Shedding Light on Shadows: A Cross-Sectional Analysis of Genital Psoriasis and Its Effects on Thai Individuals

Background Limited knowledge exists about genital psoriasis in Thai individuals. Objectives This study aimed to assess the clinical features of genital psoriasis and its effects on quality of life and sexual health in Thai patients. Materials and Methods A cross-sectional, self-administered question-based study was conducted at Siriraj Hospital. Participants were psoriasis patients older than 18 years of age with past or current genital involvement. The study assessed quality of life and sexual health. Results Among the 50 patients, 33 (66%) were female. The mean (standard deviation) age was 45.4 (±13.4) years. Genital psoriasis was active in 34% of the participants. The mons pubis (48.5%) and labia majora (18.2%) were the most frequently affected sites in females, while in males, the penile shaft (52.9%) and glans (47.1%) were the most common sites. Itch-related symptoms predominated, affecting 82% of patients. The median dermatology life quality index score was 6.5 for females and 10 for males. A sexual health survey revealed that 54% of participants had low self-esteem. This issue was more pronounced in males, with 76.5% reporting lower self-esteem compared to 42.4% of females (P=0.022). Males were also more inclined to postpone or avoid marriage (47.1% vs. 15.6%, P=0.038) and more embarrassed about sexual activities (63.6% vs. 14.3%, P=0.017). In addition, males were more inclined to avoid sexual encounters due to their genital condition. Notably, 42.9% of all patients had never disclosed to a doctor that they had genital psoriasis. Conclusions Genital psoriasis impacts quality of life and sexual function, with male patients being particularly impacted. Improved awareness of these issues among health professionals might increase patient satisfaction.


Introduction
Psoriasis is an immune-mediated infammatory disease characterized by erythematous, well-defned plaques with silvery scale.Tis condition is associated with a heightened risk of systemic comorbidities, such as cardiovascular disease, metabolic syndrome, and diabetes.Te prevalence of psoriasis varies globally; it afects approximately 2% of the population in the United States [1].Te disease exhibits a bimodal age of onset, with the frst peak occurring at approximately 22.5 years and the second peak at age 55 [2].Psoriasis is more prevalent in adults than in children [3].
Although genital psoriasis can manifest as a single episode in some psoriasis patients, its presence throughout their lifetime afects a notable portion (33% to 63%) of the population [4].Individuals experiencing genital psoriasis often report itching, pain, burning, and dyspareunia [5,6].Aggravators include stress, trauma, certain medications, and friction from sexual activity or tight clothing.Notably, 34% of patients experience worsening of psoriasis after sexual intercourse [7].
Te unique skin microbiota and anatomical location of genital psoriasis pose signifcant therapeutic challenges.Traditional psoriatic treatment modalities may not directly address this specifc manifestation.Currently, topical therapy is the conventional treatment approach.For initial therapy, low-potency corticosteroids are recommended.If needed, moderate to potent corticosteroid formulations might be used.Due to the delicate nature of the genital skin, only intermittent and short courses of these more potent steroids are suggested.Other options include topical calcineurin inhibitors and vitamin D analogs [5,8].A study by Ryan et al. revealed that ixekizumab was signifcantly more efective than placebo in treating moderate to severe genital psoriasis, relieving irritation, and enhancing sexual and general well-being [9].
Genital psoriasis profoundly afects patients' sexuality and quality of life [5,6,10,11].Meeuwis et al. reported a signifcantly higher mean dermatology life quality index (DLQI) score in patients with genital psoriasis than in those without genital involvement [6].However, due to the sensitive nature of the condition, both patients and physicians may avoid discussing it.Tis often leads to suboptimal patient care [10][11][12].Te likelihood of this happening is particularly true in Asian countries, including Tailand, where cultural sensitivities regarding sexual questions further complicate the issue [13,14].Te present study aimed to assess the clinical features of genital psoriasis and its efects on quality of life and sexual health in Tai patients.

Study Design and Participants
. Tis cross-sectional, selfadministered questions' study was conducted at the Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, a tertiary care center in Tailand.Te study protocol was approved by the Siriraj Institutional Review Board (approval number Si544/2022).All of the included psoriasis patients had past or current genital involvement and were aged 18 years or older.Te data were collected between July 2022 and March 2023.Patients who were illiterate, intellectually disabled, or unwilling to participate were excluded from the analysis.

Sample Size Estimation.
Te sample size calculation was based on DLQI data from a study by Meeuwis et al. [6].With an estimated standard deviation of 6.5, an allowable error of 2, alpha of 0.05, and beta of 0.20, and the minimum sample size was 41 patients.After allowing for a 20% margin for missing data, losses to follow-up, and withdrawals, and the fnal sample size was 50 subjects.

Baseline Characteristics.
Tis study enrolled 50 patients with genital psoriasis.Table 1 summarizes the patients' baseline demographics and clinical characteristics.Te mean age of the individuals in the cohort was 45.4 (±13.4)years, with females constituting the majority (66%).Te mean age at psoriasis onset was 31.6 (±13.1)years, and genital psoriasis manifested at a mean age of 39.5 (±12.2) years.Te cohort's mean BMI of 26 (±5.2) kg/m 2 qualifes as obese according to the World Health Organization and National Institutes of Health guidelines [16].Regarding marital status, 50% of the patients were married, 34% were single, 10% were divorced, and 6% were separated.Chronic plaque psoriasis dominated, afecting 45 (90%) participants, followed by erythrodermic psoriasis in 5 (10%) patients.

Quality of Life, Sexual Health, and Perception of Genital
Psoriasis.As shown in Table 3, the median DLQI score among all study participants was 7 (25th percentile � 3 and 75th percentile � 14).Patients with current genital involvement had a median DLQI score of 9 (3.5, 17), which was higher than that of the group without such involvement, whose score was 6 (3, 10.8).A higher median DLQI score of 10 (3, 16) was recorded for male participants than for female participants (6.5 [3,10]).In response to the specifc sexual function question in DLQI question 9 ("Over the last week, how much has your skin caused any sexual difculties?"), males reported a signifcantly greater impact on sexual function than females did (odds ratio (OR) � 4.7, P � 0.016).
Among the 25 sexually active individuals (42.4% of the females and 64.7% of the males), embarrassment during sexual activities was signifcantly more common in males (63.6% vs. 14.3%,OR = 10.5, P � 0.017).Similarly, men were also more likely to abstain from sexual behavior due to their genital psoriasis than women were, although not to a statistically signifcant degree (63.6% vs. 35.7%,P � 0.165).Interestingly, although male patients were more comfortable with genital examinations by physicians (70.6% vs. 39.4%,OR = 3.7, P � 0.037).Only 57.1% had ever discussed their genital psoriasis with their physicians.Furthermore, 60% of the patients, both male and female, indicated that their physicians had neither inquired about nor conducted examinations for genital psoriasis.Pubic region involvement strongly indicated genital psoriasis (OR � 5.5, P � 0.007).

Treatment Modalities for Genital Psoriasis. Table 5
provides a comprehensive overview of the treatment approaches for patients with active genital psoriasis.Among the 17 patients with active genital involvement, a sizeable

Discussion
Data regarding genital psoriasis in Asian populations are scarce [13,14].Tis study represents one of the most extensive investigations of this manifestation in Tailand.Te study population predominantly consisted of female patients, with a median age at disease onset of 39 years for genital psoriasis, typically following the onset of psoriasis.Notably, 8% of the patients presented genital psoriasis as their initial psoriasis manifestation.Te median PASI score of 5.1 in our sample indicated mild to moderate disease severity.
Te data indicated that 56% of the patients had a BMI of 25 kg/m 2 or higher; these patients were classifed as obese according to the World Health Organization and National Institutes of Health guidelines for Asian populations [16].Tis fnding aligns with previous studies that identifed a relationship between increased BMI and psoriasis severity [17,18].Nonetheless, there was no signifcant diference in the overweight or obese rates between patients with and without active genital psoriasis, consistent with prior fndings [17].
Te prevalence of current genital psoriasis in our cohort was 34%, echoing the results of earlier studies [7,17,19].A tendency was observed among patients with genital psoriasis to have a history of inverse psoriasis.A signifcant proportion, between 60% and 88%, had a history of fexural psoriasis involvement.Patients with current genital psoriasis exhibited higher PASI scores and increased involvement of the pubic area.It should be noted that many studies do not diferentiate genital psoriasis from inverse psoriasis [8], which may infuence the interpretation and comparison of fndings across studies.
Itch emerged as the most commonly reported symptom of genital psoriasis in both sexes, consistent with fndings from previous studies [7,10,12].Meeuwis et al. [12] also identifed itch as one of the most bothersome symptoms, and it was characterized as having the "highest intensity."Other symptoms, such as burning, discomfort, and dyspareunia, were also identifed in our cohort.Our analysis revealed no signifcant sex diferences in the prevalence of genital symptoms (itching, burning, and pain).However, dyspareunia and an exacerbation of disease postcoital activity were exclusively reported by male participants.Tis fnding may be attributed to the frequent occurrence of psoriasis on the penile shaft in males.Tese observations contrast with the fndings of Ryan et al. who suggested that women were more susceptible to experiencing dyspareunia and sexual distress due to genital psoriasis [9].
Stress emerged as the most common aggravating factor for more than half of the participants, aligning with known triggers for psoriasis in general.In addition, tight-ftting clothing and sexual activity were cited as aggravating factors, which can be explained by the Koebner phenomenon, where friction or trauma can induce new psoriatic lesions.
An elevated risk of sexual dysfunction has been associated with psoriasis [20].A systematic review revealed that the prevalence of sexual dysfunction and erectile dysfunction in these patients ranged from 40% to 55.6% and 34% to 81%, respectively [21].Anxiety, depression, psoriatic arthritis, and genital psoriasis were identifed as factors infuencing sexual dysfunction [21].Te presence of proinfammatory cytokines and systemic infammation in psoriasis may independently lead to sexual or erectile dysfunction.Tey can afect the levels of sex hormones, cause vascular dysfunctions, or involve other mechanisms that are yet to be fully understood [21].However, further research is warranted to elucidate these relationships.
Over half of patients with genital psoriasis experience a substantially worse quality of life compared to those with psoriasis on other body areas [11].Consistent with the fndings of previous studies, the median DLQI score for our patients was 7.Although the median score was greater in males than in females, no statistically signifcant diference was observed.Patients with active genital psoriasis had elevated DLQI scores relative to those without active genital lesions, suggesting a potential improvement in quality of life following lesion resolution [6,9].
Our patients, particularly males, exhibited low selfesteem, sexual shame, and a tendency to postpone or avoid marriage.Among sexually active individuals, males reported signifcantly greater embarrassment when engaging in sexual activity, leading to a decreased frequency and avoidance of sexual encounters.
Healthcare providers often face challenges in initiating discussion or conducting examinations specifcally focused on genital psoriasis [7,12].Similarly, patients often hesitate to discuss the condition with their physicians, with nearly half of the patients in a prior study reporting never having disclosed their genital psoriasis [12].In our study, fewer than half of the respondents (40%) had ever been queried or examined by their doctors regarding genital psoriasis.In addition, 42.9% of the respondents had never raised their condition with their healthcare providers.Cather et al. reported that patients preferred being interviewed about genital psoriasis via telephone rather than face-to-face due to embarrassment or discomfort experienced by discussing such a sensitive subject [10].We also investigated patients' perceptions of allowing a doctor to examine them.Surprisingly, males were signifcantly more amenable to allowing physicians to examine their genitalia.
Despite the profound impact of genital psoriasis on both sexual and overall well-being, a substantial proportion of patients continue to receive inadequate care from their healthcare providers [7,8,12].Te causative defciency in communication may be attributed to the inherent sensitivity surrounding genital health and the challenges associated with initiating open discussion about issues involving genitalia.

6
Dermatology Research and Practice Treatment of genital psoriasis presents a particular challenge due to the sensitive nature of genital skin and its response to medications.In addition, as many as two-thirds of patients with genital psoriasis have never sought formal treatment for their lesions [12].Nonpharmacological interventions for genital psoriasis emphasize good hygiene and friction reduction.It is recommended to use mild, nonsoap cleansers to keep the genital area clean without causing irritation, and to wear loose-ftting clothing to avoid the Koebner phenomenon and irritation [8].First-line therapies typically involve low-to-midpotency topical corticosteroids [5,11].However, potential side efects from prolonged corticosteroid use warrant consideration.Second-line treatments include calcineurin inhibitors, topical calcipotriol, and coal tar [8].
Topical calcineurin inhibitors (TCI) have demonstrated efectiveness and tolerability in managing both genital and facial psoriasis with minimal adverse efects.In a randomized, double-blinded, controlled study, topical tacrolimus achieved superior efcacy, with 67% of patients showing clear or excellent outcomes compared to 37% in the placebo group.In addition, there were no signifcant diferences in symptoms such as burning, stinging, or itching [22].Topical tacrolimus has also been found to be as efective as a midpotency topical corticosteroid [23].
Topical vitamin D analogs such as calcipotriol and calcitriol are another suggested long-term treatment for genital psoriasis.However, previous studies have demonstrated that they are less efective than topical corticosteroids, or TCI, and can develop more severe cutaneous irritation compared to TCI [24].Coal tar's efcacy and safety have been reported in a study in which patients responded signifcantly to coal tar 2% and topical salicylate preparations twice daily at week 8 [25].
Te International Psoriasis Council's new classifcation system for psoriasis severity recommends stratifying patients based on suitability for topical or systemic treatment, including those with facial or genital involvement.While systemic therapies are seldom prescribed for isolated genital psoriasis, they may be advantageous in severe cases involving genital lesions.In our study, methotrexate, cyclosporine, and acitretin were administered to patients with severe psoriasis complicated by genital involvement.
Ultraviolet phototherapy is generally not advised for genital psoriasis patients due to safety concerns [29].Stern et al. [30] reported that prolonged exposure to photochemotherapy (psoralen plus ultraviolet A), as well as high doses of ultraviolet B exposure, were linked to an increased risk of genital tumors in males.However, one female patient in our study reported favorable outcomes with ultraviolet B phototherapy applied to both body and genital lesions.She underwent 27 sessions over 5 months, with a fnal dose of 0.86 J/cm 2 .
Biologic therapies, bolstered by promising results from new drugs, have shown the potential to improve the sexual dysfunction of psoriasis patients [21].Ixekizumab, an anti-IL-17 agent, is presently the only biologic agent approved by the FDA as efective in treating genital psoriasis (grade of recommendation: B).In two double-blinded, placebocontrolled phase IIIb trials, ixekizumab demonstrated superior efcacy to placebo in treating moderate-to-severe genital psoriasis (body surface area ≥1%) and improving symptoms related to sexual activity [9,31].Other biologics, such as adalimumab and ustekinumab, have also been reported to be efective [32].Tese fndings highlight the potential of targeted therapies to mitigate the signifcant quality-of-life impairments associated with genital psoriasis.Early detection and intervention may further help prevent the functional and social sequelae of this debilitating condition.Our fndings indicate that patients treated with anti-IL-17 agents (ixekizumab, secukinumab, and brodalumab) achieved mostly satisfactory outcomes, followed by those treated with an anti-IL-23 agent (guselkumab).In a recent randomized, controlled study, patients with genital psoriasis who took apremilast, an oral immunomodulating phosphodiesterase 4 inhibitor, showed statistically and clinically signifcant improvements in their genital Physician Global Assessment scores as well as improvements in their signs, symptoms, severity, and quality of life.[33].
A genital psoriasis awareness program by Meeuwis et al. [34] demonstrated symptom relief and improved quality of life with simple topical interventions over a short timeframe (6 weeks).Tese fndings underscore the necessity of recognizing and prioritizing efective treatments to alleviate symptoms and improve quality of life.
Our study is limited by its small sample size and dependence on question-based data, which did not include physical examinations of all genital areas.Consequently, the information is subject to potential recall bias from the patients' self-reports.

. Conclusions
Genital psoriasis has a signifcant incidence within the Tai population.Our study highlights the considerable psychosocial and psychosexual impact of genital psoriasis, particularly among male patients.Unfortunately, a potential gap in diagnostic and therapeutic attention for genital psoriasis was identifed, with healthcare professionals sometimes overlooking the condition and patients underreporting their concerns.To optimize the management of psoriasis, healthcare providers must adopt a proactive stance in detecting and treating genital psoriasis, ensuring comprehensive care for patients.

Table 1 :
Demographic profle of patients with genital psoriasis.

Table 2 :
Clinical manifestations of genital psoriasis.

Table 3 :
Quality of life, sexual health, and perception of patients with genital psoriasis.
4 Dermatology Research and Practice majority (14 patients, or 82.4%) were receiving treatment.All these patients applied emollients, and most utilized topical therapies, predominantly topical corticosteroids.Six patients (42.9%) were receiving conventional systemic treatments, such as methotrexate, acitretin, and cyclosporine.Two patients (14.3%) received the biologic drug secukinumab, and one patient (7.1%) was treated with narrowband ultraviolet B phototherapy.Of the 50 patients with past or current genital psoriasis, 58% reported improvement with topical treatments.Emollients were credited with improvements by 36% of patients, while conventional systemic treatments

Table 4 :
Comparison of patients with psoriasis with active or inactive genital psoriasis.

Table 5 :
Treatment of patients with genital psoriasis.