4. A 43-year-old woman reports a “recalcitrant yeast infection” of the vulva, with itching and irritation. She is overweight and diabetic, with mild stress incontinence. Physical examination reveals a fairly well-demarcated red, rough plaque on the vulva and labiocrural folds, with satellite red papules and peripheral peeling. Similar plaques occur in the gluteal cleft, umbilicus, and axillae as well as under the breasts. A fungal preparation of the vagina and skin is negative.
Diagnosis: Of the several morphologic types of psoriasis, anogenital psoriasis is most often of the inverse pattern. Inverse psoriasis preferentially affects skin folds and is frequently mistaken for (and often initially superinfected with) candidiasis. Scale is thin and unapparent, and there often is a shiny, glazed appearance to the skin. Tiny satellite lesions are often visible as well. A skin biopsy of inverse psoriasis often is not diagnostic, showing only nonspecific psoriasiform dermatitis; this does not disprove psoriasis.
Psoriasis is a systemic condition and is associated with metabolic syndrome, carrying an increased risk for overweight, hypertension, diabetes, and cardiovascular disease. Management of these conditions is very important in the overall treatment of the patient.
The recommended treatment is clobetasol ointment applied to the skin folds, along with continuation of the topical miconazole cream. A week later, the patient’s condition is remarkably improved, and her biopsy shows psoriasiform dermatitis. The potency of her corticosteroid was reduced by switching to desonide cream, sparingly applied daily.
For more information on this case, see “Chronic vulvar irritation, itching, and pain. What is the diagnosis?” OBG Manag. 2014;26(6):30-37.