You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


Full-Court Press: Talking to Patients About Psoriasis in Sensitive Areas

  • Authors: Melinda Gooderham, MD, MSc, FRCPC
  • CME Released: 3/10/2023
  • Valid for credit through: 3/10/2024
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    You Are Eligible For

    • Letter of Completion

Target Audience and Goal Statement

This activity is intended for dermatologists, primary care physicians, rheumatologists, physician assistants, and other clinicians who treat patients with psoriasis.

The goal of this activity is for learners to be better able to discuss the impact of psoriasis in sensitive areas with patients and develop treatment plans.

Upon completion of this activity, participants will:

  • Demonstrate improved performance associated with
    • Discussing the impact of psoriasis in sensitive areas with patients
    • Developing a treatment plan for patients with psoriasis in sensitive areas


Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


  • Melinda Gooderham, MD, MSc, FRCPC

    Assistant Professor
    Department of Medicine
    Queen's University
    Consultant Physician
    Peterborough Regional Health Centre
    Medical Director
    SKiN Centre for Dermatology
    Peterborough, Ontario, Canada


    Melinda Gooderham, MD, MSc, FRCPC, has the following relevant financial relationships:
    Consultant or advisor for: AbbVie Inc.; Akros Pharma Inc.; Amgen Inc.; AnaptysBio, Inc.; Arcutis Biotherapeutics, Inc.; Aristea Therapeutics; Asana BioSciences, LLC; Aslan Pharmaceuticals; Bausch Health Companies Inc.; Boehringer Ingelheim International GmbH; Celgene Corporation; Eli Lilly and Company; Galderma S.A.; Janssen Biotech, Inc.; Kyowa Kirin Pharmaceutical Development, Inc.; LEO Pharma, Inc.; Novartis Pharmaceuticals; Pfizer Inc.; Regeneron Pharmaceuticals, Inc.; Sanofi Genzyme; Sun Pharmaceutical Industries, Ltd.; UCB Pharma, Inc.
    Speaker or member of speakers bureau for: AbbVie Inc.; Amgen Inc.; Arcutis Biotherapeutics, Inc.; Aslan Pharmaceuticals; Bausch Health Companies Inc.; Boehringer Ingelheim International GmbH; Celgene Corporation; Eli Lilly and Company; Galderma S.A.; Janssen Biotech, Inc.; LEO Pharma, Inc.; Novartis Pharmaceuticals; Pfizer Inc.; Regeneron Pharmaceuticals, Inc.; Sanofi Genzyme; Sun Pharmaceutical Industries, Ltd.; UCB Pharma, Inc.
    Research funding from: AbbVie Inc.; Akros Pharma Inc.; Amgen Inc.; AnaptysBio, Inc.; Arcutis Biotherapeutics, Inc.; Aristea Therapeutics; Aslan Pharmaceuticals; Bausch Health Companies Inc.; Boehringer Ingelheim International GmbH; Bristol Myers Squibb Company; Celgene Corporation; Coherus BioSciences; Dermira Inc.; Eli Lilly and Company; Galderma S.A.; GlaxoSmithKline; Incyte Corporation; Janssen Biotech, Inc.; Kyowa Kirin Pharmaceutical Development, Inc.; LEO Pharma, Inc.; MedImmune Inc.; Merck & Co., Inc.; MoonLake Immunotherapeutics; Nimbus Therapeutics; Novartis Pharmaceuticals; Pfizer Inc.; Regeneron Pharmaceuticals, Inc.; Sanofi Genzyme; Sun Pharmaceutical Industries, Ltd.; UCB Pharma, Inc.


  • Karen Badal, MD, MPH

    Senior Medical Education Director, Medscape, LLC


    Karen Badal, MD, MPH, has no relevant financial relationships.

  • Ashley Stumvoll, MRes

    Associate Medical Writer, Medscape, LLC


    Ashley Stumvoll, MRes, has no relevant financial relationships.

Compliance Reviewer

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read about the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or print it out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate, but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period, you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


Full-Court Press: Talking to Patients About Psoriasis in Sensitive Areas

Authors: Melinda Gooderham, MD, MSc, FRCPCFaculty and Disclosures

CME Released: 3/10/2023

Valid for credit through: 3/10/2024


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

Dermatologist: Hey, Joshua. It’s nice to see you again. How are you doing?

Joshua: Oh, same old. Still driving the bus. It won’t drive itself. Not yet, anyway.

Dermatologist: Are you on the downtown route still?

Joshua: No, uptown now. Doesn’t make much difference to me.

Dermatologist: Gotcha. So, how have you been feeling? How is your psoriasis?

Joshua: About the same. I think my elbow patches are getting smaller, but that might be in my head.

Dermatologist: What about behind your ears?

Joshua: It seems about the same, to be honest. Still itchy, too.

Dermatologist: Are you having any trouble anywhere else?

Joshua: No – Well, there is – no, nevermind.

Dermatologist: It’s ok, go ahead.

Joshua: [pauses]

Dermatologist: Joshua, believe me, I’ve seen and heard it all.

Joshua: I’m really itchy and know, down there. It’s driving me nuts.

Dermatologist: [nods, acknowledges]

Joshua: Me and my ex recently split, so I’ve been working out a lot. You know. Getting back in shape and whatever.

Dermatologist: Right.

Joshua: [doesn’t say anything, looks embarrassed]

Dermatologist: feel that the sweat is contributing?

Joshua: Yeah. Plus I’m on sitting on the bus all day in that polyester uniform – and it’s a busy route, so it gets a little hot on there, you know?

Dermatologist: Right. I can imagine.

Joshua: So I mean – it’s probably just jock itch, right? I bought some calamine lotion and some itch stuff at the store and it didn’t seem to help.

Dermatologist: Hmm. When did you first start to notice an increase in itching?

Joshua: About a month ago. I went to the clinic and got tested, too, just in case...since I’m, you know, back on the market. They said it wasn’t an STI, so I don’t really know what is going on.

Dermatologist: People with psoriasis in sensitive areas – like you have behind your ears – can sometimes develop plaques on other sensitive areas, like their armpits or their genitalia.

Joshua: I can have psoriasis...there?

Dermatologist: Yes, unfortunately. Are you noticing any redness or flaking?

Joshua: Uh, yeah. Lots of redness.

Dermatologist: Okay, I’d like to do a quick exam to confirm that what you’re experiencing is psoriasis, and then we can talk about treatment options.

Joshua: What, like, now?

Dermatologist: Yes, if that’s alright.

Joshua: I mean...can’t you just give me some meds or something?

Dermatologist: Joshua, to make sure that we choose the best treatment possible, it is important to make sure we have the correct diagnosis.

Joshua: Alright... Yeah, that’s fine. If you think it will help.

Dermatologist: Okay. I’m going to step out for a moment. Why don’t you change into a gown, and then we can take a quick look when you’re ready.

Joshua: Yep.

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.

Dermatologist: [after completing exam] I can confirm that this is psoriasis you are experiencing.

Joshua: Ok. Yep.

Dermatologist: I know that this is awkward. Thank you for trusting me. Now that I know what’s going on, we can work on finding an agent that will give you some relief.

Joshua: Please – that would really help. I’ll try anything. It’s miserable – and the itching is the worst part. I’m spending all day trying not to scratch – I mean, I’m in public all day.

Dermatologist: I understand...

Joshua: Also, I’m wondering why this is happening......I’m know, clean. I usually shower after the gym and when I get home, but sometimes I don’t have time. Is it like a hygiene thing? Or maybe the soap or something? I just got this fancy new soap that’s just better, texture wise, than my old soap.

Dermatologist: Certain soaps can irritate your skin and make psoriasis worse, but they don’t cause psoriasis. The same is true for sweat.

Joshua: Great. I can’t even imagine going on a date like this. They’ll think I’m going to give them something. Is that...possible?

Dermatologist: These plaques are not transmissible. Unlike a yeast infection or an STI, psoriasis is an autoimmune condition. It will only affect your body, not your partner’s.

Joshua: That’s something, I guess. If this is psoriasis too, can I just use the cream I already have?

Dermatologist: The medications you use for thick plaques, like those on your elbows, are too harsh for sensitive areas.

Joshua: Nothing is ever easy, is it? I guess I’ll have to figure out how to keep track. Ok...what about moisturizer? Would that help? Honestly, I’m kind of picky about, ah, what I use down there.

Dermatologist: Keeping the area moisturized can definitely help, but that alone will not solve the problem, unfortunately. If you have preferences on texture, we can account for those when we decide on treatment.

Joshua: Nothing that’s going to be greasy and get on my clothes – I hate that.

Dermatologist: There are many different forms of these medications – creams, foams, and so on. I’m sure we can find one that you won’t mind using. You know what – if you want to change back into your clothes, I can give you a minute before we discuss treatment options.

Joshua: Yeah, that would be good. Thanks.

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.

Dermatologist: So, there are a few options I want to go over, but first I want to talk about treatment goals.

Joshua: I mean, I want it gone -- Can you get rid of it? I don’t want anyone to see me like this. I have to change under a towel at the gym – it’s humiliating.

Dermatologist: There are a number of options we can try. However, I want to be realistic – your symptoms will get better, but maybe not right away.

Joshua: Anything would be better than it is now, honestly.

Dermatologist: I’m confident we’ll be able to decrease the itching. Genital psoriasis is similar to psoriasis on other areas of your body. You may have flares or see it returning, but we can get you to the point where we keep those flares manageable.

Joshua: Is it going to keeping getting this bad?

Dermatologist: I can’t say for sure, but there are extremely effective topical agents now available that help most people.

Joshua: What if they don’t work?

Dermatologist: Well, we are going to try this, and if it doesn’t work, we have other options. We won’t give up trying.

Joshua: Ok. And...does that mean I’ll have to use different creams for every part of my body if we stick with topicals?

Dermatologist: Not necessarily. If you’d like, we might be able to choose an agent that you can use for your other psoriasis patches as well.

Joshua: That might be can be really hard to keep them all straight.

Dermatologist: I understand. There are actually a few new topical options available as well as some longer standing treatment options. Let me go over these, talk about the risks and benefits with you, and I am sure we can find one that meets your needs...

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.

Learning Feedback Questions

What did you learn from this activity? Please proceed to a brief survey.

  • Print