ABSTRACT
Background/Objectives
To explore the clinical presentation, management and impact on quality of life in women with vulval psoriasis.
Methods
A retrospective, single‐centre cohort study of women was conducted at a large dermatology practice from January 2016 to January 2024. Sequential Vulval Quality of Life Index scores and patient data were systematically collected and recorded in an online patient database. Treatment regimens were individualised and titrated to clinical response.
Results
The study included a total of 350 patients with vulval psoriasis over an eight‐year period. 13.1% of patients required systemic treatment solely for vulval disease. The median VQLI score improved from 18.0 ± 9.4 at baseline to 9.7 ± 7.6 at the end of follow‐up (p < 0.0001). All domains showed statistically significant improvements except for ‘Sexual Function’. The domains with the greatest improvement were ‘Future Health Concerns’ (69.2%, p < 0.001), ‘Feelings and Emotions’ (63.4%, p < 0.001) ‘Symptoms’ (58.6%, p < 0.001) and ‘Activities of Daily Living’ (56.8%, p < 0.001).
Conclusions and Relevance
Vulval psoriasis has a substantial impact on quality of life but remains underdiagnosed and undertreated. While treatment can significantly improve outcomes, issues related to sexual function and relationships often persist. Systemic therapy may be required for a subset of patients with vulval‐only disease. Routine assessment and targeted management of vulval involvement are crucial to optimising patient well‐being.
Keywords: genital psoriasis, psoriasis, quality of life, vulval, vulval psoriasis
1. Introduction
Psoriasis is a common chronic inflammatory condition that affects up to 2% of the global population [1]. Genital involvement is reported in 46%–63% of cases [2], with 2%–5% of individuals experiencing psoriatic disease confined exclusively to the genital area [3]. Diagnosing genital psoriasis can be challenging due to the absence of classic features like scaling and plaques and the lack of established treatment guidelines for genital skin.
Patients with genital psoriasis experience significantly diminished quality of life compared to those with psoriasis in other regions. This is attributed to severe pruritus, sexual dysfunction, emotional distress, avoidance of intimate relationships and feelings of shame [4, 5]. Existing severity scoring systems, which are based on affected body surface area, often fail to capture the profound psychosocial and sexual impairment commonly among these individuals.
Although recent years have seen an increase in literature on genital psoriasis, discussions on gender‐specific challenges remain limited. Women with vulval psoriasis have been shown to experience more pronounced sexual impairment [4] and heightened feelings of stigmatisation due to their disease [6, 7]. Additionally, the practical challenges of applying topical treatments to the vulval area often lead to the need for systemic therapy for optimal disease control. Given the scarcity of literature on vulval psoriasis, this study aims to elucidate its clinical characteristics, management strategies and their challenges, and how treatment may improve its impact on quality of life.
2. Methods
This study was a retrospective chart review conducted at a large dermatology practice. All patients provided informed consent, and the study received approval from the [Anonymised]. Patient examinations were conducted by two dermatologists, who documented findings in the electronic medical record. Data extraction was performed by an independent clinician. Treatment escalation was determined based on a combination of clinical examination findings and Vulval Quality of Life Index (VQLI) scores.
2.1. Study Population and Inclusion Criteria
The patient database was searched for cases of ‘vulval psoriasis’ between January 2016 and January 2024 to identify patients with a clinical diagnosis of vulval psoriasis. Eligible participants were women over 18 years of age at diagnosis who had clinical photographs and/or documented clinical signs.
Data from medical records and clinical photographs were reviewed, including age of onset, reported symptoms, age at diagnosis, features visible in clinical photographs and their anatomical locations, histopathology or microbiology results, and treatments initiated, their response and adverse effects.
2.2. Vulval Quality of Life Index (VLQI)
The VQLI is a validated tool designed to assess the severity of vulval disease and monitor response to treatment in clinical settings [8] (supporting information 1). It encompasses seven domains: Symptoms (Questions 1–2), Feelings and Emotions (Questions 3–5), Activities of Daily Living (Questions 6–10), Relationships (Question 11), Sexual Function (Questions 12–13), Future Health Concerns (Question 14) and Treatment (Question 15). Patients rate each item on a 4‐point Likert scale from 0 (‘Not at all’) to 3 (‘Very much’). Total scores range from 0 to 45, with higher scores indicating greater disability. Patients complete the VQLI at each visit.
2.3. Statistical Analysis
Data were recorded in an Excel spreadsheet (Microsoft Office, 2016) and results are presented as sums or means ± standard deviation. Statistical analysis was conducted using GraphPad Prism, applying Student's t‐test or one‐way ANOVA as appropriate, with a significance level of p < 0.05.
3. Results
3.1. Patient Demographics
Table 1 summarises patient demographics. A total of 350 women aged 18 and older were included, with a mean age of onset at 39.8 ± 18.0 years and a mean age of presentation at 50.1 ± 17.1 years. The median follow‐up time was 93.8 weeks. Evidence of extragenital psoriasis was found in 72.0% of patients; however, only 20.3% of these patients had a prior diagnosis of psoriasis. Thirty percent of women reported a first‐degree family member with psoriasis. Positive microbiological swabs were found in 34.5% of women, with common pathogens including Candida species (57.3%), Gardnerella vaginalis (25.6%) and Staphylococcus aureus (17.1%).
TABLE 1.
Demographics of 350 cases of vulval psoriasis referred to a single dermatology referral practice.
| Demographics | Number (Mean ± SD) |
|---|---|
| Age of onset (years) | 39.83 ± 18.04 |
| Age of presentation (years) | 50.11 ± 17.12 |
| Duration of symptoms prior to diagnosis (years) | 10.64 ± 10.22 |
| Positive family history | 59/197 (29.95%) |
| Secondary infection | 82/238 (34.45%) |
| Staphylococcal aureus | 14 (17.07%) |
| Gardnerella vaginalis | 21 (25.61%) |
| Candida species | 47 (57.32%) |
| Streptococcus pyogenes | 2 (2.44%) |
| Psoriasis present at distant sites | 242/336 (72.02%) |
| Diagnosed prior to appointment | 49 (20.25%) |
| Symptoms | |
| Pruritus | 312/350 (89.14%) |
| Pain or fissuring | 128/350 (36.57%) |
| Discharge | 39/350 (11.14%) |
| Dyspareunia | 104/350 (29.71%) |
| Dysuria | 12/350 (3.43%) |
| Features | |
| Non‐specific erythema | 334/350 (95.40%) |
| Well‐demarcated edge | 203/350 (58.00%) |
| Raised plaque | 135/350 (38.57%) |
| Lichenification | 117/350 (22.43%) |
| Scale | 121/350 (34.57%) |
| Location of disease | |
| Labia majora | 244 (69.71%) |
| Sulcus | 197 (56.29%) |
| Labia minora | 160 (45.71%) |
| Perineum | 152 (43.43%) |
| Perianal | 138 (39.43%) |
| Natal Cleft | 65 (19.11%) |
| Inner thighs | 50 (14.71%) |
| Mons | 45 (12.86%) |
| Buttocks | 16 (4.57%) |
| Treatments | |
| Topicals | |
| Hydrocortisone acetate 1% | 29 |
| Desonide 0.05% | 14 |
| Methylprednisone aceponate 0.1% | 262 |
| Betamethasone dipropionate 0.05% | 64 |
| Betamethasone dipropionate OV 0.05% | 15 |
| Clobetasol propionate 0.02% | 4 |
| Tacrolimus 0.1% | 3 |
| Systemic treatments | 51/350 (14.57%) |
| Phototherapy | 8 (15.7%) |
| Acitretin | 9 (17.6%) |
| Cyclosporine | 2 (3.9%) |
| Apremilast | 1 (2.0%) |
| Methotrexate | 15 (29.4%) |
| Sulfasalazine | 1 (2.0%) |
| Azathioprine | 1 (2.0%) |
| Secukinumab | 8 (15.7%) |
| Adalimumab | 1 (2.0%) |
| Certolizumab | 1 (2.0%) |
| Golimumab | 1 (2.0%) |
| Bimekizumab | 2 (3.9%) |
| Tildrakizumab | 1 (2.0%) |
| Treatment response^ | |
| Phototherapy | 6/8 (75.0%) |
| Acitretin | 3/9 (33.3%) |
| Cyclosporine | 2/2 (100%) |
| Apremilast | 1/1 (100%) |
| Methotrexate | 2/15 (13.3%) |
| Secukinumab | 5/8 (62.5%) |
| Bimekizumab | 1/2 (50%) |
| Tildrakizumab | 1/1 (100%) |
Note: Patients started on systemic therapy for purely vulval disease. Treatment response was defined as clear or almost clear on clinical examination.
Abbreviation: SD = standard deviation.
3.2. Clinical Symptoms and Features
The predominant symptom was pruritus (89.1%), followed by pain or fissuring (36.6%), with less frequent reports of dyspareunia (29.7%), discharge (11.1%) and dysuria (3.4%). Common clinical features were erythema (95.4%) and well‐demarcated edges (58.0%). White scale (34.6%) and lichenification (22.4%) were less prevalent. Affected areas primarily included the labia majora (69.7%), sulcus (56.3%), labia minora (45.7%) and perianal area (43.4%) (Figure 1).
FIGURE 1.
Bar graph showing the anatomical distribution of vulval psoriasis.
3.3. Treatment
All patients were initially trialled on topical treatments. Most patients (80%) were treated with a combination of 2%–4% coal tar solution (liquor picis carbonis; LPC) and a moderate‐potency topical corticosteroid (TCS). The most common TCS used was methylprednisolone aceponate 0.1% (74.9%), followed by betamethasone dipropionate 0.05% (18.3%) (Figure 2). Systemic treatment was used in 51 patients (14.6%), with 46 patients (13.1%) requiring the addition of systemic treatments specifically for vulval disease. Five patients were switched to a biologic agent after inadequate response to methotrexate or acitretin, while six patients received a biologic as their initial systemic therapy (five on secukinumab and one on tildrakizumab) via compassionate supply.
FIGURE 2.
Bar graph showing topical corticosteroids used for treatment of genital psoriasis in our cohort.
Systemic therapies included phototherapy (n = 8), oral methotrexate (n = 15) and acitretin (n = 9). Secukinumab was the most used biologic agent (n = 8), followed by bimekizumab (n = 2) and tildrakizumab (n = 1). Patients on sulfasalazine (n = 1), azathioprine (n = 1), adalimumab (n = 1), golimumab (n = 1) and certolizumab (n = 1) had been prescribed these therapies by their rheumatologist.
3.3.1. Treatment Response and Adverse Effects
Among the 46 patients in our cohort treated with systemic agents specifically for vulval disease, complete clearance was achieved in 7 out of 11 patients (63.6%) receiving biologic agents and 14 out of 35 patients (40%) on other systemic therapies (Table 1). The remaining patients demonstrated significant improvement without full resolution.
Methotrexate (10–15 mg weekly) is the first‐line systemic agent in our study, followed by acitretin (10–20 mg daily). Acitretin demonstrated greater efficacy in achieving complete clearance compared to methotrexate (33.3% vs. 13.3%).
Among biologic agents, secukinumab (administered 300 mg monthly (n = 7) or fortnightly (n = 1)) was most frequently used. Biologic agents demonstrated variable response times, with secukinumab achieving complete clearance in 5 patients over an average of 3.8 months. One patient failed to achieve complete clearance with methotrexate and secukinumab; however, they were able to achieve clearance with bimekizumab in 3 months. Tildrakizumab achieved complete clearance in a single case in 5 months. Phototherapy was successful in select cases, achieving complete clearance in an average of 8.6 weeks, while acitretin required 5.3 months for resolution.
Potent (class III) and very potent (class IV) corticosteroids were used safely in our cohort with no adverse effects observed under supervision. Two patients stopped acitretin due to side effects of hair loss, whilst two patients stopped methotrexate due to nausea and fatigue. There were no adverse effects noted in patients treated with biologic agents.
3.3.2. Vulval Quality of Life
The median VQLI score significantly improved from 18.0 ± 9.4 at baseline (n = 124) to 9.2 ± 7.6 at the end of follow‐up (n = 48) (p < 0.0001) (Figure 3). Significant improvements were observed across all quality‐of‐life domains except for ‘Relationships’. The largest percentage improvements were noted in ‘Future Health Concerns’ (69.2%, p < 0.001), ‘Feelings and Emotions’ (63.4%, p < 0.001), ‘Symptoms’ (58.6%, p < 0.001) and ‘Activities of Daily Living’ (56.8%, p < 0.001). Less marked improvements were seen in ‘Sexual Function’ (50.0%, p = 0.008) and ‘Treatment’ (41.7%, p = 0.0181). While there was a 50.0% improvement in ‘Relationships’, it was not statistically significant. Quality of life improvement, measured by the percentage change in VQLI score over time, showed a slope of 0.7066 (Figure 4).
FIGURE 3.
Box plot showing absolute Vulval Quality of Life Index (VQLI) at initial visit (n = 125) and follow‐up (n = 48) (A) Comparison of absolute VQLI scores in the ‘Symptoms’ domain consisting of questions 1–2. (B) Comparisons of absolute VQLI scores in the ‘Feelings and Emotions’ domain consisting of questions 3–5. (C) Comparisons of absolute VQLI scores in the ‘Activities of Daily Living (ADLs)’ domain consisting of questions 6–10. (D) Comparisons of absolute VQLI scores in the ‘Relationships’ domain consisting of question 11. (E) Comparisons of absolute VQLI scores in the ‘Sexual Function’ domain consisting of questions 12–13. (F) Comparisons of absolute VQLI scores in the ‘Future Health Concerns’ domain consisting of question 14. (G) Comparisons of the absolute VQLI scores in the ‘Treatment’ domain consisting of question 15. (H) Comparisons of absolute total VQLI score. Median, interquartile range, min and max are outlined. Ns = not significant, *p < 0.05, **p < 0.01, ***p < 0.001, ****p < 0.0001.
FIGURE 4.
Lines of best fit of percentage improvement in Vulval Quality of Life Index (VQLI) scores since treatment. Mean, 95% confidence bands and slope are shown.
4. Discussion
This study is the largest single‐cohort investigation to date examining the clinical symptoms and management of vulval psoriasis. It is the first to assess the proportion of patients requiring systemic treatment, with 13.1% needing systemic agents specifically for vulval disease. Our findings highlight the under recognised and undertreated nature of this condition, underscoring the importance of proactive screening, personalised treatment strategies and a re‐evaluation of criteria for prescribing biologic agents.
Vulval psoriasis presents as an erythematous patch or thin plaque with the classic well‐demarcated edges present in just over half of our cohort. Our study highlights an important diagnostic feature—scale buildup in the sulcus, complementing previous findings on common involvement of the labia majora, perineum and labia minora [2] (Figure 5). A thorough understanding of its key features is crucial for clinicians to effectively distinguish vulval psoriasis from other vulvar dermatoses (Table 2). Pruritus was a common symptom, followed by pain and fissuring, consistent with existing literature [9, 10, 11]. There was a significant diagnostic delay of 11 years in our cohort, which may result from inadequate clinician–patient discussions and examinations [4, 9]. Proactive screening for genital involvement should be routine in clinical history and examination.
FIGURE 5.
Clinical image of vulval psoriasis. (A) Non‐specific erythema in the interlabial sulcus. (B) Well‐demarcated erythematous plaque with lichenification over the labial majora. (C) Erythema and fissuring of the natal cleft. (D) Accumulation of white scale in the interlabial sulcus.
TABLE 2.
Table summarising differential diagnoses for vulval psoriasis.
| Condition | Key features | Typical distribution | Distinguishing points |
|---|---|---|---|
| Vulval psoriasis | Well‐demarcated erythematous patches or thin plaques | Labia majora, interlabial sulcus, labia minora, perineum and perianal area |
Extension into natal cleft Accumulation of macerated scale in the interlabial sulcus |
| Chronic vulvovaginal candidiasis |
Erythematous patches with satellite pustules or papules on adjacent skin Associated vaginitis and scanty white discharge |
Intertriginous areas |
Continuous pruritus pain and dyspareunia with premenstrual exacerbation Worsening with antibiotics |
| Atopic dermatitis | Poorly demarcated erythematous plaques with scaling, excoriation and lichenification | Labia majora, perineum and perianal areas | Personal or family history of atopy |
| Allergic contact dermatitis |
Erythematous patches with vesicles or erosions Intense itching, burning and stinging |
Depends on exposure, can involve the mons pubis to thighs |
History of allergen exposure Usually acute onset (within minutes to 24 h) |
Topical corticosteroids (TCS) remain the first‐line treatment for vulval psoriasis and the only treatment that has received approval in the medical literature [12]. Higher‐potency TCS in short intervals may often be required for resistant cases. However, there are many more effective treatments for genital psoriasis than simply using TCS and indeed, the entire spectrum of medications that are available to treat psoriasis on other parts of the skin can and should be used. The fact that, as a specific entity, this has received scant attention in the literature limits our ability to treat effectively.
Systemic therapies are required in a small subset of patients with treatment‐resistant vulval psoriasis. Although acitretin was more effective in achieving complete clearance compared to methotrexate, its use was limited to post‐menopausal women due to its teratogenic potential and extremely long half‐life. Biologics were more successful in achieving complete clearance, often doing so within 3–6 months.
The evidence for the use of systemic agents in vulval psoriasis is limited to small case reports or series. For instance, oral dapsone (100 mg daily) cleared genital psoriatic lesions within 4 weeks in one reported patient [13], while mycophenolate mofetil (500 mg twice daily) resulted in partial response at 2 months in another [13]. A recent phase 3 study (DISCREET) showed that 39.6% of patients treated with apremilast (30 mg daily) achieved a modified genital Physician's Global Assessment (PGA) response of ‘clear’ or ‘almost clear’ at week 16, compared to 19.5% in the placebo group.
However, recent literature has seen a growing focus on the use of biologics for the treatment of genital psoriasis. The first randomised controlled trial on this condition (IXORA‐Q) demonstrated that ixekizumab provided rapid and sustained improvements in symptoms, quality of life and sexual well‐being for up to 1 year [14]. Interim results from the ongoing GULLIVER study looking at guselkumab which includes 200 patients, reported that 76.5% of participants achieved a genital PGA score of ‘clear’ or ‘almost clear’ at 12 weeks [15]. Comparative studies suggest that anti‐IL‐17 agents (e.g., ixekizumab, secukinumab) and anti‐IL‐12/23 agents (e.g., ustekinumab) demonstrate superior efficacy in genital psoriasis compared to TNF‐α inhibitors (e.g., adalimumab, etanercept, certolizumab) [16]. However, a recent retrospective study found no significant difference in the achievement of PGA 0/1 between IL‐23 and IL‐17 inhibitors in genital psoriasis among 136 patients [17]. Additionally, bimekizumab, a novel IL‐17F inhibitor, demonstrated high efficacy, with 98.4% of patients achieving a genital PGA score of ‘clear’ at 16 weeks in a retrospective case series of 56 patients [18]. With the increasing availability of biologics for psoriasis, further comparative studies are essential to evaluate their specific efficacy in treating genital psoriasis.
Although the availability of biologic agents for psoriasis has significantly grown over the recent years, the lack of Pharmaceutical Benefits Scheme (PBS) coverage in Australia limits access for patients with purely genital disease, leaving availability reliant on compassionate supply from pharmaceutical companies. The Pharmaceutical Benefits Scheme (PBS) supports approval for special site psoriasis (face, palms and soles) but not genital disease. In the authors' opinion, this policy should be revised to include genital disease, as it would provide patients with a dramatically improved quality of life and mental well‐being. Although all patients in our study requiring biologics were able to obtain compassionate supply, this process posed challenges. Treating dermatologists faced administrative burdens, pharmacist misunderstandings regarding compassionate use, and delays in medication access while awaiting pharmaceutical company approvals. For patients, there was the constant uncertainty of potential withdrawal of support, further complicating long‐term management. Given the distinct psychosocial and functional effects of genital psoriasis, the authors propose that disease severity be measured similar to the PASI calculation used for face, hand and foot.
Additionally, despite treatment, significant burdens on sexual function and relationships persist. Compared to previous studies looking at female vulval conditions using the VQLI, the quality‐of‐life impact of vulval psoriasis lies between that of erosive conditions like vulval lichen planus and sometimes asymptomatic but scarring conditions like vulval lichen sclerosus [19]. Vulval psoriasis can cause notable sexual distress and stigmatisation [2, 4, 9], particularly among women [6, 20]. Although a prior study noted improvement in sexual distress with treatment of genital lesions [21], this study was limited to only 17 women, highlighting the need for more research in this area.
This retrospective study is limited by the potential for observer bias, as reviewing clinical photographs of patients with established diagnoses may lead to an overestimation of clinical features. Additionally, limitations stemming from the single‐referral centre study design include variations in individual practice patterns and a potential bias toward encountering diagnostically or management‐challenging cases.
5. Conclusion
Our study underscores that vulval psoriasis is under recognised and undertreated, with substantial impacts on quality of life. The considerable need for systemic therapy emphasises the importance of proactive screening, tailored management approaches, and the need to review criteria for prescribing biologic agents. Clinicians should prioritise early detection and thorough assessments to effectively alleviate the disease burden on patients' quality of life.
Ethics Statement
The study has been approved by the Northern Sydney Local Health District (2023/ETH01106).
Consent
All patients provided informed consent to participate in the study.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgement
Open access publishing facilitated by The University of Sydney, as part of the Wiley ‐ The University of Sydney agreement via the Council of Australian University Librarians.
Funding: The authors received no specific funding for this work.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.