What are the treatment options for a patient with inverse psoriasis?

Treatment of Inverse Psoriasis

Start with low-potency topical corticosteroids or calcineurin inhibitors as first-line therapy for inverse psoriasis, reserving systemic treatments for refractory cases or when quality of life is severely impacted. 1, 2

First-Line Topical Therapy

Low-Potency Corticosteroids

• Use only low-potency topical corticosteroids in flexural areas (axillae, inframammary regions, groin, genitalia, perianal areas) to minimize the dramatically increased risk of skin atrophy and systemic absorption in these warm, moist environments 1, 2
• The enhanced medication penetration from local humidity makes mid-to-high potency steroids inappropriate despite their effectiveness in plaque psoriasis on extensor surfaces 2
• Apply as a thin layer to affected areas once or twice daily initially, then taper frequency as lesions improve 3

Calcineurin Inhibitors (Preferred Alternative)

• Tacrolimus or pimecrolimus are highly effective for inverse and genital psoriasis and represent an excellent steroid-sparing option 1, 2
• These agents carry no risk of skin atrophy, making them ideal for long-term management in sensitive flexural areas 1, 2
• Calcineurin inhibitors are particularly effective in inverse psoriasis despite being only marginally effective for plaque psoriasis elsewhere 2

Vitamin D Analogs

• Calcitriol is preferred over calcipotriene for genital and inverse psoriasis due to reduced irritation potential 2
• Alternatively, dilute calcipotriene with a moisturizer to minimize irritation, though this may affect medication stability 2
• Limit total vitamin D analog use to maximum 100g per week to avoid hypercalcemia risk 4
• Studies demonstrate efficacy of vitamin D analogs in improving flexural psoriasis symptoms 3

Second-Line and Adjunctive Therapies

Phototherapy

• Narrowband UVB phototherapy is effective for inverse psoriasis unresponsive to topical treatments 1, 5
• The 308 nm excimer laser has shown complete clearance of inverse psoriatic lesions with remission duration of at least 6 months 6
• Phototherapy can address both inflammation and associated pruritus in patients with inadequate topical response 1

Topical Retinoids

• Tazarotene cream 0.1% is FDA-approved for plaque psoriasis and may be considered, though data specific to inverse psoriasis is limited 7
• Apply only to psoriatic lesions, avoiding uninvolved skin, and reduce frequency if undue irritation occurs 7
• Patients should avoid excessive sun exposure and use sunscreen due to photosensitivity risk 7

Systemic Therapy Indications

When to Escalate

• Consider systemic therapy when topical treatments fail or when inverse psoriasis causes major quality-of-life impairment, even with less than 5% body surface area involvement 2
• The psychological impact of genital and flexural psoriasis is disproportionate to body surface area and represents the most stigmatizing location 1, 2
• Adalimumab and other TNF-α inhibitors have demonstrated success in inverse psoriasis cases unresponsive to standard treatment 8

Systemic Options

• Biologic therapies are appropriate for moderate to severe inverse psoriasis affecting vulnerable areas with significant psychosexual implications 2
• Methotrexate, cyclosporine, and other systemic agents may be effective but require careful monitoring for systemic toxicity 9

Critical Management Considerations

Diagnostic Evaluation

• Directly examine and specifically ask about genital and flexural involvement during every psoriasis evaluation, as patients frequently do not volunteer this information 1, 2
• Exclude secondary candidiasis when psoriasis presents in body folds, though the absence of satellite pustules makes candidal infection unlikely 2
• Lesions appear erythematous, well-demarcated, minimally indurated with minimal to no scale due to the moist environment 1, 2, 5

Pruritus Management

• Psoriatic lesions in inverse areas are often severely pruritic, causing significant quality of life issues 1
• For severe pruritus unresponsive to topical therapy, consider non-sedating antihistamines, or in refractory cases, gabapentin, pregabalin, or mirtazapine 1
• A change of 3-4 points on visual analog scales (VAS) or numeric rating scales (NRS) is considered clinically meaningful when evaluating pruritus severity 1

Common Pitfalls to Avoid

• Never use high-potency topical corticosteroids in flexural areas—the enhanced penetration from humidity dramatically increases irritation and atrophy risk 1, 2
• Avoid occlusive dressings or tight clothing that can exacerbate lesions through friction and Koebnerization 1, 2
• Do not use the same corticosteroid potency as you would for plaque psoriasis on extensor surfaces 2

Patient Education

• Educate patients about the role of friction and irritation from tight clothing or athletic wear in exacerbating flexural psoriasis 1
• Address the psychological and sexual impact directly, as this is often the primary driver of quality-of-life impairment 1, 2
• Moisturizers may be used as frequently as desired and should be applied at least 1 hour before topical medications 7