas, such as the genitals, can worsen QOL, especially with respect to sexual health and activities.¹¹ The relapsing and remitting course of the disease can frustrate and dishearten patients.

Scalp

Scalp psoriasis is estimated to affect 45% to 56% of patients with psoriasis in the United States.¹¹ Affected individuals often report wearing hats or growing out their hair to hide the psoriatic lesions.¹⁷ These can be highly pruritic owing to flaking and can cause pain and a burning sensation if aggravated by itching or injury through routine hair care.¹⁷ Fiber-optic hairbrushes with UV-B therapy are an expensive and less commonly available alternative to topical therapy, but systemic treatment is often more desirable.

Face

Psoriasis can affect any part of the face but most commonly affects the forehead (Figure 2). The condition tends to be more severe in this location than in other parts of the body. Given that facial psoriasis is difficult to hide and can be aggravated by routine facial care, affected patients tend to experience greater rates of shame, isolation, and depression with suicidal ideation.¹⁶ Nonsteroidal agents such as tapinarof, roflumilast, and tacrolimus have shown efficacy in the improvement of psoriasis affecting the face.^4,5,8

Figure 2. Psoriasis commonly affects the forehead, often leading to more severe manifestations than other parts of the body.¹⁶

Palmoplantar Psoriasis

This subtype of psoriasis constitutes roughly 14% of psoriasis cases.¹⁸ It can cause pain, especially if pustular lesions are present, which can severely limit a person’s ability to work or partake in the activities of daily living (Figure 3). Biologics such as secukinumab and ustekinumab have been shown to be efficacious in the treatment of palmoplantar psoriasis.¹⁸

Figure 3. Palmoplantar psoriasis can cause pain and may severely limit a person’s ability to partake in daily activities.

TALKING TO PATIENTS

Empathy and Encouragement

The National Psoriasis Foundation conducted a study of its 18,000 members and found that patients with psoriasis often feel that the condition’s impact on their lives is underestimated by their physicians. Moreover, almost half of the patients experiencing genital lesions do not discuss their symptoms with their physicians.¹⁹ Empathetically listening to and recognizing a patient’s chief concern while gathering a comprehensive history and proactively focusing on sensitive areas are crucial to physicians’ ability to provide optimal and holistic patient-centered care.

Stress and embarrassment may prevent patients from discussing their psoriasis symptoms and concerns with a physician. By reassuring patients that their physical and mental health and well-being are a priority and informing them that the involvement of sensitive areas is common and treatable, clinicians can break down communication barriers. Displaying handouts or infographics about lesions in sensitive areas in the office may promote open conversation. Another approach is to initiate conversation about the involvement of genital and other sensitive areas through gentle questioning about daily functioning and sexual health.

Mutual Decision-Making

Patient engagement can facilitate the development of a treatment plan that is compatible with their individual goals. Developing practical goals involves proper counseling so that the patient understands the course of the disease and the factors that can contribute to flares, including those that are reversible such as emotional stress, cigarette smoking, and alcohol consumption. Patient education should include information on how to identify a psoriatic lesion in a sensitive area, because it may look different than lesions elsewhere on the body. Discussion should also cover associated symptoms, sexual activities, and triggers such as tight clothing, antiperspirants, and rough toilet paper. Studies have indicated that educating patients about comorbidities can encourage them to take an active role in their health management and prevent disease progression.²⁰

Economics

The cost of care warrants discussion with patients. Financial hardship can reduce treatment adherence and increase patients’ anxiety and depression. In addition to medical treatment, patients may benefit from psychosocial intervention in the form of support groups, behavioral health services, family support, crisis intervention, and follow-up care.

CONCLUSION

It is an exciting time in psoriasis care. Rapid advances are being made in treatment. Biologic agents provide quicker and broader treatment options. Physicians have a unique opportunity to provide patients with holistic care that can improve their QOL.

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2. Sarkar R, Chugh S, Bansal S. General measures and quality of life issues in psoriasis. Indian Dermatol Online J. 2016;7(6):481-488.

3. Elmets CA, Korman NJ, Prater EF, et al. Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021;84(2):432-470.

4. Jett JE, McLaughlin M, Lee MS, et al. Tapinarof cream 1% for extensive plaque psoriasis: a maximal use trial on safety, tolerability, and pharmacokinetics. Am J Clin Dermatol. 2022;23(1):83-91.

5. Lebwohl MG, Papp KA, Stein Gold L, et al. Trial of roflumilast cream for chronic plaque psoriasis. N Engl J Med. 2020;383(3):229-239.

6. Jensen AM, Lladó MB, Skov L, Hansen ER, Larsen JK, Baadsgaard O. Calcipotriol inhibits the proliferation of hyperproliferative CD29 positive keratinocytes in psoriatic epidermis in the absence of an effect on the function and number of antigen-presenting cells. Br J Dermatol. 1998;139(6):984-991.

7. Ortonne JP, Humbert P, Nicolas JF, et al. Intra-individual comparison of the cutaneous safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment on chronic plaque psoriasis localized in facial, hairline, retroauricular or flexural areas. Br J Dermatol. 2003;148(2):326-333.

8. Hashim PW, Chima M, Kim HJ, et al. Crisaborole 2% ointment for the treatment of intertriginous, anogenital, and facial psoriasis: a double-blind, randomized, vehicle-controlled trial. J Am Acad Dermatol. 2020;82(2):360-365.

9. Hong JJ, Mosca ML, Hadeler EK, Brownstone ND, Bhutani T, Liao WJ. Genital and inverse/intertriginous psoriasis: an updated review of therapies and recommendations for practical management. Dermatol Ther (Heidelb). 2021;11(3):833-844.

10. Traidl S, Freimooser S, Werfel T. Janus kinase inhibitors for the therapy of atopic dermatitis. Allergol Select. 2021;5:293-304.

11. Griffiths CE, Reich K, Lebwohl M, et al. Comparison of ixekizumab with etanercept or placebo in moderate-to-severe psoriasis (UNCOVER-2 and UNCOVER-3): results from two phase 3 randomised trials. Lancet. 2015;386(9993):541-551.

12. Stein Gold L, Papp K, Pariser D, et al. Efficacy and safety of apremilast in patients with mild-to-moderate plaque psoriasis: results of a phase 3, multicenter, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol. 2022;86(1):77-85.

13. An Efficacy and Safety Study of Apremilast (CC-10004) in Subjects With Moderate to Severe Genital Psoriasis. US National Library of Medicine. December 15, 2022. NCT03777436. https://clinicaltrials.gov/ct2/show/NCT03777436

14. Choi J, Koo JYM. Quality of life issues in psoriasis. J Am Acad Dermatol. 2003;49(2 suppl):S57-61.

15. Meeuwis KAP, Potts Bleakman A, van de Kerkhof PCM. Prevalence of genital psoriasis in patients with psoriasis. J Dermatolog Treat. 2018;29(8):754-760.

16. Meeuwis KA, de Hullu JA, Massuger LF, van de Kerkhof PC, van Rossum MM. Genital psoriasis: a systematic literature review on this hidden skin disease. Acta Derm Venereol. 2011;91(1):5-11.

17. Yang EJ, Beck KM, Sanchez IM, Koo J, Liao W. The impact of genital psoriasis on quality of life: a systematic review. Psoriasis (Auckl). 2018;8:41-47.

18. Van de Kerkhof PC, Murphy GM, Austad J, et al. Psoriasis of the face and flexures. J Dermatolog Treat. 2007;18(6):351-360.

19. Meeuwis KA, van de Kerkhof PC, Massuger LF, de Hullu JA, van Rossum MM. Patients’ experience of psoriasis in the genital area. Dermatology. 2012;224(3):271-276.

20. Armstrong A, Bohannan B, Mburu S, et al. Impact of psoriatic disease on quality of life: interim results of a global survey. Dermatol Ther (Heidelb). 2022;12(4):1055-1064.