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E-IJD® - ORIGINAL ARTICLE
Year : 2022  |  Volume : 67  |  Issue : 2  |  Page : 205
Genital psoriasis: A prospective, observational, single-centre study on prevalence, clinical features, risk factors, and its impact on quality of life and sexual health


From the Department of Dermatology, Hospital Pulau Pinang, Penang, Malaysia

Date of Web Publication13-Jul-2022

Correspondence Address:
Ooi Shin Yi
Department of Dermatology, Hospital Pulau Pinang, Jalan Residensi, 10990 Georgetown, Pulau Pinang
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_754_21

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   Abstract 


Background: Genital psoriasis is often under-recognized and the exact burden is unknown in Malaysia. Objectives: To identify the prevalence of genital psoriasis, its clinical features, risk factors, and impact on quality of life and sexual health. Methods: This prospective, observational study was conducted in the dermatology clinic of our hospital from 1st September 2020 until 31st March 2021, involving all adult patients with psoriasis. The genital examination was performed and the subjects were interviewed using questionnaires. Results: A total of 262 patients were recruited, with a male to female ratio of 1.5:1 (mean age of 51 years old). They comprised 42.0% Chinese, followed by 36.6% of Malay, 21.4% of Indians and others. Up to 46.1% of patients had a current or history of genital psoriasis. The most common area involved for males was the scrotum (44.1%) and labia majora (62.5%) for female patients. Itching (79.2%) was the most frequent symptom encountered. Chinese patients had 2.67 times odd (CI 1.55-4.61) of having genital psoriasis compared to non-Chinese patients. Other independent risk factors included flexural involvement, male gender, and Type 1 psoriasis. Genital psoriasis was associated with greater impairment on quality of life and sexual health (mean total Dermatology Life Quality Index: 8.8 vs 6.5, P = 0.006), International Index of Erectile Function (mean: 48.5 vs 57.0, P = 0.011) and revised version of Female Sexual Distress Scales (mean: 20.7 vs 11.4, P = 0.022). Conclusions: Genital psoriasis is common and it has a profound impact on patients.


Keywords: Dermatology life quality index, female sexual function index, genital psoriasis, international index of erectile function, quality of life, sexual dysfunction


How to cite this article:
Yi OS, Huan KY, Har LC, Ali NM, Chiang TW. Genital psoriasis: A prospective, observational, single-centre study on prevalence, clinical features, risk factors, and its impact on quality of life and sexual health. Indian J Dermatol 2022;67:205

How to cite this URL:
Yi OS, Huan KY, Har LC, Ali NM, Chiang TW. Genital psoriasis: A prospective, observational, single-centre study on prevalence, clinical features, risk factors, and its impact on quality of life and sexual health. Indian J Dermatol [serial online] 2022 [cited 2022 Aug 9];67:205. Available from: https://www.e-ijd.org/text.asp?2022/67/2/205/350844





   Background Top


Psoriasis is a chronic, immune-mediated inflammatory skin disease that is often associated with systemic manifestations. It causes a significant physical and psychosocial impact on the patient. The reported prevalence of psoriasis in various countries ranged between 0.09% and 11.4%.[1],[2] A total of 21,735 patients were registered with the Malaysia psoriasis registry from the year 2007 to 2018.[3] In adult patients, the mean age of onset in Malaysia was 35 years old and most of them were in their reproductive age.

Meeuwis et al.[4] reported that the prevalence of genital psoriasis during the course of the disease was up to 63% whereas the detection rate of genital psoriasis during a physical examination by a physician was between 7% and 42%. Despite its high prevalence and burden, genital psoriasis is often underdiagnosed, presumably due to the reluctance from both healthcare providers and patients to discuss these sensitive issues, leading to inadequate evaluation and treatment.

Genital psoriasis is often characterised by well-demarcated, erythematous thin plaques, with variable degrees of the scale.This may lead to intense itch, burning sensation, dyspareunia, and worsening of symptoms after sexual intercourse.[5] Hence, genital psoriasis has a huge negative impact on quality of life, psychosexual wellbeing and sexual health.[6]

Being a multiethnic country, sexual issues are still taboo due to cultural and religious beliefs. The exact burden of genital psoriasis remains unknown in Malaysia. The objectives of our study are to explore the prevalence, clinical features, risk factors, and the impact of genital psoriasis on quality of life and sexual health.


   Methods Top


Study population

This prospective cross-sectional, observational study was conducted in the dermatology clinic of our hospital from 1st September 2020 to 31st March 2021 for 6 months duration. All adult psoriasis patients aged 18 years and above who consented to the study were evaluated on the presence of genital psoriasis. The diagnosis of genital psoriasis is based on clinical examination.

Demographic and clinical characteristics of the subjects were collected. All patients were actively screened for genital psoriasis. A comprehensive history and physical examination were performed on patients in a dedicated room for their privacy. Patients who express a preference for a gender-matched interviewer were met whenever possible and one-to-one interviews were conducted.

The genital area is defined as the glans penis, foreskin, penile shaft, scrotum and perineum for males; labia majora, labia minora, and perineum for females. Involvement of perigenital area (pubis, buttock, perianal region, gluteal cleft and inguinal fold) and flexural area (retroauricular area, axilla, umbilicus, antecubital and popliteal fossae) were recorded separately. We also recorded patients' sexual activity status whereby sexually active is defined as at least 1 sexual activity in the past 4 weeks. Sexual activity is not limited to only sexual intercourse but also included oral sex and masturbation. Patients with known gynaecological, urological, psychiatric disorders and sexually-transmitted diseases or other medical illnesses that could interfere with sexual function were excluded for further analysis of sexual health.

Assessment tools for quality of life

Dermatology Life Quality Index (DLQI) was used as a measurement of quality of life. It was first described by Finlay et al. in 1994.[7] The DLQI comprises 10 questions. The score ranges from 0-30. Higher scores of DLQI indicate a worse quality of life.

Assessment tools for sexual health

Question 9 in the DLQI 'Over the last week, how much has your skin caused any sexual difficulties' was used as one of the assessment tools for sexual health. Sexual Quality of Life Questionnaire for Use in Men (SQoL-M),[8] International Index of Erectile Function (IIEF),[9] revised versions of Female Sexual Distress Scales (FSDS-R),[10] and Female Sexual Function Index (FSFI),[11] were used for more in-depth self-reported sexual health questionnaires.

Sexual quality of life questionnaire for use in Men (SQoL-M)

The SQoL-M is a self-administered instrument that assesses the sexual quality of life in men with premature ejaculation or erectile dysfunction.[8] The instrument contains 11 items, each with a response scale ranging between 'completely agree' (1 point) and 'completely disagree' (6 points). The total score ranges from 11 to 66. A greater SQoL-M score indicates a better sexual quality of life.

International index of erectile function (IIEF)

The IIEF is a multidimensional, 15-item questionnaire for the assessment of relevant domains of male sexual function.[9] The five domains are each set up by a different cluster of items and summing the scores for individual items computes domain scores. The total score ranges between 5 and 75; higher scores indicate better sexual function.

Female sexual distress scale-revised (FSDS-R)

The FSDS-R is identical to the Female Sexual Distress Scale (FSDS) except for the addition of one question that asks women to rate their level of distress related to low sexual desire.[10],[12] FSDS-R demonstrates sensitivity and specificity that are equivalent to FSDS, with higher scores indicating a higher level of sexual distress. A cutoff score of >11 is found to be effective in discriminating between women with and without sexual distress.

Female sexual function index (FSFI)

The FSFI measures key dimensions of female sexual function. The questionnaire is composed of 19 items, with six individual domains. Calculations are performed as previously described by Rosen et al.[11] The full-scale score ranges between 4 and 95. Higher scores of the FSFI indicate better sexual function.

Statistical analysis

According to a recent local study assessing female sexual dysfunction in women with psoriasis, the incidence of genital psoriasis was as high as 23%.[13] By using single proportion calculation, the estimated sample size needed was at least 253 after adjusting for a 10% dropout rate. Descriptive statistics was employed for all variables in the study. The normally distributed continuous variables are summarized in mean and standard deviation (SD) while the non-normally distributed are expressed as the median and interquartile range (IQR). For categorical variables, frequencies and percentages (%) were tabulated. Pearson Chi-square test and Fisher's exact test were used to analyse that categorical data where applicable. Unadjusted comparisons were performed using the t-test or the Mann–Whitney U-test to determine that quantitative data where appropriate. Binominal logistic regression was used to identify the risk factors of getting genital psoriasis. Statistical significance defined as P < 0.05. Data were tabulated and analysed using IBM® Statistical Package for the Social Sciences (SPSS) Statistics for Windows, Version 24.

Ethical approval

This study was approved by the Malaysian Medical Research and Ethics Committee (MREC) number NMRR-20-802-53706.


   Results Top


Demographic characteristics of the study population [Table 1]
Table 1: Demographic and clinical characteristics of the studied population

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A total of 266 patients who attended the clinic within the duration of the study were screened. Out of this, 4 patients refused participation due to embarrassment while 262 patients were included in the study.

The mean age was 51 years old (range 19-82); with a male-to-female ratio of 1.5:1. The majority of the patients were Chinese (42.0%), followed by Malay (36.6%), Indian and others (21.4%). Most of the patients were either married or in a relationship (80.9%). Approximately two-thirds had an educational level up to secondary school. In regards to disease severity, almost 40% of them had body surface area (BSA) involvement of more than 10% and 19.8% of them had Psoriasis Area and Severity Index (PASI) of more than 10.

Prevalence and clinical features of genital involvement

[Table 2] showed the prevalence of genital psoriasis in our patients. A total of 46.1% (n = 121) of psoriasis patients had genital involvement. Up to 36.6% of them (n = 96) had current genital involvement whereas an additional 9.5% of patients (n = 25) had previous history of genital psoriasis. Only 31.0% of patients with genital involvement had a previous genital examination. The mean onset of genital involvement was 42 years old, which is 6 years after their onset of psoriasis. (mean onset of psoriasis 36.1 years old).
Table 2: Prevalence of genital psoriasis (n=262)

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The distributions of the genital lesion were scrotum (44.1%), followed by penile shaft (23.5%) and perineum (22.1%) for males; labia majora (62.5%), followed by perineum (20%) and labia minora (17.5%) in female patients. [Figure 1], [Figure 2], [Figure 3] Among patients with genital psoriasis, 86.0% of them had perigenital involvement and 65.3% of them had flexural involvement.
Figure 1: Distribution of topography of genital lesions among patients with genital psoriasis

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Figure 2: Severe genital psoriasis with perigenital involvement in an Indian patient. (Fitzpatrick skin type V)

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Figure 3: Typical appearance of genital psoriasis in a Chinese patient. (Fitzpatrick skin type III)

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Overall, itching (79.2%) was the most frequent symptom experienced by patients followed by redness (46.9%), scaliness (45.8%), discomfort (44.8%), cracking (22.9%), stinging (12.5%), burning (11.5%) and pain (9.4%).

Eighty-one per cent of male patients reported itchiness and this was followed by redness (45.7%), scaliness (44.3%), discomfort (38.6%), cracking (15.7%), stinging (8.6%), burning (7.1%) and pain (2.9%). Seventy-three per cent of female patients reported itchiness, followed by discomfort (61.5%), redness (50.0%), scaliness (50.0%), cracking (42.3%), pain (26.9%), stinging (23.1%) and burning (23.1%). Female patients experienced differently from male patients as they reported a significantly higher frequency of discomfort (P = 0.044), pain (P < 0.001), burning sensation (P = 0.029), cracking (P = 0.006) compared to male patients.

Risk factors of genital psoriasis

The risk factors associated with genital psoriasis in the univariate analyses were summarized in [Table 3]. Significant risk factors identified were male gender, Chinese ethnicity, type 1 psoriasis, severe psoriasis, longer disease duration, face involvement, presence of nail involvement, presence of flexural psoriasis and perigenital psoriasis involvement. However, age group, comorbidity, obesity, smoking status, scalp involvement, psoriatic arthropathy, sexually active status, and systemic therapy were not associated with genital psoriasis.
Table 3: Risk factors associated with genital psoriasis in univariate analysis

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[Table 4] summarized data analysis on multiple logistic regression. Chinese patients had 2.67 times odd (CI 1.55-4.61) of having genital psoriasis compared to non-Chinese patients. Other independent risk factors were flexural involvement (Adjusted OR 2.52, CI 1.48-4.29), male gender (Adjusted OR 2.05, CI 1.18-3.54), and the onset of psoriasis below 40 years old. (Adjusted OR 1.84, CI 1.06-3.19).
Table 4: Risk factors associated with the development of genital psoriasis (Multiple logistic regression, enter method)

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Impact of quality of life and sexual health

Patients with genital psoriasis had a significantly worse quality of life compared to their counterparts without genital involvement (mean DLQI score of 8.8 vs 6.5, P = 0.006). They also reported impaired sexual functioning based on question 9 in DLQI (Question 9 mean score of 0.8 vs 0.5, P = 0.046).

Among 148 sexually active patients, 10 of them refused to participate in the sexual questionnaires survey due to embarrassment. A total of 138 responses were recorded and analyzed. Men with genital psoriasis had worse sexual function with a significantly lower score for IIEF (48.5 vs 57.0, P = 0.011) and lower but not statistically significant score for SQOL-M (51.4 vs 52.6, P = 0.75). Women with genital psoriasis showed more sexual distress compared to women without as measured by FSDS-R (mean 20.7 vs 11.4, P = 0.022). There was also a lower but not statistically significant score for FSFI (mean 53.5 vs 63.6, P = 0.165). [Table 5].
Table 5: DLQI and sexual function questionnaires scoring for sexually active patients

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   Discussion Top


There is a paucity of studies that focus on genital psoriasis especially in Asian countries. Genital lesions and sexual issues remain taboo due to cultural and religious sensitivities. Most data on genital psoriasis were either questionnaire-based or only involved a single-gender.[14],[15] This reflects a hurdle to discussing genital lesions.

The prevalence of genital psoriasis was high. Nearly half of the psoriasis patients (46.1%) in our study had a history or current genital psoriasis. This is consistent with most of the other international reports.[4] To the best of our knowledge, there was only one comparable Asian study on genital psoriasis that included both genders which was done in India.[16] They reported 11.7% of patients with psoriasis had genital lesions during physical examination. Our study shared a few similarities. Both studies had more male and overweight patients and reported a mean onset of genital psoriasis 6 years after the initial diagnosis of psoriasis. The scrotum was the commonest genital site involvement. However, the prevalence of genital psoriasis was much higher in our study and this discrepancy may be due to the different demographic backgrounds in Malaysia. Our study cohort was older, had a longer disease duration, and had more heterogeneities in ethnic distribution.

Our study was unique compared to the previous report on genital psoriasis as our patients come from different ethnicities. As a country composed of a multi-ethnic population, there were 42.0% Chinese, followed by 36.6% Malay, and 21.4% Indian and other ethnicities in our study. Interestingly, being Chinese was an independent risk factor for developing genital psoriasis. Among all patients with genital psoriasis, more than half of them were Chinese patients (56.4%) despite they only comprised 42% of the studied population. Chinese patients had 2.67 times the odds of having genital psoriasis compared to non-Chinese patients. However, this finding was not observed in other studies involving the same ethnicity. In China, a nationwide survey of psoriasis patients reported 38% of patients had genital involvement.[17] Type 1 psoriatic patients were another independent risk factor for developing genital psoriasis. Many previous studies had shown that type 1 psoriasis was associated with family history and genetic predisposition.[18],[19],[20],[21] Therefore, genetic predisposition could be the contributing factor to explain the high tendency for genital psoriasis in both Chinese and type 1 psoriatic patient.

Male gender, increased disease severity as measured by higher BSA and PASI, longer duration of disease, face, nail, and flexural involvement were risk factors associated with genital psoriasis. These results were similar to previous studies.[22],[23] An interesting finding from our study was the association of perigenital involvement with the genital lesion. This could be helpful for dermatologists as the examination of the perigenital area will serve as a clue when patients are reluctant or too embarrassed to volunteer their genital lesion history. The clinicians should be more vigilant and adopt a more proactive measure when dealing with patients with early disease onset and with flexural involvement, as these groups of patients had a higher risk of developing the genital disease.

The genital lesion was more common in hair-bearing genital skin.[22] In our study, the commonest genital area involved in males was the scrotum, while in females it was the labia majora. Circumcision was not associated with the development of genital psoriasis contrary to another study.[23] A high proportion (31%) of our male patients had undergone circumcision and this may explain the finding. In regards to symptoms reported by patients, itchiness was the most symptom reported in men (81.4%) and women (73.1%). Identifying erythema in the skin of colour is always challenging. Redness was a common complaint among patients with genital psoriasis despite approximately half of our patients (45.5%) with genital psoriasis consisting of patients with Fitzpatrick skin type IV to V. Up to 46.9% of patients suffered from redness and this proportion was even higher in Chinese patients (60.0%).

All aspects of patients' lives can be affected by psoriasis, regardless of the involvement of visible areas or hidden areas like genital skin.[24],[25],[26],[27],[28],[29],[30] Schmid et al.[31] demonstrated that patients with sensitive regions (lower abdomen and genital region) affected by psoriasis felt significantly more stigmatised than those with visible regions affected. Patients with genital psoriasis were also found to have significantly worse quality of life and sexual function compared to their counterparts without genital involvement.[23] Our study had confirmed the impact of genital lesions on quality of life.

As a stigmatising disease that often leads to anxiety and depression, psoriatic patients may avoid physical contact and refrain from starting a relationship. However, data on sexual health in psoriasis patients are heterogeneous because various assessment tools had been used. A systematic review on sexual dysfunction in psoriasis patients concluded that psoriasis patients have a higher risk of sexual dysfunction as compared to the general population.[25]

In our study, men with genital psoriasis showed no significant different scores on SQoL-M but had a significantly worse sexual function as measured by IIEF. Interestingly, women with genital psoriasis showed significantly more sexual distress instead of sexual function as measured by FSDS-R compared to their counterparts without genital involvement. The FSFI cut off score of ≤55 showed that 27.3% of our female psoriatic patients had sexual dysfunction despite no statistically significant differences between the means scores on the FSFI questionnaire in both groups. This was higher than our other local data WHERE 20.3% of female psoriatic patients were observed to have female sexual dysfunction by using the FSFI questionnaire.[13] Up to 9.5% of patients with psoriasis had sexual difficulty as defined by scores 2 or 3 in DLQI question 9 in another study.[32] The proportion was even higher in our cohort (12.8%). The discrepancies could be explained by the utilisation of more specific questionnaires directed towards sexual health in our study.

Patients with genital psoriasis were often reluctant to discuss genital lesions. They face many barriers including poor awareness of genital dermatoses and misdiagnosis.[33],[34],[35] Psoriasis is well known for its association with systemic inflammation and co-morbidities.[36],[37] However, the awareness of genital psoriasis was still poor among dermatologists. Only 31% of patients with genital psoriasis in our study had underwent a genital examination before this. Genital involvement and sexual health are an integral part of holistic care for psoriatic patients as genital involvement may warrant systemic therapy.[38]

There were several limitations in our study. As a single-centre study, our finding may not reflect the Malaysian population and our sample size was relatively small. Being a cross-sectional study, we cannot determine the causal relationship of genital psoriasis and its risk factors. Recall bias may present for those patients who had refused physical examination. Nonetheless, we believe our study had added more information and value to this sensitive yet special area.

In conclusion, our study highlighted a high prevalence of genital psoriasis and its impact on quality of life and sexual health. Genital psoriasis involvement is an integral part of psoriatic patients' assessment. Dermatologists should be aware of risk factors and the clinical associations of genital psoriasis as neglecting this small but vital area may lead to a big impact on patients' life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

We would like to thank the Director General of Health, Malaysia for the permission to publish this report. We would also like to thank all the doctors, Dermatological Society of Malaysia, respective organization for use of copyright of questionnaires and Clinical Research Centre (CRC) Ministry of Health, Malaysia.

Financial support and sponsorship

Research Grant from Dermatological Society of Malaysia.

Conflicts of interest

There are no conflicts of interest.



 
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Strober B, Ryan C, van de Kerkhof P, van der Walt J, Kimball AB, Barker J, et al. Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. J Am Acad Dermatol 2020;82:117-22.  Back to cited text no. 38
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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