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Genital and Inverse/Intertriginous Psoriasis: an Updated Review of Therapies and Recommendations for Practical Management

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Genital and Inverse/Intertriginous Psoriasis: an Updated Review of Therapies and Recommendations for Practical Management UCSF UC San Francisco Previously Published Works Title Genital and Inverse/Intertriginous Psoriasis: An Updated Review of Therapies and Recommendations for Practical Management. Permalink https://escholarship.org/uc/item/2fn5q7zj Journal Dermatology and therapy, 11(3) ISSN 2193-8210 Authors Hong, Julie J Mosca, Megan L Hadeler, Edward K et al. Publication Date 2021-06-01 DOI 10.1007/s13555-021-00536-6 Peer reviewed eScholarship.org Powered by the California Digital Library University of California Dermatol Ther (Heidelb) (2021) 11:833–844 https://doi.org/10.1007/s13555-021-00536-6 REVIEW Genital and Inverse/Intertriginous Psoriasis: An Updated Review of Therapies and Recommendations for Practical Management Julie J. Hong . Megan L. Mosca . Edward K. Hadeler . Nicholas D. Brownstone . Tina Bhutani . Wilson J. Liao Received: February 18, 2021 / Published online: April 29, 2021 Ó The Author(s) 2021 ABSTRACT Key Summary Points Genital and inverse psoriasis can develop in more than one-third of patients who have pso- Among patients with psoriasis, up to 63% riasis. Psoriatic plaques in the genital and may develop genital psoriasis and 79% intertriginous skin are challenging to treat develop inverse psoriasis. because the skin is thin and often occluded, Patients with genital psoriasis often making it more sensitive to certain therapies. experience significant internalized stigma Traditional guidelines indicate topical thera- and physical distress, including sexual pies, such as corticosteroids, topical calcineurin dysfunction. inhibitors (TCI), and vitamin D analogs as first- line recommendation in treating genital and Because of the sensitive nature of the skin inverse psoriasis. There have been develop- surrounding genital and intertriginous ments in the treatment of genital and inverse areas, it is important to understand the psoriasis using systemic therapies, including IL- benefits and side effects of different 17 inhibitors and PDE-4 inhibitors. treatments for genital and inverse psoriasis. The first-line recommended therapy is topical corticosteroids, topical calcineurin Keywords: Psoriasis; Genital; Inverse; inhibitors, and topical vitamin D analogs. Intertriginous; Special site psoriasis The second-line recommendations are topical coal tar preparations and topical PDE-4 inhibitors. For recalcitrant or severe cases of genital psoriasis, biologic and other systemic therapies are recommended, with the most data available for ixekizumab. J. J. Hong (&) Á M. L. Mosca Á E. K. Hadeler Á Currently, clinical trials are evaluating the N. D. Brownstone Á T. Bhutani Á W. J. Liao efficacy and safety of apremilast (oral PDE-4 Department of Dermatology, Psoriasis and Skin inhibitor) and guselkumab (IL-23 inhibitor) Treatment Center, University of California San Francisco, 515 Spruce Street, San Francisco, for the treatment of genital psoriasis. CA 94118, USA e-mail: [email protected] 834 Dermatol Ther (Heidelb) (2021) 11:833–844 DIGITAL FEATURES elevation, and scale). A score of 0 (clear) indi- cates that there is residual or no erythema, no plaque elevation, and no scaling. A score of 1–2 This article is published with digital features, a (minimal-to-mild) indicates a faint, light-pink summary slide, to facilitate understanding of erythema with slight plaque elevation and some the article. To view digital features for this fine, white surface dryness or scales. A score of article, go to https://doi.org/10.6084/m9. 3–4 (moderate-to-severe) represents moderate- figshare.14406215. to-severe amount of erythema, substantial pla- que elevation with well-defined edges, and INTRODUCTION coarse scales on most to all lesions. A score of 5 (very severe) represents deep-red erythema with Psoriasis is a chronic inflammatory condition very significant plaque elevation and thick, characterized by the development of itchy, adherent scales that cover most or all lesions. erythematous plaques on the body and can An instrument called the Genital Psoriasis have a negative psychosocial impact on Symptoms Scale (GPSS) has also been developed patients. Psoriasis is also one of the most com- to record patient-reported outcome measures mon skin conditions affecting the genitalia, and specific for genital psoriasis [5]. about 63% of psoriatic patients will develop The treatment of genital and inverse psoria- genital lesions during the course of their disease sis must be approached with special care as the [1]. Psoriatic lesions in these areas may be skin is much thinner and considerably more smooth and non-scaly, and the genital local- susceptible to side effects of certain therapies ization can result in debilitating emotional and [6]. Although there is a limited number of physical distress as well as sexual dysfunctions. clinical trials that demonstrate the efficacy and Genital psoriasis is associated with poor quality safety of treatments, specific data show that of life and significant amount of stress, even genital and inverse psoriasis can be successfully though it affects only a small portion of body managed with both topical and systemic ther- surface area (BSA) [2, 3]. While it is more com- apies, including biologic and small-molecule mon in men, the severity of symptoms is higher inhibitors. Within the past 2 years, systematic in women [1]. Approximately 79% patients will reviews have been published for available also develop inverse or intertriginous psoriasis treatments for genital [7] and inverse psoriasis [1]. Because of the location of their psoriatic [8]. The goal of this paper is to focus on the lesions in sensitive areas, patients will not often most current, known benefits and potential side disclose their disease to physicians until they effects of the different treatment modalities for are asked. genital and inverse psoriasis and the current In clinical trials, the severity of genital pso- recommendations in navigating therapy for riasis has been assessed using a validated each individual patient. instrument. The Static Physician’s Global Assessment of Genitalia (sPGA-G) scale is a well- established, validated outcome measure that METHODS was developed to assess the severity of genital A literature search was performed using the psoriasis [4]. In women, the assessment includes MEDLINE (PubMed) and Embase database using the clitoral prepuce, labia majora, labia minora, the search terms (‘genital’ OR ‘inverse’ OR ‘in- and perineum. In men, it includes the penis, tertriginous’) AND ‘psoriasis’ AND ‘treatment’ scrotum, and perineum. This scoring system AND (‘topical’ OR ‘corticosteroid’ OR ‘cal- does not include the pubis, inguinal folds, cineurin inhibitor’ OR ‘vitamin D’ OR ‘phos- perianal region, or the gluteal cleft. phodiesterase-4 inhibitor’ OR ‘antiseptic’ OR sPGA-G is a 6-point numerical scale that ‘antifungal’ OR ‘coal tar’ OR ‘biologic’ OR ‘TNF’ ranges from 0 (clear) to 5 (very severe) at a given OR ‘systemic’ OR ‘adalimumab’ OR ‘etanercept’ time point and is determined by a combination OR ‘infliximab’ OR ‘certolizumab’ OR of three plaque characteristics (erythema, Dermatol Ther (Heidelb) (2021) 11:833–844 835 ‘secukinumab’ OR ‘brodalumab’ OR ‘ixek- included in other reviews on treatments of izumab’ OR ‘guselkumab’ OR ‘tildrakizumab’ genital and inverse psoriasis [7, 8]. OR ‘risankizumab’ OR ‘mirikizumab’ OR ‘ustekinumab’ OR apremilast OR ‘non-standard’ Topical Treatments OR ‘phototherapy’ OR ‘excimer laser’ OR ‘bo- tulinum’). One reviewer identified all included Topical Corticosteroids articles (J.H.). Only studies written in the Eng- The current first-line recommendation for the lish language were reviewed. All original short-term treatment of mild-to-moderate gen- prospective, retrospective studies, and nonex- ital (grade of recommendation: B) and inverse perimental descriptive studies, such as case ser- psoriasis (grade of recommendation: C) is low- ies and case reports, were chosen for the to mid-potency topical corticosteroids [10]. purpose of this paper. Systematic review articles Fluticasone propionate 0.005%, a mid-strength were examined to identify studies that were not topical steroid, used twice daily for 2 weeks has found in the original PubMed search. Inclusion shown more than 50% improvement in facial criteria were patients with psoriasis affecting the and intertriginous psoriatic lesions [11]. These genital and intertriginous areas, discussed results were maintained for 8 more weeks with treatments for their disease, and published prior once-daily application for 2 consecutive days to November 2020. Exclusion criteria were every week, suggesting gradual taper can help studies that did not discuss genital or inverse with long-term ([ 4 weeks) management. The psoriasis or did not discuss treatment for genital risk of side effects may be reduced with the use or inverse psoriasis. This article is based on of low-potency steroids. They may also be used previously conducted studies and does not in conjunction with other topical therapies to contain any new studies with human partici- enhance efficacy [10–12]. pants or animals performed by any of the Because the skin in the genital region is thin, authors. there is an increased amount of percutaneous Evidence levels are reported based on the absorption [13, 14]. Also, due to the occlusive best available evidence as discussed in American nature in the intertriginous areas, steroids have Academy of Dermatology (AAD) psoriasis increased penetration and therefore are recom- guidelines [9]. Grade A indicates that recom- mended for short-term therapy [15]. The rec- mendation is based on consistent
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