Treatment of Genital Psoriasis: A Systematic Review · systemic and topical medications may improve genital psoriasis lesions, but there is a lack of high-quality evidence to guide

REVIEW

Treatment of Genital Psoriasis: A Systematic Review

Kristen M. Beck . Eric J. Yang . Isabelle M. Sanchez . Wilson Liao

Received: June 14, 2018 / Published online: August 25, 2018� The Author(s) 2018

ABSTRACT

Genital psoriasis affects approximately 63% ofpsoriasis patients at least once in their lifetime.More than any other area on the body, genitallesions significantly impair patients’ psycho-logic well-being and quality of life. We aimed tosystematically review the published evidence onthe safety, efficacy, and tolerability of treat-ments of genital psoriasis and synthesize theavailable clinical data. A total of 1 randomizedcontrolled trial, 11 open-label studies, and 26case reports were included in our analysis, rep-resenting a total of 458 patients, of which 332were adults and 126 were children. Topicalcorticosteroids were commonly used first-linefor genital psoriasis and were well tolerated.Nonsteroidal agents, such as topical calcineurininhibitors or vitamin D analogs, were also effi-cacious, but were often irritating. One systemicagent, ixekizumab, demonstrated efficacy in

reducing genital psoriasis symptoms in a large,randomized, placebo-controlled trial. Varioussystemic and topical medications may improvegenital psoriasis lesions, but there is a lack ofhigh-quality evidence to guide clinical decision-making. Specific reporting of efficacy for genitalpsoriasis in larger controlled studies of psoriasistreatments are necessary to improve the avail-able evidence regarding the optimal treatmentregimen for genital psoriasis.

Keywords: Genital psoriasis; Psoriasis; Therapy;Treatment

INTRODUCTION

Sixty-three percent of adults with psoriasisdevelop psoriatic lesions in the genital area atleast once during their lifetime [1]. In the pres-ence of inverse psoriasis, the prevalence ofgenital psoriasis increases to approximately 79%[2, 3]. In 2–5% of psoriasis patients, lesions onlyoccur in the genital region [3]. Genital psoriasiscan occur in all age groups, from newborns togeriatric patients, with a slight predilection foryounger male patients with relatively severedisease [4]. In children under 2 years of age,genital psoriasis typically presents as intensewell-demarcated erythema in the diaper area,termed napkin psoriasis [5, 6].

Kristen M. Beck and Eric J. Yang contributed equally tothe work.

Enhanced digital features To view enhanced digitalfeatures for this article go to https://doi.org/10.6084/m9.figshare.6950072.

K. M. Beck (&) � E. J. Yang � I. M. Sanchez � W. LiaoDepartment of Dermatology, UCSF Medical Center,San Francisco, CA, USAe-mail: [email protected]

Dermatol Ther (Heidelb) (2018) 8:509–525

https://doi.org/10.1007/s13555-018-0257-y

http://dx.doi.org/10.6084/m9.figshare.6950072




https://doi.org/10.1007/s13555-018-0257-y

http://crossmark.crossref.org/dialog/?doi=10.1007/s13555-018-0257-y&domain=pdf

http://crossmark.crossref.org/dialog/?doi=10.1007/s13555-018-0257-y&domain=pdf

Patients with psoriasis lesions in their genitalarea experience significantly worse quality oflife than patients with psoriasis on any otherareas, particularly with respect to pruritus, sex-ual function, sexual health, sexual distress,avoidance of sexual relationships, embarrass-ment, shame, and psychologic depression[4, 7–9].

Despite the high prevalence of genital pso-riasis, almost half of patients with genitallesions do not discuss their symptoms withtheir physician [8, 10, 11]. Lack of communi-cation and awareness about genital psoriasis inthe healthcare environment may result inunderdiagnosed and under-treated genital pso-riasis, subsequently increasing the risk of inap-propriate self-treatment [10].

Although there are many effective treat-ments in the therapeutic armamentarium forpsoriasis, treatment of lesions on the genitaliaand surrounding skin folds remains challeng-ing. Topical treatments have increased pene-tration through the thin, sensitive, and oftenoccluded genital skin, increasing the risk of sideeffects from common psoriasis medications[12]. A review of the literature in 2011 found alack of evidence regarding the efficacy andsafety of various treatments for genital psoriasis[3]. This review summarizes the most currentliterature regarding the efficacy and safety ofavailable therapies for psoriasis affecting thegenital skin.

METHODS

A literature search using the MEDLINE andEmbase health literature databases was con-ducted using the terms (‘‘psoriasis’’) AND (‘‘pe-nile’’ OR ‘‘penis’’ OR ‘‘genital*’’ OR ‘‘glans’’ OR‘‘scrotal’’ OR ‘‘scrotum’’ OR ‘‘anal’’ OR ‘‘diaper’’OR ‘‘napkin’’ OR ‘‘shaft’’ OR ‘‘foreskin’’ OR‘‘prepuce’’ OR ‘‘perianal’’ OR ‘‘vulva*’’ OR ‘‘labia’’OR ‘‘labium’’ OR ‘‘groin’’ OR ‘‘preputial’’ OR‘‘penoscrotal’’). Two independent reviewersidentified the included articles (EY, IS) andextracted information. The review methodswere established prior to the conduct of thereview and did not deviate during the course ofthe study. Articles were included if they

included patients with psoriasis or psoriasiformnapkin dermatitis affecting the genital area,discussed the results of treatment with respectto the genital lesions, and were published priorto 31 July 2018. Studies were excluded if theydid not study genital psoriasis, did not discussthe results of treatment in the genital region,were in a foreign language, were conferenceabstracts, or were a review or meta-analysis.Study results were extracted using a standard-ized data form recording information on thepublication date, type of psoriasis, site, age andgender of patients, and reported efficacy andadverse events. In addition, the quality of allstudies was rated based on the Oxford Centrefor Evidence-Based Medicine Levels of Evidencerating scheme [13].

The article is based on previously conductedstudies and does not contain any studies withhuman participants or animals performed byany of the authors.

RESULTS

A total of 1964 potentially relevant uniquecitations were identified from our literaturesearch (Fig. 1). Of these, 128 articles wereselected for further evaluation based on therelevance of their title and abstract. A total of 32articles examining the treatment of genitalpsoriasis were ultimately included in this study.Table 1 summarizes the data for adults. Table 2summarizes the findings for infants andchildren.

Treatments for Genital Psoriasis in Adults

A total of 21 articles examined treatment out-comes for adults with genital psoriasis (Table 1),including 1 randomized controlled trial (grade1), 8 open-label studies (grade 4), and 16 casereports (grade 5), representing a total of 332patients. Of these, topical corticosteroids wereused in the regimen of 201 patients for suc-cessful treatment (Table 2). Low-potency topicalsteroids were used in 132 patients, moderate-potency steroids were used in 120 patients, andhigh-potency steroids were used in 15 patients.Antifungal medications were used as part of

510 Dermatol Ther (Heidelb) (2018) 8:509–525

successful treatment in 3 patients, while coal tarpreparations were effective in clearing genitallesions in 126 patients. Topical tacrolimus 0.1%ointment resulted in significant improvementin genital lesions in 38 patients across 4 open-label studies (grade 4) and 2 case reports (grade5). Tacrolimus was fairly well tolerated by mostpatients, with side effects of mild pruritus and/or burning sensation of limited duration.However, use precipitated extreme irritation inone case report, requiring discontinuation oftherapy [14]. Other agents used for successfultreatment of genital psoriasis include topicalcyclosporine, which was well tolerated in threepatients [15].

Vitamin D preparations were used success-fully in 40 patients, often in combination withtopical corticosteroids for genital psoriasis[16–18]. Additional reports of vitamin D prepa-ration use in genital psoriasis patients exist inthe literature; these studies often do not report

outcomes specifically for the genital area. Arandomized, double-blind, head-to-head com-parison (grade 1) of calcitriol ointment 3 lg/gtaken twice daily was compared with tacrolimusointment 0.3 mg/g taken twice daily for 6 weeksin 49 patients with either facial or gen-itofemoral psoriasis [19]. Of these patients, fivehad genital psoriasis; two were treated withcalcitriol, and three were treated with tacroli-mus. Both treatments were well tolerated in thestudy, and tacrolimus treatment resulted in amore significant reduction of target lesion size,but results were not stratified for lesions on theface and genitalia.

In addition to topical treatments, severalinjectable and oral medications have beenreported to successfully clear genital lesions ofpsoriasis (Table 3). Ixekizumab, an IL-17A inhi-bitor approved for the treatment of moderate-to-severe psoriasis and active psoriatic arthritis[20], is the first biologic to report formal clinical

Fig. 1 Genital psoriasis: study selection for treatment

Dermatol Ther (Heidelb) (2018) 8:509–525 511

Table1

Studieson

treatm

entsforgenitalpsoriasisin

adults

Sources

Stud

ycharacteristics

Treatments

andou

tcom

es

Stud

ydesign,

levelof

evidence

Typeof

psoriasis

Site

Age

(years)

Coh

ort

(M/F)

Successful

(sideeffects)

Unsuccessful(sideeffects)

Notes

JFam

Pract

2016

[41]

Casereport,5

Plaque

psoriasis

Groin

451M

Triam

cinolone

cream,

clobetasol

ointment

1%hydrocortisone

cream,topicalantifungals,

oralantifungals

90%

improvem

entafter

1month,95%

improvem

ent

after2months

Albertet

al.

[14]

Casereport,5

Plaque

psoriasis

Anogenital

area,

genitocrural

folds

711F

Oraldoxepin,

methotrexate

7.5–

10mg/week(G

Idisturbance)

Mild

toultra-potent

topicalcorticosteroids,

topicaltacalcitol,topicaldoxepin,

twice

weeklyPU

VAfor2months,topical0.1%

tacrolim

us(extremeirritation,w

orsening

ofpruritus)

Oraldoxepinpartially

helpful

inalleviatingitching,

methotrexateim

proved

genitocruralfoldsbut

abandonedbecauseof

GI

disturbance

Albertet

al.

[14]

Casereport,5

Plaque

psoriasis

Groin,genitalia

extend

ingto

perianaland

natalcleft

771F

–Clomitrazole1%

,hydrocortisone1%

Minimalim

provem

ent

Bissonn

ette

etal.[33]

Open-label

case

series,

4

Plaque

psoriasis

Penis,scrotum

42(29–

70)

12M

Topical0.1%

tacrolim

ustwice

daily

(mild

pruritus

orburningsensationof

limited

duration)

–MeangenitalPA

SIdecreased

from

15.8

to1.2after

8weeks

Cassano

etal.[26]

Open-label

case

series,

4

Plaque

psoriasis

Genitalia

18?

9cEfalizum

ab1mg/kg

weekly

–Considerableim

provem

entin

genitallesionsafter

12weeks

Fischeret

al.

[16]

Open-label

case

series,

4

Plaque

psoriasis

Vulva

33(15–

56)

8F

TCS,

2%LPC

,topical

calcipotriol

–Resolutionof

vulvitis

Foureuretal.

[39]

Casereport,5

Napkin

psoriasis

Diaperarea

771F

Betam

ethasone

0.05%

cream

Bifo

nazolecream

daily

Cured

in1month

Foureuretal.

[39]

Casereport,5

Napkin

psoriasis

Diaperarea

871M

Bifo

nazolecream

daily

–Im

proved

in1month

Foureuretal.

[39]

Casereport,5

Napkin

psoriasis

Diaperarea

100

1F

Betam

ethasone

0.05%

cream

–Cured

in1month

Foureuretal.

[39]

Casereport,5

Napkin

psoriasis

Diaperarea

871F

Bifo

nazolecream

daily,o

ral

fluconazole100mgdaily

–Im

proved

withfluconazole

after1month

Guglielmetti

etal.[23]

Casereport,5

Plaque

psoriasis

Vulva,groin,

perianal

region

421F

Dapsone

100gdaily,

mycophenolate

mofetil

500mgtwicedaily

20mgmethotrexateweekly(U

TI)

Com

pleteclearanceafter

4weeks

ofdapsone,

remission

for2yearsusing

topicaltacrolim

us0.1%

and

calcipotriol.Slow

improvem

entwith

mycophenolate

mofetilafter

2months,partial

therapeuticresponse

with

methotrexate,stoppedat

4months


Table1

continued

Sources

Stud

ycharacteristics

Treatments

andou

tcom

es

Stud

ydesign,

levelof

evidence

Typeof

psoriasis

Site

Age

(years)

Coh

ort

(M/F)

Successful

(sideeffects)


Notes

Jemec

etal.

[15]

Open-label

case

series,

4

Plaque

psoriasis

Glans

penis,

innerfold

ofprepuce

433M

Topicalcyclosporine

solution

100mg/mlthreetimes

daily

–Meanbaselin

escorea

decreased

from

4.8to

0.8after

8weeks,cyclosporinewell

tolerated

Jese

etal.

[24]

Casereport,5

Plaque

psoriasis

Glans,foreskin,

glutealfold

371M

Adalim

umab

40mgevery

2weeks

Topicalpimecrolim

us,topicalcorticosteroids,

methotrexate15

mgweekly(nausea,

vomiting,headache,insom

nia)

Nearcompleteregression

at90

days,com

pleteclearance

at6months

Kapila

etal.

[18]

Open-label

case

series,

4

Plaque

psoriasis

Vulva

30(2–8

4)145F

Methylpredn

isoloneaceponate

0.1%

(110),2%

LPC

(118),

hydrocortisone

1%(94),

calcipotriol

0.05%

(10),

betamethasone

dipropionate

0.05%

(7),betamethasone

dipropionate

0.05%

?calcioptriol

0.05%

(4),UVBphototherapy

(3),

clioquinol

1%(1),clobetasol

propionate

0.05%

(1),

methotrexate(1)

Methylpredn

isoloneaceponate0.1%

(7),2%

LPC

(5),hydrocortisone

1%(6)

93.8%respondedto

topical

treatm

ent

Martin-

Ezquerra

etal.[46]

Open-label

case

series,

4

Plaque

psoriasis

Intertriginous

folds

18?

8M/7

F0.1%

tacrolim

usointmenttwice

daily

–Im

provem

entas

earlyas

day

15,m

eantotalscoreb

from

6.88

to0.37

after60

days

Meeuw

iset

al.[17]

Open-label

case

series,

4

Plaque

psoriasis

Genitalia

50(20–

80)

25M/

17F

Low

-potency

corticosteroid

cream

with(18)

andwithout

(16)

vitamin

Danalog

ointment,moderate-potency

corticosteroid

cream

(5),

daily

tacrolim

uswithlow-

potencycorticosteroid

cream

(2),alternatingmild

and

higher

potencycorticosteroid

cream

(1)

–Significant

improvem

entin

PASI,IA,SUM,D

LQI,

FSDS,sQ

oL-M

Quanet

al.

[43]

Casereport,5

Pustular

psoriasis

Glans

penis,

penileshaft

231M

Oralitraconazole200mgbid,

triamcinolone,d

esonide,

mom

etasonefuroate,baking

soda

preparation

Hydrocortisone1%

,coaltar2%

,naftifin

ehydrochloride

Someim

provem

entwith

itraconazole,m

inim

alim

provem

entwith

hydrocortisone

andcoaltar

Rallis

etal.

[47]

Open-label

case

series,

4

Plaque

psoriasis

Glans

penis,

scrotum

37(22–

72)

7M

0.1%

tacrolim

usointmenttwice

daily

for10

days,thenevery

7days

thereafter

–Com

pleteclearanceafter

3weeks,4

3%still

clearat

12weeks


Table1

continued

Sources

Stud

ycharacteristics

Treatments

andou

tcom

es

Stud

ydesign,

levelof

evidence

Typeof

psoriasis

Site

Age

(years)

Coh

ort

(M/F)

Successful

(sideeffects)


Notes

Ryanet

al.

[50]

Randomized,

placebo-

controlled

phaseIII

clinical

trial,1

Plaque

psoriasis

Genitalia

43(19–

77)

56M/

19F

Ixekizum

ab160mgat

week0,

then

80mgevery2weeks

thereafter

–Significant

improvem

entin

genitalpsoriasissymptom

scomparedwithplaceboas

measuredby

sPGA-G

0/1

(74%

vs.8

%),GenPS

-SFQ

item

2score0/1(78%

vs.

21%),andC

3point

reductionin

genitalitch

NRS(60%

vs.8

%)

Sezeret

al.

[51]

Casereport,5

Plaque

psoriasis

Glans

penis,

penileshaft

261M

Betam

ethasone

valerate,topical

5%salicylicacid

–Markedregression

ofthe

lesions

Shim

amoto

etal.[25]

Casereport,5

Pustular

psoriasis

Groin

801M

Oralchlorpromazine

125mg/day

Corticosteroids,antibiotics,griseofulvin

Resolutionof

skin

symptom

sseveralw

eeks

afterinitiation

oftreatm

ent,associated

with

reductionin

manic

symptom

s

Singhet

al.

[22]

Casereport,5

Pustular

psoriasis

Glans

penis

371M

Dapsone

100mgdaily,

doxycycline,metronidazole,

penicillin,

topicalsteroid

ointments

–Com

pleteclearancein

4weeks

withdapsone,maintenance

withdapsone50

mgdaily

Winrauch

etal.

Casereport,5

Plaque

psoriasis

Labium

majus

221F

Betam

etasone17-valeratethree

times

daily

–Clearance

oflesions

Yao

etal.

[40]

Casereport,5

Plaque

psoriasis

Glans

penis

371M

Tacrolim

us0.1%

ointment

twicedaily

Topicalketoconazolecream

for2weeks

Resolutionof

lesionsafter

3weeks

Zam

petti

etal.[48]

Casereport,5

Plaque

psoriasis

Glans

penis

451M

Topicaltacrolim

us0.1%

ointmentdaily

–Com

pleteresolution

after

3weeks

PASI

PsoriasisAreaandSeverityIndex,IA

investigator’sassessmentof

affected

genitalskin,SU

Msumof

severityscoreforerythema,desquamation,andinduration,D

LQIDermatologicalLife

QualityIndex,

FSDSFemaleSexualDistressScale,SQ

oL-M

SexualQualityof

Life

questionnaireforusein

men,sPG

A-G

staticPh

ysician’sGlobalA

ssessm

entof

Genitalia,G

enPS

-SFQ

GenitalPsoriasisSexualFrequency

Questionn

aire,N

RSnu

mericrating

scale

aMeasuredon

a6-pointscalegradingredn

ess,scaling,andmaceration

bMeasuredon

a9-pointscalegradingerythema,infiltration,

anddesquamationof

face,genitalia,and

intertriginous

areas

cUnspecifiedsex


Table2

Evidenceon

topicaltreatm

entsforgenitalpsoriasisby

medication

Medication

Successful

Unsuccessful

Zincpaste

Fergussonet

al.[35]

And

ersenet

al.[28],Baggioet

al.[36],Greco

etal.[37]

Salicylicacid

And

ersenet

al.[28]

Anilin

edye

And

ersenet

al.[28]

Topicalantibiotics

Cretu

etal.[37]

Topicalantifungals

Watanabeet

al.[38],Foureuret

al.[39]

Baggioet

al.[36],Greco

etal.[37],Foureuret

al.[39],Yao

etal.[40],JFam

Pract2016

[41]

Topicalcorticosteroids

Low

potency

Cretu

etal.[37],Kapila

etal.[18],Meeuw

iset

al.[17],Kam

er

etal.[42]

And

ersenet

al.[28],Baggioet

al.[36],Cretu

etal.[37],

Fergussonet

al.[35],Greco

etal.[37],Albertet

al.[14],

Meeuw

isetal.[17],Quanetal.[43],Singhetal.[22],JFam

Pract2016

[41]

Mid

potency

Afsar

etal.[6],B

aggioet

al.[36],Kapila

etal.[18],Meeuw

is

etal.[17],Weinrauch

etal.[44],JFam

Pract2016

[41]

Amichaiet

al.[29],Hernand

ezet

al.[45],Albertet

al.[14],

Meeuw

iset

al.[17],Jese

etal.[24]

Highpotency

Hernand

ezetal.[45],Foureuretal.[39],JFam

Pract2016

[41]

Albertet

al.[14],Meeuw

iset

al.[17]

Topicalcalcineurininhibitors

Amichaietal.[29],Bissonn

etteetal.[33],Martin-Ezquerraetal.

[46],R

allis

etal.[47],Zam

pettiet

al.[48],Jemec

etal.[15],

Yao

etal.[40]

Albertet

al.[14],Jese

etal.[24]

Vitam

inD

analogs

Amichaiet

al.[29],Albertet

al.[14]

Coaltar

And

ersenet

al.[28]

Quanet

al.[43]

Topicaldoxepin

Albertet

al.[14]

Com

bination

therapies

Topicalantifungalandtar

Kapila

etal.[18]

Low

-potency

TCS?

topical

antifungals

And

ersenet

al.[28],Rattetet

al.[49],Kapila

etal.[18]

Albertet

al.[14]

Low

-potency

TCS?

TCIs

Kapila

etal.[18]

Low

-potency

TCS?

tar

Kapila

etal.[18]

Kapila

etal.[18]


Table2

continued

Medication

Successful

Unsuccessful

Low

-potency

TCS?

topical

vitamin

Danalog

Meeuw

iset

al.[17]

Low

-potency

TCS?

tar?

vitamin

D

analog

Fischeret

al.[16]

Low

-potency

TCS?

mid-

potencyTCS?

tar

Kapila

etal.[18]

Kapila

etal.[18]

Low

-potency

TCS?

mid-

potency

TCS?

tar?

vitamin

D

analog

Kapila

etal.[18]

Mid-potency

TCS?

tar

Kapila

etal.[18]

Kapila

etal.[18]

Mid-potency

TCS?

tar?

vitamin

D

analog

Kapila

etal.[18]

High-potency

TCS?

vitamin

D?

tar

Kapila

etal.[18]


trial data for the treatment of genital psoriasis[21]. In this randomized, double-blind, placebo-controlled phase III trial (grade 1), adult sub-jects with moderate-to-severe genital psoriasiswere randomized to receive either placebo(n = 74) or ixekizumab 160 mg subcutaneouslyat week 0 followed by 80 mg every 2 weeksthereafter (n = 75). The primary outcome ofpatients achieving static Physician’s GlobalAssessment of Genitalia score of ‘‘clear’’ or‘‘minimal’’ (sPGA-G 0/1) by week 12 was met bysignificantly more subjects on ixekizumabtreatment than placebo (74% vs. 8%). Addi-tionally, significantly more patients treatedwith ixekizumab reported improved sexualactivity as measured by Genital Psoriasis SexualFrequency Questionnaire (GenPS-SFQ) item 2score 0/1 (78% vs. 21%) and clinically mean-ingful reduction in genital itch as measured bythe genital itch numeric rating scale (NRS) (60%

vs. 8%) compared with placebo. Safety out-comes were similar to the overall safety profileof ixekizumab, with the most common adverseevents including diarrhea, injection site reac-tions, nasopharyngitis, upper respiratory tractinfections, and headaches.

Two cases (grade 5) reported that oral dap-sone given 100 mg daily was found to be suc-cessful in clearing psoriasis lesions within4 weeks, without any reported adverse events[22, 23]. Mycophenolate mofetil and oral dox-epin have both been reported as successfultreatments for genital psoriasis in one case eachas well [14, 23]. Methotrexate 7.5–20 mg weeklyimproved genital symptoms in two of fourgenital psoriasis patients [14, 18, 23, 24]. How-ever, methotrexate use was associated withgastrointestinal disturbance, headache, insom-nia, and urinary tract infections. There is onereport of genital pustular psoriasis clearance

Table 3 Evidence on systemic treatments for genital psoriasis by medication

Medication Successful Unsuccessful

Phototherapy

UVB phototherapy Kapila et al. [18]

PUVA Albert et al. [14]

Immunosuppressants

Mycophenolate mofetil Guglielmetti et al. [23]

Methotrexate Albert et al. [14], Kapila et al. [18] Guglielmetti et al. [23], Jese et al. [24]

Biologics

Adalimumab Jese et al. [24]

Ixekizumab Ryan et al. [50]

Efalizumaba Cassano et al. [26]

Oral antifungals Foureur et al. [39], Meeuwis et al. [17] J Fam Pract 2016 [41]

Oral antibiotics Quan et al. [43] Singh et al. [22]

Dapsone Guglielmetti et al. [23], Singh et al. [22]

Doxepin Albert et al. [14]

Antihistamines Cretu et al. [37]

Antipsychotics Shimamoto et al. [25]

Calcium gluconate Cretu et al. [37]

a Formerly available treatment


after initiation of chlorpromazine for treatmentof a concurrent manic episode [25]. Adali-mumab has also been shown in one case reportto result in clearance of genital psoriasis by6 months without adverse effects [24]. Efal-izumab considerably improved genital pruritusin 9 patients (grade 4) given at a dose of 1 mg/kgweekly for 12 weeks [26]. However, 2 of 55patients in this study experienced adverseevents requiring treatment discontinuationwithin 12 weeks (psoriasis flare and neurologicsymptoms), and 7 patients described self-lim-ited treatment-associated papular psoriasis.Efalizumab has since been removed from themarket because of safety concerns [27].

Treatment of Genital Psoriasisin the Pediatric Population

A total of 12 articles examined treatments forgenital psoriasis in infants and children(Table 4). Three of these articles were open-labelstudies (grade 4), while the remaining ten werecase reports (grade 5) describing the effects oftreatment on pediatric patients. Treatmentoutcomes were described for a total of 126patients. Mild, topical coal tar preparationswere effective in clearing genital lesions among91 pediatric patients from two case series[16, 28].

Topical corticosteroid-based regimens led tosuccessful treatment outcomes in 37 cases. Low-potency topical steroids were used in 26patients; moderate- and high-potency steroidswere used in 6 patients and 1 patient, respec-tively. Successful treatment in six patients alsoincluded topical antifungal medications, pri-marily ketoconazole cream and clotrimazolecream. There was one case report (grade 5) ofcomplete resolution of psoriatic lesions withtopical pimecrolimus 1% ointment treatment[29]. All of the therapies used in children werewell tolerated, without any significant adverseevents reported.

DISCUSSION

In the past several years, there has been amoderate increase in studies assessing

treatments for genital psoriasis. At the time ofthe last published review on this topic in 2011,only 6 case reports and 1 open-label studydescribed the effects of therapies for genitalpsoriasis, while 24 articles reflected expertonion on treatment for this disease [3]. In ouranalysis, we found 1 randomized controlledtrial (grade 1), 11 open-label studies (grade 4),and 26 case reports (grade 5) describing theefficacy and safety of topical and systemictreatments for genital psoriasis. Various thera-pies have been shown to be effective for genitalpsoriasis in case reports and case series, buthigh-quality evidence in the form of random-ized controlled trials remains inadequate forgenital psoriasis treatments.

Low-to-mid-potency topical corticosteroidsare recommended as the first-line treatment forgenital psoriasis [30] (grade of recommenda-tion: D) and are commonly reported in the lit-erature to be a critical component of treatmentfor these lesions. However, topical corticos-teroids are generally approached with greatcaution for genital psoriasis patients because ofthe unique environment of the genitalia [31].The thin skin and constant occlusion of thisenvironment cause topical medications to haveincreased penetration in the groin area, which isa particular problem for infants, who have ahigh surface area-to-body mass ratio, predis-posing them to systemic side effects. Mildtopical corticosteroids may not be potentenough to induce a clinically significantresponse in some patients [11, 32] and are oftenused in combination with second-line topicaltherapies to yield clinical benefit (Table 2).Moderate-to-high-potency corticosteroids havebeen used effectively in adults and childrenwith genital psoriasis, both as monotherapy andin combination with other topical agents,without reports of significant adverse effects(Table 2). There was a lack of reporting onadverse effects from topical corticosteroids instudies included our analysis; therefore, there isnot enough evidence to determine whetherthere were no side effects with these therapies orif they simply were not mentioned. From theexisting evidence, topical corticosteroids con-tinue to be recommended as first-line treatment


Table4

Studieson

treatm

entsforgenitalpsoriasisin

childrenandinfants

Sources

Stud

ycharacteristics

Treatments

andou

tcom

es

Stud

ydesign,

levelof

evidence

Typeof

psoriasis

Site

Age

Coh

ort

(M/F)

Successful

Unsuccessful

Result

Afsar

etal.

[6]

Case

report,

5

Napkin

psoriasis

Diaperarea

5.5 months

1M

0.05%

clobetasone17-butyrate

cream

daily,emollient

cream

–Overallregression

with

interm

ittent

mild

flares

Amichai

etal.[29]

Case

report,

5

Plaque

psoriasis

Glans

penis,

distal

partsof

shaft

10years

1M

1%pimecrolim

uscream

Betam

ethasone

1%

cream,

calcipotriol

ointment

Resolutionof

psoriatic

lesionsafter3weeks

of

topicalpimecrolim

us,

recurrence

treated

successfully

And

ersen

etal.[28]

Open-

label

case

series,

4

Psoriasiform

napkin

derm

atitis

Diaperarea

2.1 months

(0–2

1)

35M/

32F

Tar

(64),corticosteroid-

vioform

ointment(3)

Zincpaste,salicylic

ointment,

steroid

ointment,or

aniline

dye

solutions

Tar

effectivein

64patients,

corticosteroid-vioform

ointmenteffectivein

3

patients

Baggioetal.

[36]

Case

report,

5

Psoriasiform

napkin

derm

atitis

Diaperarea

18

months

1F

Fluticasonepropionate

cream

Zincoxide-based

ointments,

antifungal

creams,desonide

cream

Com

pleteresolution

at

1week

Cretu

etal.

[37]

Case

report,

5

Napkin

psoriasis

Anogenital

area,

buttocks,

upper

1/3

thighs

4months

1M

System

icantihistam

ines,

nonspecific

desensitization

treatm

ent,rigorous

hygiene,

non-fluorinated

topical

corticosteroids

Antibiotic

ointmentfor

5days,calcium

gluconate,

topical

corticosteroids

Significant

improvem

entby

day2of

treatm

ent


Table4

continued

Sources

Stud

ycharacteristics

Treatments

andou

tcom

es

Stud

ydesign,

levelof

evidence

Typeof

psoriasis

Site

Age

Coh

ort

(M/F)

Successful

Unsuccessful

Result

Fergusson

etal.[35]

Open-

label

case

series,

4

Psoriasiform

napkin

derm

atitis

Diaperarea

Infants

22a

Zinc-oxidepaste

Topicalsteroids

Com

pleteclearance

Fischer

etal.[16]

Open-

label

case

series,

4

Plaque

psoriasis

Vulva

6years

(2–1

2)

27F

LPC

andtopicalcalcipotriol

with1%

hydrocortisone

(23)

ormethylpredn

isolone

aceponate0.1%

ointment(4)

–Symptom

remission,L

PC

welltolerated

Greco

etal.

[37]

Case

report,

5

Napkin

psoriasis

Diaperarea

18

months

1F

–Zincoxidepaste,

nystatin,

hydrocortisone

acetate2.5%

ointment

Minim

alim

provem

ent

Hernand

ez

etal.[45]

Case

report,

5

Vulvar

psoriasis

Vulva,

perianal

area

5years

1F

Clobetasol0.05%

ointment

twicedaily

Triam

cinolone

0.1%

ointment

twicedaily

Significantlyim

proved

erythemaon

innerlabial

andperianalareasat

2weeks,com

plete

resolution

at4weeks

Kam

eretal.

[42]

Case

report,

5

Napkin

psoriasis

Diaperarea

10weeks

1F

Low

-potency

topical

corticosteroids

–Clearance

oflesionsat

2weeks


Table4

continued

Sources

Stud

ycharacteristics

Treatments

andou

tcom

es

Stud

ydesign,

levelof

evidence

Typeof

psoriasis

Site

Age

Coh

ort

(M/F)

Successful

Unsuccessful

Result

Rattetet

al.

[49]

Case

report,

5

Psoriasiform

napkin

derm

atitis

Diaperarea

12

months

1F

Clomitrazole1%

cream,

hydrocortisone

1%cream

threetimes

daily

–Clearance

oflesionsat

2weeks

withmild

erythema

Rattetet

al.

[49]

Case

report,

5

Psoriasiform

napkin

derm

atitis

Diaperarea

5weeks

1M

Clomitrazole1%

cream,

hydrocortisone

1%cream

threetimes

daily

–Clearance

oflesionsat

4weeks

Watanabe

etal.[38]

Case

report,

5

Pustular

psoriasis

Diaperarea

4months

1M

0.2%

ketoconazolecream

daily

–Com

pleteclearanceat

1month

LPC

liquorpiciscarbonis

aUnspecifiedsex


for genital psoriasis (grade of recommendation:C).

The data in this analysis do not show supe-rior efficacy for nonsteroidal topical treatmentscompared with topical corticosteroids for thetreatment of genital psoriasis (Table 2). Topicalcalcineurin inhibitors did improve genital pso-riasis in several patients and were fairly welltolerated. Mild burning or pruritus can beassociated with using these treatments in thesensitive groin region, but these symptoms areoften manageable and limited in duration [33].Topical coal tar preparations demonstrate effi-cacy in both adults and children with genitallesions and are not associated with significantadverse effects. Vitamin D analogs are some-times recommended for patients with generalpsoriasis (grade of recommendation: D), but thisis less reported in the literature [11, 30]. How-ever, these nonsteroidal topical therapies mayincrease the risk for lymphoma, be more irri-tating, and be more costly than topical corti-costeroids [34]. Topical calcineurin inhibitors,coal tar preparations, and vitamin D analogsmay thus be used as second-line therapies forpsoriasis lesions in the genital area (grade ofrecommendation: C).

Systemic therapies such as dapsone andmethotrexate can work well for patients withgenital lesions and should be considered forpatients with debilitating quality of lifeimpairment (grade of recommendation: C) [30].Our analysis did not find any evidence on theuse of other traditional systemic agents, such asoral cyclosporine, acitretin, or apremilast,specifically for genital psoriasis. Althoughnumerous effective biologics are available forthe treatment of psoriasis, there is only onepublished clinical trial result on the efficacy ofcurrently approved biologics specifically forgenital psoriasis.

A recent study has shown ixekizumab tohave high efficacy specifically for genital psori-asis, with rapid improvement seen as early as1 week into treatment [21]. This medicationsignificantly improves genital lesion appear-ance, genital itch, sexual health, and quality oflife and may be a promising solution forpatients suffering from recalcitrant genital pso-riasis. Ixekizumab is currently the only

medication with FDA labeling specificallymentioning genital psoriasis (grade of recom-mendation: B).

Although not specifically addressed in themajority of articles in our analysis, goodhygiene and reduction of friction are essentialfirst-line measures for the treatment of genitalpsoriasis patients (grade of recommendation: D)[11]. Gentle, non-soap cleansers are recom-mended to keep the genitals clean withoutirritating the area, and patients should beadvised to wear loose-fitting, unrestrictiveclothing to avoid koebnerization and furtherirritation [30]. Patients with genital psoriasisshould always use lubricant or lubricated con-doms with any sexual activity to avoid exacer-bation of genital symptoms. In combinationwith proper pharmacologic therapy, these sup-portive measures are necessary for minimizingthe impact of genital psoriasis.

Despite increased research into genital pso-riasis in recent years, the optimal treatmentapproach for affected patients remains unclear.Overall, available evidence is limited, especiallyregarding the efficacy of systemic agents forgenital psoriasis. This is most likely becausesystemic treatments are indicated for moderate-to-severe psoriasis, and efficacy evaluationstypically do not specifically assess genitalsymptoms. Genital psoriasis is ill defined, variesin characterization throughout the literature,and is not distinguished from inverse psoriasisin several studies. The existing literature thususes various different measures to evaluatetreatment efficacy or assess symptom improve-ment qualitatively so studies can be difficult tocompare. The introduction of novel assessmenttools for genital psoriasis will facilitate a greaterunderstanding of how various treatmentscompare.

Additionally, most studies included in ouranalysis did not assess or report safety data orside effects with treatment, which is especiallyimportant for the sensitive genital area. Mostrecommendations for treating genital psoriasisare based on case reports or expert opiniononly, and randomized controlled trials for thisdisease are lacking [3, 11]. Larger sample sizesand controlled studies are needed to properlyassess the safety and efficacy of treatments for


genital psoriasis to better understand the opti-mal management approach for these patients.

CONCLUSIONS

Recently, a growing number of studies haveevaluated the efficacy of various treatmentsspecifically for genital psoriasis, including onerandomized clinical trial for a biologic agent [3].A variety of topical therapies have shown vary-ing success for treatment of genital psoriasis,while far fewer systemic and biologic therapieshave been evaluated for genital psoriasis. Fur-ther inquiry into the optimal treatment regi-men for genital psoriasis is necessary.

ACKNOWLEDGEMENTS

Funding. No funding or sponsorship wasreceived for this study or publication of thisarticle. Wilson Liao is funded in part by grantsfrom the National Institutes of Health(R01AR065174, U01AI119125).

Authorship. All named authors meet theInternational Committee of Medical JournalEditors (ICMJE) criteria for authorship for thisarticle, take responsibility for the integrity ofthe work as a whole, and have given theirapproval for this version to be published.

Disclosures. Kristen M Beck, Eric J Yang,Isabelle M Sanchez, and Wilson Liao havenothing to disclose.

Compliance with Ethics Guidelines. Thearticle is based on previously conducted studiesand does not contain any studies with humanparticipants or animals performed by any of theauthors.

Open Access. This article is distributedunder the terms of the Creative CommonsAttribution-NonCommercial 4.0 InternationalLicense (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommer-cial use, distribution, and reproduction in any

medium, provided you give appropriate creditto the original author(s) and the source, providea link to the Creative Commons license, andindicate if changes were made.

REFERENCES

1. Meeuwis KAP, Potts Bleakman A, van de KerkhofPCM, Dutronc Y, Henneges C, Kornberg LJ, MenterA. Prevalence of genital psoriasis in patients withpsoriasis. J Dermatol Treat. 2018:1–7.

2. Wang G, Li C, Gao T, Liu Y. Clinical analysis of 48cases of inverse psoriasis: a hospital-based study.Eur J Dermatol. 2005;15:176–8.

3. Meeuwis KA, de Hullu JA, Massuger LF, van deKerkhof PC, van Rossum MM. Genital psoriasis: asystematic literature review on this hidden skindisease. Acta Derm Venereol. 2011;91:5–11.

4. Ryan C, Sadlier M, De Vol E, Patel M, Lloyd AA, DayA, Lally A, Kirby B, Menter A. Genital psoriasis isassociated with significant impairment in quality oflife and sexual functioning. J Am Acad Dermatol.2015;72:978–83.

5. Morris A, Rogers M, Fischer G, Williams K. Child-hood psoriasis: a clinical review of 1262 cases.Pediatr Dermatol. 2001;18:188–98.

6. Afsar FS, Uysal SS, Salis FM, Calli AO. Napkin pso-riasis. Pediatr Int. 2016;58:420–2.

7. Meeuwis KA, de Hullu JA, van de Nieuwenhof HP,Evers AW, Massuger LF, van de Kerkhof PC, vanRossum MM. Quality of life and sexual health inpatients with genital psoriasis. Br J Dermatol.2011;164:1247–55.

8. Zamirska A, Reich A, Berny-Moreno J, Salomon J,Szepietowski JC. Vulvar pruritus and burning sen-sation in women with psoriasis. Acta Derm Vener-eol. 2008;88:132–5.

9. Cather JC, Ryan C, Meeuwis K, Potts Bleakman AJ,Naegeli AN, Edson-Heredia E, Poon JL, Jones C,Wallace AN, Guenther L, Fretzin S. Patients’ per-spectives on the impact of genital psoriasis: aqualitative study. Dermatol Ther (Heidelb).2017;7:447–61.

10. Meeuwis KA, van de Kerkhof PC, Massuger LF, deHullu JA, van Rossum MM. Patients’ experience ofpsoriasis in the genital area. Dermatology.2012;224:271–6.


http://creativecommons.org/licenses/by-nc/4.0/

http://creativecommons.org/licenses/by-nc/4.0/

11. Menter A, Korman NJ, Elmets CA, Feldman SR,Gelfand JM, Gordon KB, Gottlieb A, Koo JY, Leb-wohl M, Leonardi CL, Lim HW, Van Voorhees AS,Beutner KR, Ryan C, Bhushan R. Guidelines of carefor the management of psoriasis and psoriaticarthritis: section 6. Guidelines of care for the treat-ment of psoriasis and psoriatic arthritis: case-basedpresentations and evidence-based conclusions.J Am Acad Dermatol. 2011;65:137–74.

12. Farage M, Maibach HI. The vulvar epithelium dif-fers from the skin: implications for cutaneous test-ing to address topical vulvar exposures. ContactDermatitis. 2004;51:201–9.

13. Howick J, Chalmers I, Glasziou P, Greenhalgh T,Heneghan C, Liberati A, Moschetti I, Phillips B,Thornton H. The 2011 Oxford CEBM levels of evi-dence (introductory document). Oxford Centre forEvidence-Based Medicine. 2011.

14. Albert S, Neill S, Derrick EK, Calonje E. Psoriasisassociated with vulval scarring. Clin Exp Dermatol.2004;29:354–6.

15. Jemec GB, Baadsgaard O. Effect of cyclosporine ongenital psoriasis and lichen planus. J Am AcadDermatol. 1993;29:1048–9.

16. Fischer G. Chronic vulvitis in pre-pubertal girls.Aust J Dermatol. 2010;51:118–23.

17. Meeuwis KA, de Hullu JA, IntHout J, Hendriks IM,Sparreboom EE, Massuger LF, van de Kerkhof PC,van Rossum MM. Genital psoriasis awareness pro-gram: physical and psychological care for patientswith genital psoriasis. Acta Derm Venereol.2015;95:211–6.

18. Kapila S, Bradford J, Fischer G. Vulvar psoriasis inadults and children: a clinical audit of 194 cases andreview of the literature. J Lower Genit Tract Dis.2012;16:364–71.

19. Liao YH, Chiu HC, Tseng YS, Tsai TF. Comparisonof cutaneous tolerance and efficacy of calcitriol 3microg g(-1) ointment and tacrolimus 0.3 mg g(-1)ointment in chronic plaque psoriasis involvingfacial or genitofemoral areas: a double-blind, ran-domized controlled trial. Br J Dermatol.2007;157:1005–12.

20. TALTZ (ixekizumab) [package insert]. Indianapolis:Eli Lilly and Company. 2017.

21. Ryan C, Menter A, Guenther L, Blauvelt A, Bisson-nette R, Yang F, Potts Bleakman A. Efficacy andsafety of ixekizumab in a randomized, double-blinded, placebo-controlled, phase 3b clinical trialin patients with moderate-to-severe genital psoria-sis. J Sexual Med. 2018;15:S6–7.

22. Singh N, Thappa DM. Circinate pustular psoriasislocalized to glans penis mimicking ‘circinate bal-anitis’ and responsive to dapsone. Indian J Derma-tol Venereol Leprol. 2008;74:388–9.

23. Guglielmetti A, Conlledo R, Bedoya J, Ianiszewski F,Correa J. Inverse psoriasis involving genital skinfolds: successful therapy with dapsone. DermatolTher (Heidelb). 2012;2:15.

24. Jese R, Perdan-Pirkmajer K, Dolenc-Voljc M, TomsicM. A case of inverse psoriasis successfully treatedwith adalimumab. Acta Dermatovenerol Alp Pan-nonica Adriat. 2014;23:21–3.

25. Shimamoto Y, Shimamoto H. Annular pustularpsoriasis associated with affective psychosis. Cutis.1990;45:439–42.

26. Cassano N, Mastrandrea V, Buquicchio R, Mira-capillo A, Loconsole F, Filotico R, Vena GA. Efal-izumab in moderate-to-severe plaque psoriasis: aretrospective case series analysis from clinicalpractice. J Biol Regul Homeost Agents.2008;22:185–93.

27. Talamonti M, Teoli M, Botti E, Spallone G, Chi-menti S, Costanzo A. Patients with moderate tosevere plaque psoriasis: one year after the EuropeanMedicines Agency recommendation of efalizumabsuspension. Dermatology. 2011;222:250–5.

28. Andersen SL, Thomsen K. Psoriasiform napkin der-matitis. Br J Dermatol. 1971;84:316–9.

29. Amichai B. Psoriasis of the glans penis in a childsuccessfully treated with Elidel (pimecrolimus)cream. J Eur Acad Dermatol Venereol.2004;18:742–3.

30. Menter A, Korman NJ, Elmets CA, Feldman SR,Gelfand JM, Gordon KB, Gottlieb AB, Koo JY, Leb-wohl M, Lim HW, Van Voorhees AS, Beutner KR,Bhushan R. Guidelines of care for the managementof psoriasis and psoriatic arthritis: section 4.Guidelines of care for the management and treat-ment of psoriasis with traditional systemic agents.J Am Acad Dermatol. 2009;61:451–85.

31. Kivelevitch D, Frieder J, Watson I, Paek SY, MenterMA. Pharmacotherapeutic approaches for treatingpsoriasis in difficult-to-treat areas. Expert OpinPharmacother. 2018;19:561–75.

32. Czuczwar P, Stepniak A, Goren A, Wrona W, Pasz-kowski T, Pawlaczyk M, Piekarska-Myslinska D,Wozniak S, Pietrzak A. Genital psoriasis: a hiddenmultidisciplinary problem—a review of literature.Ginekol Pol. 2016;87:717–21.

33. Bissonnette R, Nigen S, Bolduc C. Efficacy and tol-erability of topical tacrolimus ointment for the


treatment of male genital psoriasis. J Cutan MedSurg. 2008;12:230–4.

34. Broeders JA, Ahmed Ali U, Fischer G. Systematicreview and meta-analysis of randomized clinicaltrials (RCTs) comparing topical calcineurin inhibi-tors with topical corticosteroids for atopic der-matitis: a 15-year experience. J Am Acad Dermatol.2016;75:410–419 (e413).

35. Fergusson AG, Fraser NG, Grant PW. Napkin der-matitis with psoriasiform ‘‘ide’’. A review of fifty-two cases. Br J Dermatol. 1966;78:289–96.

36. Baggio R, Le Treut C, Darrieux L, Vareliette A, SafaG. Psoriasiform diaper rash possibly induced by oralpropranolol in an 18-month-old girl with infantilehemangioma. Case Rep Dermatol. 2016;8:369–73.

37. Greco M, Chamlin SL. An 18-month-old girl withchronic diaper dermatitis. Psoriasis presenting inthe diaper area. Pediatr Ann. 2006;35(79):82–3.

38. Watanabe M, Tabata N, Tagami H. Explosive diaperpustular psoriasis. Pediatr Dermatol. United States.2002;19:564–5.

39. Foureur N, Vanzo B, Meaume S, Senet P. Prospectiveaetiological study of diaper dermatitis in theelderly. Br J Dermatol. 2006;155:941–6.

40. Yao XJ, Zhang TD. Psoriasis localized to the glanspenis in a 37-year-old man. CMAJ. 2018;190:E747.

41. Usatine RP. Itchy rash in groin. J Fam Pract.2016;65(11).

42. Kamer B, Pyziak K, Krawczyk T, Socha-Banasiak A,Rotsztejn H. A rare case of psoriasis resemblingdiaper dermatitis. Przeglad Pediatryczny.2012;42:160–1.

43. Quan MB, Ruben BS. Pustular psoriasis limited tothe penis. Int J Dermatol. 1996;35:202–4.

44. Weinrauch L, Katz M. Psoriasis vulgaris of labiummajus. Cutis. 1986;38:333–4.

45. Hernandez M, Simms-Cendan J, Zendell K. Guttatepsoriasis following streptococcal vulvovaginitis in afive-year-old girl. J Pediatr Adolesc Gynecol.2015;28:e127–9.

46. Martin Ezquerra G, Sanchez Regana M, HerreraAcosta E, Umbert Millet P. Topical tacrolimus forthe treatment of psoriasis on the face, genitalia,intertriginous areas and corporal plaques. J DrugsDermatol. 2006;5:334–6.

47. Rallis E, Nasiopoulou A, Kouskoukis C, Roussaki-Schulze A, Koumantaki E, Karpouzis A, Arvanitis A.Successful treatment of genital and facial psoriasiswith tacrolimus ointment 0.1%. Drugs Exp ClinRes. 2005;31:141–5.

48. Zampetti A, Gnarra M, Linder D, Digiuseppe MD,Carrino N, Feliciani C. Psoriatic pseudobalanitiscircinata as a post-viral koebner phenomenon. CaseRep Dermatol. 2010;2:183–8.

49. Rattet JP, Headley JL, Barr RJ. Diaper dermatitis withpsoriasiform ID eruption. Int J Dermatol.1981;20:122–5.

50. Ryan C, Menter A, Guenther L, Blauvelt A, Bisson-nette R, Meeuwis K, Sullivan J, Cather JC, Yosipo-vitch G, Gottlieb AB, Merola JF, Callis Duffin K,Fretzin S, Osuntokun OO, Burge R, Naegeli AN,Yang FE, Lin CY, Todd K, Potts Bleakman A. Efficacyand safety of ixekizumab in a randomized, double-blinded, placebo-controlled phase 3b study ofpatients with moderate-to-severe genital psoriasis.Br J Dermatol. 2018.

51. Sezer E, Lehman JS, Yalcın O, Tufek I, Keskin S,Durmaz EO, Sahin S. Oyster-shaped hyperkeratoticplaques on the penis. Dermatol Pract Concept.2015;5(4):37–8. https://doi.org/10.5826/dpc.0504a09.


http://dx.doi.org/10.5826/dpc.0504a09

Treatment of Genital Psoriasis: A Systematic Review · systemic and topical medications may improve genital psoriasis lesions, but there is a lack of high-quality evidence to guide

Documents