Joshua is a 42-year-old man with a history of psoriasis. He presents today with new psoriasis plaques in his genital area.

Melinda Gooderham, MSc, MD, FRCPC: Hello, I'm Dr Melinda Gooderham, a dermatologist, clinical researcher, and assistant professor in the Department of Medicine at Queens University, and I want to welcome you to this program entitled "Full-Court Press: Talking to Patients About Psoriasis in Sensitive Areas."

Psoriasis is a chronic immune-mediated inflammatory disease that affects up to 3% of the population. It can affect multiple areas of the body with different degrees and severity. It commonly involves areas such as the elbows, knees, the umbilicus, and the lumbar region, but it can also affect sensitive areas such as the face and the genitals, as well skin folds, the axilla, the groin, and the gluteal cleft. We know that involvement in the genital area develops in about 63% of the patients at some point during the course of their disease.

We also know that psoriasis can cause a considerable disease burden on patients, and this burden is often higher in patients who have genital involvement, even though it only affects a small portion of the body surface area. When the genitals are involved, it can impact a patient's self-esteem, their sexual health and intimacy, and can affect their overall quality of life. With the impact on sexual health, it can lead to avoidance of intimacy and can impact sexual relationships. And for those who do have a partner or those who are engaging in any activity, even at a lower frequency, there can be some discomfort associated. There may be an impaired sexual experience during sexual activity, and sometimes it can even lead to worsening of psoriasis symptoms due to irritation or even koebnerization.

Almost half of patients with lesions in their genital area do not discuss their symptoms with their clinician, partly because they don't know what psoriasis is or they could be embarrassed. And as we saw in the previous scene, patients can be reluctant or embarrassed to bring it up just because they have not made that association. So it's up to us as clinicians to ask them about any new symptoms that they're experiencing. A few tips on approaching this with patients: I let them tell me about their skin disease or their involvement, and then at the end I say, "Is there anywhere else that you haven't mentioned?" And then I ask specifically, "Is there anything in the groin that maybe you didn't know was psoriasis?" Sometimes they'll say, "Nope, it's all clear." And other times they will pause and say, "Yes, actually, I didn't know that was psoriasis."

So we always need to do a full body exam to confirm that diagnosis because maybe they do have something else going on. We need to actually visualize it to make the correct diagnosis. So how I go about it is I provide every patient with a gown, as well as a sheet, and then the privacy to change. I'll let them know, I'll step out for a minute and I'll be back. And then, I advise them to remove their undergarments if they're comfortable with that. If not, we can always move things around to take a better look and always remember to ask permission of the patient to do that examination.

Patients may not think this is psoriasis because the symptoms and the quality of the plaques can present differently. Here, the skin can be smooth and red, as opposed to thick and scaly. It might look tight and shiny, as opposed to rough and flaky. Because of the moistness of that area, you don't get the same buildup of scale. Common complaints about lesions in the general area may be some itching, some redness, discomfort, tenderness, stinging, burning, and pain. So let's return to the visit and see what happens next.

Dr Gooderham: As we saw in the previous scene, patients can have misconceptions about their psoriasis. Some may think that they have a sexually transmitted disease and be very fearful. So it's really important to explain the diagnosis to them, and assure them that this is not a result of something that they've done, and it is not contagious or transmissible. And once a diagnosis is confirmed, and patients have questions about their psoriasis, we need to give them our time and answer their questions.

The next step then is in deciding on a treatment. And the treatment of the genital area can be challenging, as the genital skin is a bit thinner, and a little more sensitive, and can be more susceptible to side effects of specific therapies. So because of the proportion of the body surface area, which is usually less, the first line of therapy is topical therapy, and it's important to include the patient in that decision. So I like to find out what therapies have they liked to use, and what did they not like to use? Some patients don't like a greasy ointment. Some patients prefer a greasy ointment. So you need to have that conversation. I usually ask them about their experience with other therapies. And they may have something at home that they've already been using, and you need to ask a bit about that to find out what is going to be the right treatment for them. We ask the patient what their preferences are. We go through what the options are, and then we incorporate that into a shared decision-making exercise, where we then decide on what's the best treatment for that patient, because we know that that will improve adherence and lead to the best outcomes possible.

Now, let's return to the visit.

Dr Gooderham: When deciding on a treatment with a patient in that shared decision approach, it's helpful to offer information about all of the available agents to the patient, including the efficacy and the safety of the agent, the convenience of using it, how long it might take for them to see results. So we can set expectations, discuss any potential adverse effects, and what their insurance coverage might be to see if there are limitations. Also, providing this information to the patient, along with discussing the vehicle, you can come to a decision on what treatment is best for them.

Overall, we do that with all treatment selection, but when it comes to specific areas, like the genital skin, which has some special considerations, you want to look at the morphology of the condition. Is it very thick? Is it very thin? Is there any fissuring or pain? Is it itchy? And what some other comorbidities might be, but at this point, traditionally, we have used topical corticosteroids. Because of the location, we need to limit that to mild potency topical steroids. Sometimes, patients have been using other agents in the area. So examination is also important there because you may see some adverse effects, such as striae, which I have seen before in the genital area. There are also calcineurin inhibitors, which are used off-label, and these can lead to stinging and burning in some patients, but do have some efficacy. Then, the vitamin D analogs, although they are steroid free, they can often be irritating in these areas.

So, this has made treating the genital region challenging, but thankfully there are some new treatments that are available that are non-steroidal. We have roflumilast 0.3% cream, which was approved, and it's actually approved for use in intertriginous areas. They did a number of studies where they looked at the intertriginous IGA score as a specific secondary endpoint. What they showed was clinical benefit or intertriginous IGA success in about 70% of patients using the cream in the genital area or in sensitive areas. That 70% had an IGA of clear or almost clear. When you look at those patients, actually, 60% were completely clear in those sensitive areas or in those intertriginous areas.

We also have tapinarof 1% cream. This is another nonsteroidal. Although they did not specifically look at efficacy in the genital area or intertriginous areas, they did look at investigator-assessed local tolerability in sensitive areas where they found the cream was very well tolerated when applied on sensitive or intertriginous skin.

So, 2 new options to discuss with patients when you are in that shared decision approach coming up with the best treatment for them. They have good tolerability. The other benefit is that they can also be used outside the genital area on other parts of the body, which then add to the convenience of having one treatment that they can use on the body and in the genital area, but most importantly, we need to discuss it with our patients. We need to confirm the diagnosis, discuss the treatment options, and then choose a treatment the patient would like to use.

Thank you for joining me today in the Medscape Clinic. I hope you found the information presented here valuable to your practice. Please continue on to answer the questions that follow and complete the evaluation.

This transcript has not been copyedited.

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