Sex and the PASI: patients affected by a mild form of psoriasis are more predisposed to have a more severe form of erectile dysfunction

The impact of low-dose methotrexate on erectile dysfunction, sex hormone profile and spermiogram in male patients with psoriasis: a prospective study

PURPOSE

Psoriasis, affecting approximately 2% of the world's population, often necessitates systemic treatments, with methotrexate (MTX) as a cornerstone therapy. Despite documented systemic side effects of MTX, concerns about its impact on male reproductive health persist. We aim to investigate low-dose MTX effect on hormonal, cellular and functional ability of male reproductive system.

MATERIALS AND METHODS

Our prospective study on 40 male psoriasis patients receiving low-dose MTX (<15mg/week) comprehensively investigates its effects on erectile function, sex hormones, and spermiogram parameters.

RESULTS

After six months of MTX treatment, a significant decline in erectile function (p < 0.001) decreased total testosterone levels (p = 0.03) were observed. No significant reduction in sperm count was noted after six months of MTX treatment.

CONCLUSIONS

Our study highlights a significant decline in erectile function following low-dose MTX therapy, warranting further investigation into this potential side effect. While reassuring for sperm quantity and quality, the findings emphasise the necessity for larger cohorts and longer follow-up times to validate results and comprehend the complex interactions between MTX and male sexual health.

Sexual Dysfunction in Women and Men with Psoriasis: A Cross-Sectional Questionnaire-Based Study

Background and objectives: Psoriasis can lead to feelings of stigmatization, hinder social functioning, and impair quality of life. Psoriasis can also affect sexual activity, but there is still little research on this topic. The present study investigated whether and to what extent psoriasis, its severity, location and extent of skin lesions affect sexual dysfunction. Materials and Methods: A total of 45 women and 64 men aged 18 to 73 years hospitalized for psoriasis exacerbations were included in the study. Psoriasis severity, as assessed by the Psoriasis Area and Severity Index (PASI), ranged from 0.2 to 65 points (mean: 17.0 ± 14.9 points). After collecting demographic and clinical data, each subject was asked to complete the Dermatology Life Quality Index, the 11-item Sexual Life Questionnaire and the International Index of Erectile Function (only men). Results: Our study found that more than 90% of the patients surveyed felt at least a slight unattractiveness due to psoriasis. In approximately 80% of the subjects, the skin lesions at least occasionally affected their sex life, and more than 50% at least sometimes avoided sexual contact. The location of psoriasis, particularly in the genital area (p = 0.01), on the face (p = 0.03) and hands (p = 0.05), also had a significant impact on the level of sexual problems. Psoriasis has a significant impact on the quality of life (QoL), and a deterioration in QoL was strongly correlated with sexual dysfunction (r = 0.6, p < 0.001), PASI scores (r = 0.36, p < 0.001), self-assessment of psoriasis severity and location of psoriatic lesions. Conclusions: Psoriasis leads to various limitations, especially in the sphere of sexual life. Patients with psoriasis feel stigmatized, have lowered self-esteem and consequently experience significant sexual problems. Awareness of the co-occurring psychological aspect of psoriasis and the routine use of validated scales in dermatology practice should contribute to the rapid identification of patients with sexual dysfunction.

Influence of psoriasis lesions' location and severity on psychosocial disability and psychopathology. Observational study and psychometric validation of the SAPASI Portuguese version

OBJECTIVES

The psychosocial impact of psoriasis is well documented. However, the contributing role of clinical disease characteristics is not satisfactorily explored. This study aimed to validate the Self-administered Psoriasis Area and Severity Index (SAPASI) to a Portuguese population (SAPASI-PT) and to perform its cross-validation, assessing how the results will generalize to an independent data set, with the Psoriasis Area and Severity Index (PASI), in order to assess the influence of psoriasis' severity on psychosocial disability and psychopathology.

METHODS

A cross-sectional study with 228 patients with psoriasis was carried out. Data was collected through a sociodemographic and clinical questionnaire, SAPASI-PT, the Psoriasis Disability Index (PDI) and the Brief Symptoms Inventory (BSI). The cultural and linguistic adaptation of SAPASI to a Portuguese version and the cross validation with PASI was carried out. Multiple associations between psychosocial disability, psychopathology and severity, discomfort and location of lesions were investigated through logistic regression models.

RESULTS

A good adjustment model for SAPASI-PT is found. Also, associations between psychosocial disability, psychopathology and the psoriasis severity and discomfort are found. The existence of lesions is positively associated with the severity of the disease. Patients with lesions in hands or genitals are those reporting a greater discomfort. The presence of lesions in hands is positively associated with PDI, i.e., with leisure and with treatment, marginally. Additionally, patients scoring higher in the personal dimension are found to have a significantly greater percentage of lesions in the genitals.

CONCLUSIONS

The psoriasis severity and location of lesions are important determinants of patients´ quality of life. Lesions on face, hands and genitals are associated with a higher impact on psychosocial wellbeing of patients. Psychological counselling should be considered within psoriasis treatment context in patients with the described disease manifestations.

Erectile Dysfunction in Men With Psoriatic Arthritis: A Population-based Cohort Study

OBJECTIVE

To define the incidence of erectile dysfunction (ED) in a population-based cohort of men with psoriatic arthritis (PsA).

METHODS

Data pertaining to demographics, ED, and potential confounding diagnosis were extracted from a comprehensive medical record system for a population-based cohort of men with PsA and an age-matched male comparator cohort. Cumulative incidence of ED adjusted for competing risk of death was compared between the 2 cohorts.

RESULTS

There were 128 age-matched pairs of men with PsA and without PsA in the described cohorts. At baseline, there was a 7% prevalence of ED in men with PsA prior to diagnosis compared to a 3% prevalence of ED in the comparator cohort (P = 0.16). After PsA diagnosis/index date, diagnosis with PsA was associated with an increased risk of ED (age-adjusted HR 1.45, 95% CI 0.79-2.68), but this association did not reach statistical significance. This was based on 24 cases of ED in the men with PsA and 18 cases within the comparator cohort. No confounding factors or ED treatment strategies differed significantly between men with PsA and ED and comparators with ED.

CONCLUSION

Men with PsA may have an increased risk of ED, which was detected but likely underpowered in this study. Whether this difference is secondary to higher prevalence of traditional risk factors of ED in men with PsA compared to the general population will require further study.

Male Sexual Health and Reproduction in Cutaneous Immune-Mediated Diseases: A Systematic Review

INTRODUCTION

Information about the possible effects of cutaneous immune-mediated diseases (cIMDs) on male sexual function and reproduction is scarce. Factors known to impair sexual health and reproduction, such as inflammation, medication use, and hypogonadism, can be present in a significant proportion of male patients with cIMD.

OBJECTIVES

To systematically review the literature for the influence of paternal cIMD on many aspects of male sexual and reproductive health, such as sexual function, reproductive hormones, fertility, and pregnancy and offspring outcomes.

METHODS

A systematic literature search was performed. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes, and offspring's health with a list of cIMDs.

RESULTS

The majority of the identified studies included patients with psoriasis (22 of 27), and sexual function was the most common outcome of interest (20 of 27). For patients diagnosed with psoriasis, the prevalence of male sexual dysfunction reported in these studies ranged from 34 to 81%. Hypogonadism in patients with psoriasis was reported in 2 of 3 studies. Sperm analysis abnormalities in patients with psoriasis were reported in 3 of 4 studies. No information about the effect of paternal disease on pregnancy and offspring outcomes was identified.

CONCLUSIONS

Disease activity in psoriasis might play an important role in the development of sexual dysfunction, hypogonadism, and abnormal sperm quality. For the other cIMD included in this review, there is insufficient information regarding male sexual and reproductive health to draw firm conclusions. More research is needed to understand the association between cIMD and impaired male sexual and reproductive health. Perez-Garcia LF, Dolhain R, te Winkel B, et al. Male Sexual Health and Reproduction in Cutaneous Immune-Mediated Diseases: A Systematic Review. Sex Med Rev 2021;9:423-433.

Genital Psoriasis: Impact on Quality of Life and Treatment Options

Psoriasis involving the genital skin occurs in up to two-thirds of psoriasis patients but is often overlooked by physicians. Furthermore, psoriasis objective and subjective severity indexes for common plaque psoriasis often neglect the impact this small area of psoriasis can have on a patient. It can have a significant impact on patients' psychosocial function due to intrusive physical symptoms such as genital itch and pain, and a detrimental impact on sexual health and impaired relationships. The mainstay of treatment is topical therapy. In patients with genital psoriasis refractory to traditional topical treatment, biologic treatments may greatly improve patient outcomes.

Risk Factors of Sexual Dysfunction in Patients with Hidradenitis Suppurativa: A Cross-Sectional Study

BACKGROUND

Hidradenitis suppurativa (HS) has a high impact on quality of life. However, sexual health has scarcely been investigated.

OBJECTIVE

To describe the frequency of sexual dysfunction (SD) in women and erectile dysfunction (ED) in men with HS and to explore potential risk factors.

PATIENTS AND METHODS

We conducted a cross-sectional study using a crowd-sourced online questionnaire spread by the Spanish hidradenitis suppurativa patients' association (ASENDHI).

RESULTS

In total, 393 participants answered the questionnaire. SD was found in 51% (95% CI 45-57%) of women and ED in 60% (95% CI 49-70%) of men. Factors related to SD were education status, patient's global assessment for disease activity, numeric rating scale for pain and unpleasant odour and the absence of a stable relationship. Factors related to ED were increasing age, the presence of active lesions in the genital area and the number of areas affected by active lesions.

CONCLUSIONS

There is a high prevalence of SD and ED in HS patients. Being in a stable relationship has been a protective factor of SD in women. The results suggest that sexual impairment in HS patients is due, at least in part, to disease activity, symptoms and active lesions.

Analysis of Sexual Problems in Men With Psoriasis

Psoriasis may have a negative impact on many aspects of patient life. The aim of the study was to evaluate the influence of psoriasis on erectile dysfunction and other sexual problems in men with psoriasis. A total of 76 men aged between 20 and 66 years (mean 43.9 ± 13.2 years) were enrolled. Psoriasis severity assessed according to the Psoriasis Area and Severity Index (PASI) ranged from 2.0 to 49.8 points (mean 15.1 ± 10.3 points). All patients were asked to complete the International Index of Erectile Function, the Beck Depression Inventory (BDI), and the Dermatology Life Quality Index. A detailed medical history regarding sexual problems was also collected. Erectile dysfunction was found in 43.8% of patients. The severity of erectile dysfunction negatively correlated with the age of patients (ρ = -0.42; p <  0.01) and depressive symptoms assessed by BDI (ρ = -0.39, p <  0.01). The majority of patients (77.6%) declared that the skin condition at least occasionally negatively influenced their sexual life. Patients with more severe psoriasis more often avoided sexual intercourse (p < 0.01) and felt ashamed in front of their sexual partners (p = 0.04). The vast majority of men (96.1%) felt unattractive during psoriasis exacerbation and felt embarrassed if skin lesions were present on uncovered body regions. More than half avoided social activities and sexual intercourse due to psoriasis. Moreover, 44.7% experienced rejection during their life because of psoriasis. Psoriasis negatively influences mostly emotional aspects of sexual life. Psychological disturbances, severity of the disease, smoking, metabolic syndrome, and other concomitant diseases might influence the presence and progression of erectile dysfunction in psoriatic patients. Dermatologists should be aware of these problems to put more attention on this aspect of psoriasis.

Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the US population. This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations on the basis of available evidence.

Evaluation of the occurrence of sexual dysfunction and general quality of life in female patients with psoriasis

BACKGROUND

Psoriasis has a significant impact on quality of life (QoL). Sexual life can also be affected, with sexual dysfunction being reported by 25-70% of patients.

OBJECTIVES

To determine the occurrence of sexual dysfunction and evaluate QoL in women with psoriasis.

METHODS

This case-control study included women aged 18-69 years. The validated Brazilian Portuguese versions of the Female Sexual Function Index (FSFI) and of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) were administered to all participants to assess sexual function and QoL, respectively. Patients with psoriasis underwent clinical evaluation for the presence of comorbidities, especially psoriatic arthritis and other rheumatic manifestations. Location of lesions and the extent of skin involvement were also assessed.

RESULTS

The sample consisted of 150 women, 75 with diagnosis of psoriasis and 75 healthy controls. Prevalence of sexual dysfunction was high in women with psoriasis (58.6% of the sample). Prevalence was statistically higher in women with psoriasis than in controls (P = 0.014). The SF-36 domain scores were also lower in women with psoriasis, with role limitations due to physical health, limitations due to emotional problems, and mental health being the most affected domains.

STUDY LIMITATIONS

Sample size was calculated to evaluate the association between the occurrence of sexual dysfunction and psoriasis, but it did not include the determination of the possible causes of this dysfunction.

CONCLUSIONS

QoL and sexual function were altered in women with psoriasis and should be taken into consideration when assessing disease severity.

Psoriasis and sexual dysfunction: links, risks, and management challenges

According to the WHO, sexual health is not merely the absence of disease. Sexual dysfunction may be present in 40.8% of psoriasis patients, furthermore, 68% prevalence was found in Brazilian women with psoriasis. The moderate prevalence of psoriatic lesions in the genital area (35%-42%) does not explain the alarming prevalence of sexual dysfunction. Other factors, such as anxiety, depression, and also psoriasis treatment may contribute to its development. Likewise, atherosclerosis of the pelvic vasculature is involved in the pathogenesis of erectile dysfunction. Risk factors for erectile dysfunction tend to be confused with the comorbidities seen in psoriasis patients. We also highlight that it may serve as a marker of cardiovascular risk.

The impact of genital psoriasis on quality of life: a systematic review

Psoriasis is a chronic immune-mediated inflammatory disease with significant medical and psychological comorbidities. In addition to having increased cardiovascular risk and mortality, psoriasis patients are more likely to be depressed, anxious, and endorse suicidal ideation than the general population. These patients often have low self-esteem and feel stigmatized due to their skin disease, which can prevent them from pursuing relationships, dating, and attending social activities. Up to 63% of adult psoriasis patients experience psoriatic lesions on their genital area during their lifetime, but often do not discuss these issues with their physicians due to embarrassment, stigmatization, or shyness about this sensitive location. However, psoriasis in sensitive areas, such as the genitals, may result in quality of life impairment greater than that of patients with psoriasis elsewhere on their body, particularly in respect to romantic relationships, intimacy, and sexual function. This article evaluates the current literature regarding the impact of genital psoriasis on the quality of life of affected patients.

Association Between Psoriasis and Erectile Dysfunction: A Meta-Analysis

BACKGROUND

Several studies have shown a relationship between psoriasis and erectile dysfunction (ED), but a meta-analysis of the data has not been performed.

AIM

To conduct a comprehensive meta-analysis of existing evidence to quantify and compare the risk of ED with psoriasis.

METHODS

A systematic literature search was conducted using MEDLINE, EMBASE, Cochrane databases, and Google Scholar. We calculated pooled odds ratios (OR), standardized mean difference (SMD), and 95% CI.

OUTCOMES

Outcome measures included characteristics of included studies, association between psoriasis and ED risk, and association for adjusted-for-covariates studies between psoriasis and ED risk.

RESULTS

In total, 9 studies with 36,242 psoriasis patients and 1,657,711 controls (participants without psoriasis) met inclusion criteria and showed that there was statistically significant association between psoriasis and ED risk (OR 1.35; 95% CI 1.29-1.41; P < .00001; I² = 44%). A significant association for adjusted-for-covariates studies between psoriasis and ED risk was also observed (OR 1.22; 95% CI 1.08-1.37; P = .002; I² = 43.8%). It revealed the International Index of Erectile Function-5 score was statistically significantly lower in the psoriasis group than controls (SMD -3.09; 95% CI -4.81 to -1.37; P = .0004; I² = 77%). A subgroup analysis was performed to potentially explain heterogeneity. It examined the main potential sources of inter-study variance including variance sample sizes and different assessment tools for ED.

CLINICAL TRANSLATION

The risk of ED in psoriasis patients should also be assessed by physicians.

CONCLUSIONS

This study is a well-designed and comprehensive meta-analysis to examine the relationship between psoriasis and risk of ED. However, the included studies are mostly cross-sectional or have small sample cohorts, which could bring bias and heterogeneity into the analysis. Our findings support the hypothesis that psoriasis is associated with an increased risk of ED. Furthermore, additional prospective cohort studies are needed to elucidate these relationships and to advance knowledge in this field. Wu T, Duan X, Chen S, et al. Association Between Psoriasis and Erectile Dysfunction: A Meta-analysis. J Sex Med 2018;15:839-847.

Prevalence of genital psoriasis in patients with psoriasis

BACKGROUND

Psoriatic lesions in the genital area (GenPs) can cause considerable physical and emotional distress. To increase physician awareness, we estimated the GenPs prevalence among patients with psoriasis.

METHODS

An English language literature search was performed. Articles reporting GenPs prevalence met the search criteria and were included. Because GenPs is rarely reported in demographics of prospective clinical trials, GenPs prevalence and baseline demographics of patients with and without GenPs in two prospective randomized phase 3b trials (NCT02561806 and NCT02634801) involving patients with moderate-to-severe psoriasis are reported.

RESULTS

Overall, 600 references were screened. Eighteen articles met the search criteria. Patient populations were highly heterogeneous across articles. Broadly, the presence of GenPs was either physician-reported (physical examinations) or patient-reported (questionnaires). In the literature, GenPs prevalence at the time of reporting ranged from 7% to 42% and the prevalence of GenPs at any time during the course of psoriasis ranged from 33% to 63%. In the two prospective clinical trials, the prevalence of GenPs at the time of enrollment was 35-42%.

CONCLUSION

A substantial proportion of patients experience genital lesions at some time during the course of psoriasis. Increased awareness of GenPs prevalence may drive improved assessment and treatment.

Impact of ixekizumab treatment on skin-related personal relationship difficulties in moderate-to-severe psoriasis patients: 12-week results from two Phase 3 trials

BACKGROUND

Psoriasis symptoms may decrease quality of life for patients. Skin-related personal relationship difficulties in psoriasis patients are common, under-reported and poorly understood.

OBJECTIVE

To assess the effect of ixekizumab (IXE) treatment on skin-related personal relationship difficulties in patients with moderate-to-severe psoriasis.

METHODS

Pooled data (N = 2570) on skin-related relationship problems were obtained from two large phase 3 trials (UNCOVER-2 and UNCOVER-3) in patients with moderate-to-severe plaque psoriasis randomized to subcutaneous placebo (PBO, N = 361), etanercept (ETN; 50 mg twice weekly, N = 740), or 80 mg IXE as one injection every 4 (IXEQ4W, N = 733) or 2 weeks (IXEQ2W, N = 736) for 12 weeks, following a 160-mg initial dose. The Dermatology Life Quality Index (DLQI) Personal Relationships Domain (PRD) (Items 8 and 9) was used to assess how much the skin caused any personal relationship difficulties at weeks 0, 2, 4 and 12. Improvement was compared for IXE vs PBO and ETN using logistic models. Factors associated with improvement were assessed using multiple linear regressions. DLQI Item 9, assessing sexual difficulties, was also analysed separately.

RESULTS

PRD scores (mean ± standard deviation) at baseline were similar across all treatment groups (PBO: 1.8 ± 1.9; ETN: 1.7 ± 1.8; IXEQ4W: 1.6 ± 1.8; IXEQ2W: 1.7 ± 1.8). Treatment with IXE rapidly and significantly improved the mean PRD score compared to PBO and ETN (P < 0.001 at all time points). Baseline PRD score was the strongest negative predictor of improvement. IXE enabled significantly more patients with moderate-to-severe plaque psoriasis to reduce their skin-related sexual difficulties at Week 12 compared to PBO (P < 0.001) or ETN (P < 0.001).

CONCLUSION

Ixekizumab improves patient-reported skin-related PRD difficulties in patients with moderate-to-severe psoriasis.

Psychosexual disorders and dermatologists

Sexual problems that are psychological in origin, rather than physiological, are called psychosexual disorders. Multiple factors, such as general health of the patient, chronic illnesses, psychiatric/psychological disorders, and socio-cultural factors, alone or in combination can be attributed to the development of psychosexual dysfunctions. The symptoms of these disorders vary for each individual and differ with gender. These disorders may be categorized as sexual dysfunction, paraphilias, and gender identity disorders. Dermatologists are sometimes consulted for sexual dysfunctions in their routine practice by the patients visiting sexually transmitted infections (STI) clinics because a majority of the patients believe that these problems are caused by dysfunctions in the sex organs, and because people are hesitant to go to sexuality clinics and psychiatrists for such problems. Sometimes these patients are referred from other specialties such as urology or gynecology; most often, we attempt to search for STIs or other dermatoses on the genitalia and refer them back. We often underestimate the prevalence of sexual concerns of the patients or feel uncomfortable discussing matters of sexuality with them. Dermatologists should understand basic sexual medicine and ask patients for sexual problems. They should be trained to manage such patients accordingly. In this review, we will be focusing on sexual dysfunctions, their etiopathogenesis, and management from a dermatologist's perspective.