A Statistic That Stops You in Your Tracks
PA Buchi Neita and PA Shanna Miranti open the episode with a number that surprised even a 23-year veteran: two-thirds of all psoriasis patients have some degree of genital involvement — over six million Americans. Miranti admits she didn't know that going into the conversation, and their guest, Dr. Tina Bhutani, says most clinicians react the same way.
Dr. Bhutani, a dermatologist, clinical researcher, associate clinical professor at UCSF, and CEO of Synergy Dermatology in San Francisco, helped spearhead the genital psoriasis wellness consortium convened by Arcutis. She frames the core problem plainly: genital psoriasis is under-diagnosed, under-treated, and under-recognized. The consortium aimed to raise awareness, give providers a framework for what is admittedly an awkward conversation, and offer practical treatment strategies to optimize outcomes.
Why the Full-Body Skin Exam Matters
Dr. Bhutani explains that genital psoriasis often looks nothing like the thick, scaly plaques clinicians expect elsewhere. Patients frequently don't recognize it as psoriasis at all — they assume it's tinea, jock itch, or an STD — and they're often too embarrassed to bring it up. Simply asking 'do you have psoriasis in your genital area?' will yield a 'no,' because to the patient it doesn't look like psoriasis.
Her recommendation: do periodic full-body skin checks, especially at the first visit for a new patient with an established diagnosis, then set reminders to repeat them annually or every two years. Because genital disease is tougher to treat, patients may be clear elsewhere while residual plaques persist in sensitive areas.
She also models the language she uses to normalize it: telling patients it's very common to have psoriasis in the folds and sensitive areas, and that she'd like to do a full-body skin check to make sure nothing is being missed. Staff who room patients can be trained to have that conversation and gown patients ahead of time. Neita highlights that this normalizing language also relieves patients who feared they had an STI they might pass to a partner.
The Emotional and Social Burden
When Miranti asks about the psychological toll, Dr. Bhutani is blunt: many patients are avoiding relationships and close partnerships entirely because they're scared to pass it on, scared to be seen, or scared to explain it. She notes there is strong data showing a major impact on sexual health and intimacy — another reason diagnosis and treatment matter.
For pediatric patients, the hosts and Dr. Bhutani agree the conversation is more delicate — but often the parents, not the child, are the harder audience, since kids have typically already been examined during routine pediatric visits. Age matters too: young children are unbothered, while teenagers can be deeply embarrassed. The exam may not need to happen at the first visit; building 'therapeutic rapport' first can help. Miranti also stressed explaining why the exam is needed and obtaining the child’s assent with a parent present.
Recognizing Genital Psoriasis as Its Own Diagnosis
A key consortium point was recognizing genital psoriasis as a distinct diagnosis, potentially with its own ICD-10 code. Dr. Bhutani explains this serves two purposes: it can help drive more targeted treatments and better options, and it acknowledges that genital disease takes more time and effort at a visit even when the rest of the body is clear.
Treatment Strategies for Sensitive Skin
Dr. Bhutani says treatment decisions are easier now that effective non-steroidal therapies exist, so clinicians no longer have to default to a topical steroid in sensitive areas. She also urges providers not to fear moving to systemic therapy: even a limited body surface area doesn't mean a patient is only appropriate for topicals — if they've already failed topicals, it's fine to take the next step, because the goal is treating quality of life, not just skin.
She points to the recent approval of roflumilast foam (Zoryve foam) for scalp and body psoriasis as an exciting, elegant option for the genital area because it isn't greasy and leaves no residue. On tolerability, she notes the vehicle contains no alcohol, penetration enhancers, or sensitizers like propylene glycol, and is formulated at physiologic pH—all factors that reduce the stinging and burning that can plague thin, tender genital skin. As Miranti puts it, you want a product that's therapeutic and that patients will actually use.
Finally, Dr. Bhutani confirms she's comfortable combining these newer topicals with a biologic. Even the best biologic may not fully clear or prevent flares in special sites, so having a topical on hand at home lets patients treat a flare promptly.