An Overview of Genital Psoriasis

Why It Happens and How to Maintain a Healthy Sex Life

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Genital psoriasis is a form of psoriasis—an inflammatory condition associated with skin plaques—that occurs on or around the genitals. Although it can develop on its own, genital psoriasis most often accompanies psoriasis on other parts of the body.

Psoriasis of the genitals can often cause severe symptoms as the skin of the penis, labia, vulva, clitoris, scrotum, and anus is very delicate and rich in nerve endings. Abrasions, cracks, and bleeding can easily lead to secondary infections. To complicate matters, some of the topical drugs used to treat psoriasis on other parts of the body can cause pain or discomfort when applied to the genitals.

According to a 2018 study in the Journal of Dermatological Treatment, 33% to 63% of people with psoriasis will develop genital psoriasis at some point in their life. It can affect both men and women, interfering with sexual enjoyment and quality of life. There is no clear explanation as to why some people with develop genital people and others don't.

Genital psoriasis cannot be transmitted through sexual contact and has no impact on pregnancy, sexual function, or menopause.

Symptoms

The signs and symptoms of genital psoriasis are similar to those of psoriasis on any other part of the body. The autoimmune disease is characterized by inflammation and the rapid build-up of skin cells on the outermost layer of skin called the epidermis.

Because the cells are being produced faster than they can be shed, the affected skin develops red, inflamed patches (plaques) covered with white to silvery scales. Itching and dandruff-like flaking are common. When scratched, the plaques will easily bleed and worsen. Over time, the plaques can consolidate and create large areas of dry, cracked skin.

Genital psoriasis generally affects the skin of the penis, vulva, or rectum. The mucus lining inside the vagina or rectum is typically unaffected.

The symptoms can vary based on the type of psoriasis you have:

  • Plaque psoriasis is the most common form, accounting for roughly 80% of cases.
  • Pustular psoriasis causes the eruption of pus-filled blisters on the affected skin.
  • Inverse psoriasis tends to develop in folds of skin (such as the groin) and is more common in overweight people.

Sexual Problems

Genital psoriasis can interfere with your sex life due not only to the physical symptoms but the embarrassment of having to explain the condition to a sexual partner. Weeping and inflamed skin can often be misread as a sexually transmitted infection such as herpes or genital warts. Rather than face rejection, some people will simply avoid sex, leading to isolation and depression.

Even if your psoriasis is under control, the friction induced by intercourse can inadvertently trigger an outbreak of symptoms, called a flare. Certain lubricants, particularly spermicidal ones, may be irritating to the skin and trigger a flare.

According to a 2015 study in the Journal of the American Academy of Dermatology, no less than 42% of people with genital psoriasis report decreased sexual intercourse as a result of their physical and emotional symptoms.

Causes

As an autoimmune disorder, psoriasis is characterized by an immune system gone awry. For reasons poorly understood, the immune system will suddenly attack normal cells and tissues. With psoriasis, the assault will be primarily focused on keratinocytes, a type of skin cells that makes up 90% of the epidermis.

When this happens, the ensuing inflammation causes hyperproliferation (overproduction) of keratinocytes, leading to the formation of plaques.

It is unclear why some people experience psoriasis of the genitals in particular. It has been proposed that past infections or skin traumas may increase the density of keratinocytes in tissues, providing more "targets" for the autoimmune assault. Further research is needed to support this hypothesis.

Scientists believe that psoriasis affecting any part of the body is caused by a combination of genetic and environmental factors. Several genetic mutations have already been identified that appear to predispose an individual to the disease. However, the actual expression of the disease may require an environmental trigger, such as an infection, for symptoms to manifest.

Diagnosis

Genital psoriasis is diagnosed based on a review of your symptoms and medical history. The medical history may reveal conditions or a family history that places you at an increased risk for psoriasis, or reveal alternate explanations for your condition (such as contact dermatitis).

If your symptoms are atypical or you are resistant to treatment, your dermatologist may obtain a tissue sample by scraping or biopsying the skin. Under the microscope, psoriatic tissue will have dense, compacted cells. This can help differentiate psoriasis from other likely causes, such as eczema or cancer.

Unlike some autoimmune disorders, there are no blood tests or imaging studies that can definitively diagnose psoriasis.

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Treatment

Genital psoriasis is approached differently than psoriasis on other parts of the body. This is because topical drugs used to treat psoriasis elsewhere can penetrate the thin, sensitive skin of the genitals more profusely, increasing the risk of side effects. Medication used to treat psoriasis on the scalp or elbows, for example, would be too harsh and/or concentrated to be applied to the labia or scrotum.

Over-the-Counter (OTC) Drugs

Low-potency topical medications are typically used in the first-line treatment of genital psoriasis to reduce the risk of side effects and damage to already-affected skin. These are used on a case-by-case basis under the direction of a dermatologist, who can adjust dosages and show you how (and where) to apply the medications safely.

Mild genital psoriasis is typically treated with a short course of an over-the-counter (OTC) 1.0% hydrocortisone ointment. Higher-dose hydrocortisone can be irritating and may cause irreversible skin thinning if overused, increasing the risk of dyspareunia (painful intercourse).

Mild coal tar is another, though less common, OTC option. It can be used alone or alongside hydrocortisone cream on the external genitalia only.

Prescriptions

If long-term therapy is needed, Dovonex (calcipotriene cream) is considered a safe and effective option. It is available by prescription and can be used on the more delicate tissues of the vulva, clitoris, and anus.

Protopic (tacrolimus) and Elidel (pimecrolimus) are topical immunosuppressants that are reserved for people who fail to respond to hydrocortisone or Dovonex. If the skin becomes infected, topical antibiotics may be prescribed. Your doctor may also recommend lubricants or emollients to relieve or prevent skin dryness and cracking.

If these options don't work, prescription topical steroids may be used but only under the supervision of a dermatologist. The prolonged use of steroids can also cause irreversible skin atrophy. This is especially worrisome in women, as it could lead to the "drooping" of the labia and the partial obstruction of the genital hiatus (the gap between the vagina, urethra, and rectum).

If your symptoms are severe, systemic treatment may be required. Generally speaking, these oral and injectable drugs are reserved for when psoriasis involves more than 10% of the body surface area, rather than just the genitals alone. Options include:

  • Methotrexate, a disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and other autoimmune disorders
  • Acitretin, an oral retinoid drug that can reduce inflammation
  • Biologic drugs, such as Humira (adalimumab), Orencia (abatacept), Enbrel (etanercept), and Rituxan (rituximab), which interrupt immune signals that trigger autoimmune symptoms

Phototherapy, a technique involving UV light exposure and photosensitizing drugs, is not commonly used to treat genital psoriasis but may be explored if larger areas of skin are involved.

Coping

In addition to treatment, there are strategies that can help you cope and/or prevent the recurrence of genital psoriasis. Among some of the more useful self-help tips:

  • Use mild, fragrance-free cleansers: When bathing, avoid antibacterial soaps and body washes. These can irritate delicate skin and cause psoriasis flares. (The same goes for deodorant products.)
  • Use quality toilet paper: This can help reduce irritation. Pre-moistened disposable wipes (non-fragranced) can also be soothing.
  • Take care when wiping: Avoid getting urine or feces on genital psoriasis patches, as this can cause flares. In addition, the introduction of feces onto dried, cracked skin can lead to secondary infections.
  • Wear loose-fitting underwear and clothing: Tight-fitting clothing can cause friction, which can worsen genital psoriasis.

When it comes to sex when you have genital psoriasis:

  • Communicate with your partner: Because people can mistake a psoriasis outbreak for a sexually transmitted infection, advise your partner about your condition before having sex.
  • Use condoms: Using a condom may help reduce some of the friction that can induce a flare. Use plenty of hypoallergenic, water-based lubricant as well (this type is less likely to compromise latex condoms).
  • Explore other forms of sex: Sexual intercourse is only one of the many varieties of sex you can enjoy. If your genitals are too sore for penetration, explore mutual masturbation with light touching. Some sex toys can provide pleasure without causing too much friction. Role-playing can also do wonders for your sex life and compel you to interact on a more intimate level.

A Word From Verywell

Genital psoriasis, like psoriasis on other parts of the body, is something you will need to manage over the long term. If you begin to notice lesions in your genital area, it is important to speak with your doctor or dermatologist as soon as possible. By acting early, you may be able to control the condition and reduce the severity or frequency of flares.

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Article Sources

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  1. Dopytalska K, Sobolewski P, Błaszczak A, et al. Psoriasis in special localizations. Reumatologia. 2018;56(6):392-8. doi:10.5114/reum.2018.80718

  2. Johnson E, Groben P, Eanes, A, et al. Vulvar Skin Atrophy Induced by Topical Glucocorticoids. J Midwifery Women Health. 2012 May-Jun;57(3):296-9. doi:10.1111/j.1542-2011.2012.00189.x

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