Vulval Psoriasis

What is psoriasis?

Psoriasis is a chronic skin condition that affects around 5% (1 in 20) of people.  It tends to run in families.  It often shows up during the teenage years, but it can occur in young children.  It tends to be a lifelong issue that intermittently flares and calms down.  People notice it is worse if they are stressed, if they have another illness, or if the skin is exposed to anything irritating.  Psoriasis is NOT the result of infection and is NOT passed through touch or sex.

Psoriasis mainly affects the skin, scalp, and nails.  On the skin it shows up as red to pink areas that are flaky.  Sometime there is just dry scaly skin, especially on the eyes or behind the ears.  Flaky skin on the scalp is often mis-labelled as ‘dandruff’.  The nails may be weak, split easily, have a rough surface, or become pitted. Rarely, people can develop psoriatic arthritis, meaning they have joint pain due to the same process as the skin issues.  This usually can be controlled with medications.  This information sheet will focus on vulval psoriasis, which looks and behaves a bit differently to psoriasis on other parts of the body.

How do I know if I have psoriasis on the vulva?

While most people with psoriasis have it in lots of places, some just have it in the vulval area.  It is common to have psoriasis on the face or body that people don’t even notice, while the vulval psoriasis is obvious and causes major symptoms.

Psoriasis on the hair bearing areas, like the mons pubis or labia majora (see Vulval anatomy), can look like psoriasis anywhere else on the body.  It is red to pink, slightly raised, covered in flake or scale, with an obvious border between affected and unaffected skin.  Sometimes psoriasis is itchy, but symptoms may be minimal.

Psoriasis in hairless areas and skin folds, like the labia minora and perineum, tends to look different.  It is shiny, a bit swollen, and pink-red.  The border with unaffected skin isn’t that obvious.  There are often skin splits, especially at the interlabial fold, perineum, and natal cleft.  There might be increased discharge on the skin.  Psoriasis in this area tends to produce discomfort, itch, or stinging pain.  During or after sex, the skin may be even more swollen and painful.

Will a biopsy or some other test prove the diagnosis?

Psoriasis can be a difficult diagnosis to prove.  It may look similar to other vulval conditions, like chronic vulvovaginal candidiasis, chronic dermatitis, and fungal infections (see Vulvovaginal candidiasis and Dermatitis sheets).  Swabs and scrapings of the skin can help to show if there are yeast or fungi that are causing or contributing to the problems.  Under the microscope, skin affected by psoriasis looks thickened with mild inflammation.  Several other skin conditions also look like this.  So, biopsy can support the diagnosis of psoriasis, but often cannot ‘prove’ it.

An expert in vulval skin conditions can recognise vulval psoriasis and look for signs of psoriasis at other places.  Then they examine you over time.  If you respond to psoriasis treatments, but have occasional flares over the years, it is very likely that the problem is psoriasis.

How is vulval psoriasis treated?

Psoriasis is a chronic condition, so it can be managed but not cured.  Management of psoriasis is divided into 2 phases – ‘getting it’ under control and ‘keeping it’ under control.  Getting psoriasis under control usually requires corticosteroid ointments.  Usually people need a daily moderate-strength steroid for a few weeks at first, to settle the symptoms and heal the skin splits.  This steroid should not be used long-term but can be helpful for a couple days to settle periodic flares.

Keeping psoriasis under control requires excellent vulval care (see Vulval care advice).  People with vulval psoriasis need to avoid heat, moisture, friction, and sweat.  This often means making changes to things like clothing, exercise, and managing periods or incontinence.  A soothing barrier ointment or thick zinc cream used 2 or 3 times a day is usually required. For many people, this is enough to manage the problem long-term.

If the psoriasis is a bit more difficult to keep under control, some doctors will prescribe a compounded preparation, like 2% liquor picis carbonis in zinc cream to use twice a day.  Other options include mild steroid ointment, vitamin D analogs, and calcineurin inhibitors.  Each has its own set of side effects, so your doctor will discuss details.  Severe cases, especially with joint involvement, are managed with tablets or injections by dermatologists or rheumatologists.

Candidiasis commonly complicates psoriasis, especially in younger patients.  In some people this becomes a recurrent problem and they need to take tablets daily or several times a week to prevent it from coming back.

Will vulval psoriasis interfere with my sex life?

Untreated psoriasis can cause pain with sex.  This is especially true if there are skin splits or recurrent candidiasis.   Over time, skin irritation may lead to the nerves and pelvic floor muscles becoming overactive.  If this happens, pain with sex continues even after the skin condition improves.  In this situation, people might need tablets for nerve pain, specialised pelvic floor physiotherapy, or both.  Most people with psoriasis can get these problems under control and have a healthy sex life.

Are there long-term complications due to vulval psorasis?

Psoriasis does not result in scarring and does not change the anatomy of the vulva.  It does not appear to increase the risk of vulval cancers or precancers.  Vulval psoriasis does not impact on pregnancy and birth.  Many people find their psoriasis gets a bit better during pregnancy.  Using topical steroid ointments is safe if there is a flare during pregnancy.