3.1 Consensus Statements and Key Considerations

All statements reached consensus and are presented in their final form in Table 1. The key considerations that informed statement development within each of the three focus areas are outlined below.

Table 1 Consensus statements from the Genital Psoriasis Wellness Consortium for the approach to a genital psoriasis physical exam, diagnosis, and treatment across age groups3.1.1 Physical Exam, Diagnosis, and Patient Conversations

Topic 1. Incorporate full-body exams in routine dermatologic care

Consensus statement: Patients should have a full-body exam for their psoriasis, which includes genitals, for the initial and ongoing treatment of their genital psoriasis.

Key considerations: Considering the high rates of genital involvement in psoriasis and the common variations in manifestations [8, 15], the panel emphasized that comprehensive skin examinations are essential for accurate diagnosis and effective management as part of both initial assessments and ongoing follow-up visits. This approach not only aligns with best practices for chronic disease monitoring but also ensures that treatment plans address the complete burden of disease. Integrating full-body skin exams into the standard of dermatologic care can help to normalize genital assessment and ultimately lead to better clinical outcomes.

Topic 2. Normalize routine full-body skin exams

Consensus statement: Rapport framework should be based on empathy and acknowledge the impact of disease burden e.g., “We know some patients may find this uncomfortable; a routine full skin exam includes the genitals."

Key considerations: Establishing a respectful empathetic rapport during dermatologic visits is important for addressing disease in sensitive areas [14]. By acknowledging potential discomfort and explicitly framing a genital examination as a routine part of a comprehensive skin assessment, HCPs can help reduce stigma and build trust. The panel suggested using simple and affirming language to facilitate more transparent communication, improve diagnostic accuracy, and support therapeutic alliance. This approach reinforces the incorporation of full-skin exams by creating the interpersonal conditions necessary for successful implementation.

Topic 3. Reduce stigma through proactive education

Consensus statement: Healthcare professionals should proactively discuss and educate on all presentations of psoriasis, including genitals.

Key considerations: Proactively initiating conversations about all presentations of psoriasis, including on the genitals, was considered by the panel to be crucial for destigmatizing the condition and supporting comprehensive care. Genital psoriasis often presents differently from lesions on other body areas [16,17,18], leading patients to misattribute symptoms to other conditions (such as uncleanliness or sexually transmitted infections) or dismiss them entirely. Without clear guidance from HCPs, patients may not recognize these manifestations as genital psoriasis or may be unsure whether it is appropriate to raise concerns about this body site with a dermatologist. Building on the themes of the previous two statements, the consensus panel highlighted that proactive dialogue on genital psoriasis presentation can further encourage disclosure of sensitive symptoms, support earlier diagnosis and tailored treatment, and reinforce that genital involvement is a recognized and manageable aspect of the condition.

Topic 4. Best practices for full-body skin exams

Consensus statement: At a minimum, verbal consent should be obtained prior to the start of the full-body skin exam with the option for a chaperone/third party presence, dependent on institutional or state requirements.

Key considerations: Panelists noted that establishing trust and ensuring patient comfort during physical exams is critical, particularly when examining the genitals. Obtaining verbal consent before the start of the exam, ideally before the patient disrobes, helps set clear expectations and respect for personal boundaries. Offering the option of a chaperone or third-party presence is recommended as standard practice to further reinforce a sense of safety and professionalism, while also recognizing that some patients may prefer not to have a chaperone/third-party presence and that this preference should be respected and documented [39]. These practices align with trauma-informed care principles and help mitigate anxiety or uncertainty surrounding genital examinations. By consistently integrating consent protocols into standard dermatologic workflows, clinicians not only fulfill institutional and ethical responsibilities but also create a more transparent, respectful, and patient-centered clinical environment.

Topic 5. Address mental health and sexual well-being

Consensus statement: Elevate and normalize conversations in dermatology to include anxiety, depression, and psychological impact and ramifications of their disease.

Key considerations: The psychosocial impact of genital psoriasis is profound yet often inadequately addressed in routine dermatologic care [1,2,3,4,5]. Feelings of embarrassment, anxiety, and depression are common, particularly when patients perceive their symptoms as embarrassing or isolating. Many individuals may hesitate to disclose the emotional burden of their disease unless HCPs “create space” for these conversations. The panel recognized that when clinicians actively acknowledge the psychological ramifications of genital psoriasis, patients feel more supported and are more likely to engage meaningfully in their care. As discussed earlier, integrating empathetic rapport that includes questions about mental health and sexual well-being [40] as part of standard care can help validate the patient experience and promote more comprehensive patient-centered outcomes.

Topic 6. Prioritize rapid and effective disease resolution

Consensus statement: Choose more aggressive skin treatments to achieve rapid disease resolution which can improve psychosocial and psychological outcomes.

Key considerations: The consensus panel underscored the importance of timely and visible treatment response in genital psoriasis, where disease burden is compounded by intimacy-related distress, embarrassment, and diminished self-esteem. While some patients may be hesitant about escalating treatment, achieving rapid clearance in the genital area can yield meaningful improvements in both physical and emotional well-being. Delays in treatment or suboptimal efficacy may prolong psychological strain and reinforce avoidance behaviors around intimacy and care seeking. The panel highlighted selecting more effective therapies, particularly therapies with evidence for rapid onset and durability early in the treatment journey, when appropriate, to improve patient satisfaction, reduce emotional burden, and restore QoL. Prioritizing rapid and effective resolution reflects the true urgency of symptom relief in this intimate area.

Topic 7. Apply a differential diagnostic framework

Consensus statement: When evaluating genital psoriasis, ensure consideration of other possibilities in the differential, which can be categorized using the following approaches:

a)

morphology of lesions (e.g., patch, plaque, annular).

b)

depth of the lesion (e.g., epidermal, dermal, subcutaneous).

c)

assignment to etiologic categories (inflammatory, infectious, malignancy, or other).

Key considerations: Given the unique characteristics of genital skin, including thinner epidermis, skin-on-skin contact, and increased moisture, many dermatoses may present with overlapping features, complicating diagnosis. Dermatoses, including inflammatory (e.g., lichen planus, contact dermatitis), infectious (e.g., candidiasis, erythrasma), or neoplastic (e.g., Paget’s disease, Bowen’s disease) conditions may mimic genital psoriasis, particularly in the absence of classic features (i.e., reduced scaling) seen on other body sites [16,17,18]. A structured diagnostic framework that incorporates lesion morphology, patient history, and judicious testing (e.g., cultures, biopsies) to evaluate a broad differential diagnosis will help guide clinical reasoning and minimize misdiagnosis. This methodical approach aligns with best practices in complex dermatologic assessments and supports timely and appropriate treatment initiation, which is important in sensitive anatomical regions where misdiagnosis can lead to unnecessary biopsies, ineffective treatment, and patient distress.

3.1.2 Pediatric and Adolescent Treatment Considerations

Topic 1. Best practices for treatment decisions

Consensus statement: Pediatric patients with genital psoriasis should have access to the full spectrum of treatment options, utilizing a shared decision-making approach, so that treatment regimens can be fully tailored to each patient’s specific needs and true disease burden.

Key considerations: Pediatric patients with genital psoriasis often face substantial unmet needs because of delayed diagnosis, limited access to approved systemic therapies, and under-recognition of the psychosocial burden of disease. Despite advances in treatment, many children remain undertreated or receive regimens that are not adequately tailored to disease severity or impact on QoL [19]. The consensus panel affirmed the role of access to the full spectrum of therapeutic options (including topicals, phototherapy, systemics, and biologics) as essential to address both physical symptoms and broader developmental and emotional implications. Furthermore, the panel endorsed the use of a shared decision-making framework to empower patients, families, and caregivers to engage in meaningful dialogue with clinicians, ensuring that treatment plans are not only evidence based but also reflect the preferences, concerns, and values of the patient and their support network. This approach supports adherence, builds trust, and helps mitigate long-term disease burden during critical periods of growth and development. Moreover, the emphasis on collaborative care can be reinforced throughout the treatment journey to address evolving psychosocial needs across different age groups.

Topic 2. Minimize treatment burden

Consensus statement: All other things being equal (treatment class, time to onset, efficacy, and safety), when using injectable medications, consider therapies with the least required annual injections to minimize treatment burden while maintaining efficacy (and offer in-clinic injections).

Key considerations: In pediatric psoriasis care, the balance between therapeutic efficacy (including onset of effect) and treatment burden is critical to fostering long-term adherence and preserving QoL. While biologics offer effective disease control, panelists highlighted that the frequency of injections can become a barrier for children and their caregivers, contributing to treatment fatigue, anticipatory anxiety, and reduced follow-through. The panel advocated for selecting agents within the same therapeutic class with equivalent time to onset, efficacy, and safety that require fewer injections per year to reduce this burden without compromising therapeutic effect. Additionally, offering in-clinic administration provides an opportunity to support both the child and the caregiver, ensure proper technique, address concerns, and reinforce a positive treatment experience. This approach complements the collaborative care strategy by aligning therapy selection with both clinical and practical considerations.

Topic 3. Empower patients/caregivers with education and tools to promote adherence

Consensus statement: Provide education and tools to empower patients/caregivers to promote adherence. Consider gamified accountability tools to allow pediatric patients to feel actively involved in their own care.

Key considerations: As previously discussed, supporting adherence in patients with genital psoriasis requires a proactive education-centered approach. In the context of pediatric genital psoriasis, this includes both patients and their caregivers. The panel emphasized the importance of clear accessible education on disease mechanisms, treatment expectations, and realistic outcomes to build trust and promote long-term engagement with care plans. Moreover, panelists agreed that involving children in their own disease management by including gamified tools, treatment calendars, or visual trackers, can foster autonomy and increase motivation, especially when tailored to developmental stages and communication preferences. These strategies operationalize the shared decision-making model by empowering families and fostering engagement.

Topic 4. Educate patients/caregivers on the life-long and changing nature of genital psoriasis

Consensus statement: Educate patients and caregivers about the chronicity of the disease and discuss age-dependent clinical manifestations and therapies.

Key considerations: Elaborating further on the education-centered approach, panelists recognized that establishing a strong foundation of education for both pediatric patients and their caregivers is essential for effective long-term management of genital psoriasis. Panelists agreed that early conversations should clearly explain the chronic nature of the disease while normalizing its presence across all body sites, including the genital area. Likewise, the panel advocated for tailoring education to the developmental stage of the child to ensure that clinical manifestations and treatment options are presented in an accessible and reassuring manner that fosters resilience in managing a chronic condition. These discussions not only reinforce earlier themes of open communication, destigmatization, and trust building but also equip families with the knowledge needed to navigate the long-term nature of the disease and adapt to evolving therapeutic goals. Moreover, this approach complements the shared decision-making strategy by considering developmental stage, caregiver capacity, and the psychosocial context of chronic disease management in children and adolescents.

Topic 5. Align genital psoriasis care with routine pediatric care

Consensus statement: Dermatologists should be familiar with standard vaccination schedules and manage treatment in collaboration with primary care providers, ensuring any necessary treatment pauses for vaccinations are kept as brief as possible.

Key considerations: In pediatric patients receiving systemic or biologic treatment for psoriasis, panelists noted that it is essential to balance disease control with routine preventative care, including adherence to standard vaccination schedules. Dermatologists should be well versed in standard vaccination schedules and engage in proactive collaboration with primary care providers to ensure coordination of care. In cases where treatment interruptions are required, such as pausing systemic or biologic therapies around live vaccinations, these pauses should be minimized to prevent disease flares and maintain therapeutic momentum. Timely communication with families about the rationale and duration of any pauses can reduce confusion and support adherence. A coordinated multidisciplinary approach supplements the shared decision-making framework by maintaining continuity of care and aligning with best practices in pediatric chronic disease management.

Topic 6. Support treatment adherence through shared decision making

Consensus statement: Discuss the risks and benefits of each treatment, including the risks of not treating the disease, and engage in shared decision making to optimize treatment selection and adherence.

Key considerations: Expanding on the decision-making framework already established, panelists recommended a transparent discussion of treatment options, including benefits and potential side effects of treatment and the risks associated with untreated disease, to be central to empowering families and promoting adherence in pediatric psoriasis care. Panel members agreed that engaging patients and caregivers in shared decision making fosters trust and supports the selection of treatment strategies that are both clinically appropriate and personally acceptable. This approach ensures families understand the rationale behind therapeutic choices, mitigates misconceptions about medications (particularly systemic and biologic agents), and reinforces the importance of consistent disease control. Employing the empathetic rapport framework in this context validates concerns about stigma and treatment anxiety, as well as the psychosocial toll of chronic visible symptoms, especially in sensitive areas. Clear communication and collaborative planning can help align expectations and improve long-term outcomes by supporting adherence and sustained engagement in care.

Topic 7. Support shared decision making through transparent therapy option discussions

Consensus statement: Emphasize the benefits of advanced targeted topical and systemic treatments, which typically have fewer side effects, and patients’ rights and options to participate in their therapy selection.

Key considerations: When discussing treatment options with pediatric patients and their caregivers, the panel aligned on the importance of highlighting the availability and benefits of newer targeted therapies that offer improved safety, tolerability, and efficacy, further building on the shared decision-making framework. There is a scarcity of clinical data pertaining to pediatric and adolescent genital psoriasis disease management, particularly in pediatric trials involving systemic agents; however, etanercept (tumor necrosis factor-α inhibitor), ustekinumab (interleukin [IL]-12/23 inhibitor), secukinumab (IL-17 inhibitor), and ixekizumab (IL-17 inhibitor) have demonstrated favorable benefit-risk profiles and durable disease control in children and adolescents with moderate-to-severe psoriasis [20, 41, 42]. Ixekizumab maintained high levels of efficacy through 108 weeks, with a low incidence of serious adverse events and no new safety signals [41]. Likewise, etanercept, adalimumab (tumor necrosis factor-α inhibitor), and ustekinumab reported generally low rates of serious infections and no increased risk of malignancy or other severe adverse outcomes during follow-up periods that ranged from 3 months to over 5 years [20, 42, 43]. Alongside these systemic agents, topical roflumilast (PDE4 inhibitor) has demonstrated efficacy and a favorable safety profile, with low rates of application-site reactions and negligible systemic absorption in children and adolescents with mild-to-moderate psoriasis, including involvement of intertriginous areas [21, 31, 44, 45]. Similarly, topical tapinarof (AhR inhibitor) has shown durable disease control and was generally well tolerated in adults with moderate-to-severe psoriasis, including intertriginous areas [29, 30], with studies in pediatric patients currently underway [46]. These advanced targeted topical therapies have demonstrated safety and effectiveness as short-term and long-term alternatives to TCSs [25, 30, 47]. Panelists recognized that discussing the efficacy and safety of advanced targeted topical treatments can reduce caregiver hesitancy and promote confidence. Empowering families with this information and reinforcing the patient’s role in selecting treatment may enhance treatment adherence, especially when framed around minimizing disease burden and supporting QoL over time [25].

Topic 8. Address access barriers

Consensus statement: Recognize potential risks of therapeutic barriers such as treatment delays due to insurance denials, prior authorization requirements, and/or costs, along with standard processes employed to overcome these hurdles.

Key considerations: The panel acknowledged that, in practice, therapeutic delays caused by insurance denials, prior authorization requirements, or high out-of-pocket costs can disrupt continuity of care, exacerbate disease burden, and undermine the adherence efforts outlined earlier. Panelists were especially concerned about these barriers in pediatric care, where timely treatment is critical to prevent progression, maintain school attendance, and support psychosocial development. There was agreement that recognizing the predictable nature of these obstacles allows clinicians to proactively engage with standard processes (compiling documentation, appealing denials, and coordinating with specialty pharmacies) to minimize delays. Transparent communication with families about anticipated timelines and coverage challenges, paired with the shared decision-making strategies discussed earlier, can help set realistic expectations and reduce frustration. In keeping with previous themes of empowerment and trust building, proactively navigating these barriers is essential to preserving therapeutic momentum and family confidence.

Topic 9. Selection of effective and well-tolerated topical therapies

Consensus statement: When a topical agent is appropriate, choose one that is both effective and comfortable for the patient to apply. Provide a sample for the patient to try before they leave the office, when possible, to support shared decision making.

Key considerations: There was agreement among the panelists that treatment decisions should account for both clinical effectiveness and patient comfort during application. Sensitive skin in the genital region may be more prone to irritation, and discomfort during application can reduce adherence. Certain formulations, including topicals that are not a corticosteroid and newer creams and foams with favorable tolerability profiles, may be more acceptable to children and their caregivers [17]. The panel highlighted that, when possible, offering a sample for an in-office trial allows patients and caregivers to assess acceptability before starting therapy at home, helping to align expectations and promote shared decision making. This can contribute to greater satisfaction and increase both short-term and long-term adherence to therapy, especially when paired with clear education.

Topic 10. Selection of evidence-informed systemic therapy

Consensus statement: When a systemic agent is appropriate, choose one that demonstrates safety and efficacy based on clinical trial data for genital use.

Key considerations: Systemic therapy may be considered for pediatric patients with psoriasis involving the genitals when the disease is extensive, unresponsive to topical treatments, or substantially affects QoL [20, 41]. In these cases, the panel prioritized selecting an agent with demonstrated efficacy and safety in treating genital involvement. While most clinical trials for systemic agents have not focused exclusively on genital psoriasis in the pediatric and adolescent populations, risankizumab (IL-23 inhibitor) and ixekizumab, secukinumab, and brodalumab (IL-17 inhibitors) have shown rapid clearance and symptomatic relief in genital-specific sub-analyses of adult trials [6, 35, 48,49,50,51,52,53]. These agents offer favorable benefit-risk profiles and sustained disease control, which are especially important in pediatric care. Using genital-specific data, when available, supports evidence-based decision making and reinforces confidence in therapy selection for patients and caregivers.

Topic 11. Supporting evidence-informed treatment choices

Consensus statement: Ensure the chosen treatment has an approved indication for genital or intertriginous use and if not, explain the risks and benefits of off-label use.

Key considerations: When selecting a therapy for genital psoriasis, prescribers should ensure the treatment is approved for genital or intertriginous use whenever possible. However, in cases where the most clinically appropriate agent does not carry a specific indication for these sensitive areas, the panel emphasized that it is critical to clearly communicate the potential risks and benefits of off-label use with patients and caregivers. This includes a discussion of drug-selection rationale, the safety profile, and any clinical experience in genital areas with pediatric populations. These discussions not only reinforce previous themes of open communication and trust building but also support shared decision making, especially in scenarios where efficacy and tolerability outweigh regulatory labeling limitations.

Topic 12. Mitigate delays and distress through evidence-based advocacy

Consensus statement: Providers should clearly communicate insurance companies’ contraindications to step therapy requirements to obtain the most appropriate medication for the patient.

Key considerations: As a continuation of the access barrier strategy previously discussed, panelists recognized that navigating insurance requirements can present a substantial hurdle in timely access to effective treatments. In cases where step therapy mandates trials of less suitable agents, providers should proactively advocate for the patient by clearly documenting and communicating any clinical contraindications to such requirements. This includes highlighting safety concerns, disease severity, coexisting conditions, and the unique burden of genital involvement. In addition, panelists noted that some US states have enacted legislation limiting or prohibiting step therapy protocols, and referencing relevant state or local statutes may further support appeals for appropriate treatment access. Strong evidence-informed appeals can help secure appropriate therapy more quickly, minimize delays in care, and avoid exacerbation of symptoms and associated psychosocial distress.

Topic 13. Document the lived experience to support individualized care

Consensus statement: Document the impact of disease on quality of life and associated comorbidities, using direct patient quotes and validated tools such as patient-reported outcome questionnaires. Address specific challenges including needle phobia, lab requirements, and disruptions to daily life to guide personalized care.

Key considerations: The panelists advocated for accurate and comprehensive documentation of disease impact as a vital component of individualized care. Incorporating validated patient-reported outcome measures (such as itch severity scores or QoL questionnaires) alongside patient or caregiver quotes can help to capture the lived experience of disease and inform therapeutic decisions. This approach is especially important for surfacing concerns that may not be readily apparent, such as treatment fatigue, needle phobia, or challenges related to school, sports, or social development. As mentioned previously, thorough documentation also strengthens insurance justifications and supports a holistic patient-centered care plan.

3.1.3 Adult and Geriatric Treatment Considerations

Topic 1. Personalize care through shared decision making

Consensus statement: Obtain a comprehensive medical history from the patient (and family/caregiver as needed) and consider the whole patient in a shared decision-making process. Tailor care for older adult patients, recognizing their susceptibility to polypharmacy and unique skin, genital, and cognitive needs.

Key considerations: Treatment decisions should consider sex and reproductive-specific factors, such as pregnancy and breastfeeding status in individuals of reproductive potential, as well as menopause-related changes that can exacerbate skin dryness, genital irritation, and sensitivity to certain therapies. Psoriasis management in older adults remains a critical gap in clinical practice and research, with older adults frequently excluded from clinical trials and evidence-based guidelines [37]. The panel emphasized the need to obtain a comprehensive medical history, as these patients often present with age-specific challenges, including polypharmacy, thinner skin, urogenital symptoms unrelated to genital psoriasis (such as urinary incontinence), cognitive decline, and functional impairments that complicate diagnosis and limit treatment choices [6, 7, 36]. Moreover, clinicians may hesitate to escalate therapy because of concerns about coexisting conditions or drug interactions, leading to undertreatment despite a significant disease burden. This decision-making approach builds upon collaborative care principles originally introduced in the pediatric context to guide the development of treatment plans that integrate efficacy, tolerability, and patient-centered goals, while concurrently addressing systemic barriers to care, most notably those related to access and insurance coverage. This framework enables clinicians to acknowledge the complexity of geriatric care and aims to reduce the persistent disparities in treatment outcomes for this vulnerable population.

Topic 2. Promote equitable care through comprehensive assessment

Consensus statement: Advocate for patients by letting their experience guide treatment decisions. Document symptoms and quality of life impacts to justify care, rather than relying solely on clinical scores or third-party guidelines. If no Food and Drug Administration-approved drugs are available, explain to patients and caregivers that insurance thresholds may be higher, and explore options like compassionate use to ensure access.

Key considerations: In managing genital psoriasis, particularly in older or underserved populations, the panelists agreed that disease severity and treatment decisions cannot be accurately assessed through objective clinical scores alone. As previously mentioned, many patients underreport symptoms because of embarrassment or the assumption that their condition is a sexually transmitted infection. They may also assume their symptoms are not treatable. These factors contribute to a disconnect between clinical evaluation and lived experience. Patient narratives (such as persistent itching, painful fissures, sexual distress, or daily disruptions) should carry diagnostic and therapeutic weight. Incorporating validated patient-reported outcomes and open-ended assessments of QoL burden ensures that management plans reflect the true impact of disease. Where regulatory approvals lag behind clinical need, clinicians may consider insurance exceptions or compassionate use mechanisms, particularly for medications with well-established efficacy and safety in broader psoriasis populations. This narrative-driven care model mirrors the patient-centered strategies highlighted in the earlier patient conversation and pediatric considerations sections to promote equitable care access.

Topic 3. Use a multimodal approach to achieve comprehensive disease control

Consensus statement: Consider combining systemic therapies with topicals for genital psoriasis to address coexisting conditions, sexual health, and quality of life to achieve disease control.

Key considerations: Achieving disease control in genital psoriasis often requires a multimodal approach that addresses both the inflammatory burden and the functional impact of disease. There was agreement among panel members that topical agents offer rapid symptomatic relief, while systemic therapies are better suited to managing persistent or coexisting inflammatory activity. When used in combination, these approaches can target the local symptomatology of genital involvement while simultaneously addressing systemic inflammation linked to coexisting conditions such as psoriatic arthritis, depression, and metabolic syndrome. Moreover, the panelists emphasized that the ability to tailor treatment intensity (e.g., using advanced targeted topical treatments in tandem with a biologic) can improve symptom resolution without increasing systemic exposure or toxicity. This integrated strategy also creates opportunities to address issues related to sexual health and intimacy, which may not be resolved by monotherapy alone [7, 15].

Topic 4. Optimize treatment through contextualized geriatric care

Consensus statement: Select class of therapy based on coexisting conditions, concurrent medications, lifestyle, and symptoms. Select treatment options within class based on dosing, vehicle, formulation, and insurance coverage. Avoid using age as the sole determinant for treatment decisions.

Key considerations: Panel members highlighted that chronological age alone is not a reliable predictor of treatment tolerance, adherence, or success in patients with genital psoriasis. Older adults often present with complex medication regimens, physical limitations, or coexisting conditions (such as cardiovascular disease or diabetes mellitus) that influence treatment suitability [6, 7,