Skill Checkup: A 32-Year-Old Man With an Acute Flare of Psoriasis

David T. Robles, MD, PhD, FAAD


May 11, 2022

Genital psoriasis affects up to 63% of patients with psoriasis, and 79% of these patients develop inverse psoriasis. Genital psoriasis is associated with poor quality of life and a significant amount of stress, even though it affects only a small portion of BSA. The treatment of genital and inverse psoriasis must be approached with special care, as the skin is much thinner and considerably more susceptible to side effects of certain therapies. Genital and inverse psoriasis can be successfully managed with both topical and systemic therapies, including biologic and small-molecule inhibitors. Among the biologics, ixekizumab has been the most widely tested in genital psoriasis.

Low to mid-potency topical corticosteroids are often recommended as a first-line treatment for genital psoriasis. However, topical corticosteroids are generally approached with great caution for patients with genital psoriasis because of the unique environment of the genitalia. The thin skin and constant occlusion of this environment cause topical medications to have increased penetration in the groin area.

The second-line recommendations are topical coal tar preparations and topical phosphodiesterase-4 inhibitors. The use of topical immunomodulator agents, such as tacrolimus or 1% pimecrolimus cream, have shown benefits for long-term therapies and should be regarded as a third-line treatment option. Patients should be monitored for complications such as local irritation, stinging, irritant or allergic contact dermatitis, candidiasis, and/or (re)activation of viral skin infections.


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