Clinics in Dermatology (2015) 33, 456–461

Psoriasis inversa: A separate identity or a variant

of psoriasis vulgaris?
Silje Haukali Omland, MD, Robert Gniadecki, MD ⁎
Department of Dermatology, Bispebjerg Hospital, Copenhagen University, Copenhagen, Denmark

Abstract Psoriasis is a chronic skin disorder affecting approximately 2% of the European and American
population. The most common form of psoriasis is the chronic plaque type. Inverse psoriasis, also
named flexural or intertriginous psoriasis, is not considered a separate disease entity but rather a special
site of involvement of plaque psoriasis, characterized by its localization to inverse/intertriginous/flexural
body sites. We review current evidence and establish whether inverse psoriasis is a separate disease
entity based on characteristics in terms of epidemiology, pathogenesis, clinical and histologic
presentation, microbiology, and treatment.
© 2015 Elsevier Inc. All rights reserved.

Psoriasis is a chronic skin disorder affecting approxi-
mately 2% of the European and American population.1 The
most common form of psoriasis is the chronic plaque type.
Inverse psoriasis, also named flexural or intertriginous
psoriasis, is not considered as a separate disease entity but
rather a special site of involvement of plaque psoriasis,
characterized by its localization to inverse/intertriginous/
flexural body sites. The skin at the inverse body sites differs
from skin at extensor sites with less epidermal keratinization
and more sweat glands. This might suggest a different
disease pathogenesis as is seen for psoriasis on the palm and
soles and might have an impact on the choice of treatment.
The aim of this systematic literature review was to
provide an overview of current knowledge in this field and
to try to clarify whether there is adequate support to
categorize inverse psoriasis as a separate disease entity,
based on characteristics in terms of epidemiology, patho-
⁎ Corresponding author. Tel.: +45 31343171.
E-mail address: R.gniadecki@gmail.com (R. Gniadecki).
genesis, clinical and histologic presentation, microbiology,
and treatment modalities.
Methods
We searched for relevant literature in the PubMed
database with the MeSH terms “flexural psoriasis” OR
“inverse psoriasis” OR “psoriasis inversa” OR “intertriginous
psoriasis” OR “genital psoriasis.” We screened all reviews
and original contributions on title and abstract. Because
literature regarding inverse psoriasis alone was very limited,
we also included case reports. The selection of literature was
restricted to work published in English from the year 2000
and forward.
Our PubMed search resulted in 213 publications
(Figure 1). A first screening based on the contribution
and/or abstract title led to exclusion of 133 publications.
The remaining 80 abstracts and, if in doubt, full text
contributions were read and a further 21 were excluded for

http://dx.doi.org/10.1016/j.clindermatol.2015.04.007
0738-081X/© 2015 Elsevier Inc. All rights reserved.
Psoriasis inversa: A separate identity or a variant of psoriasis vulgaris?
Fig. 1 Flow chart for literature search.
various reasons. The 59 papers left were carefully read, and
38 publications were included in this literature review
(Figure 1). The remaining 15 papers in the reference list are
background literature.
Results
Epidemiology
The prevalence of inverse psoriasis among psoriatic patients
ranges from 3.2%2 to 7% in Chinese populations3 to 12%4 to
36%5 among Europeans. This difference depends somewhat
on whether genital psoriasis is evaluated as being part of
inverse psoriasis or is considered a distinct entity. In a
questionnaire-based study from the Netherlands, appearance of
flexural and genital psoriasis was often found independently;
one third reported current involvement of genital areas, and of
these 38% did not have flexural involvement. Previous genital
involvement in patients currently affected by flexural psoriasis
was only reported in 33% of cases. Based on this, the authors
argue that flexural and genital psoriasis are distinct entities.6
The true prevalence of inverse psoriasis remains unknown,
and a clear-cut definition of inverse psoriasis is necessary to
obtain a more accurate impression of the frequency.
457
Clinical presentation
Chronic plaque psoriasis is typically localized to extensor
surfaces of the skin, whereas inverse psoriasis is defined by
its localization to inverse/intertriginous/flexural areas where
two skin surfaces meet. Inverse psoriasis can be localized to
the axillae, groin, genital area, umbilicus, postauricular area,
intergluteal cleft, inframammary creases, antecubital fossae,
and popliteal fossae. The predilection site for inverse
psoriasis has only been reported in one retrospective study
investigating 48 patients with inverse psoriasis. This study
reported that the site most commonly involved is the groin
(95.8%) and the antecubital fossae less commonly (18.8%).3
Inverse psoriasis can be present in intertriginous areas alone
or in combination with psoriasis at extensor sites.
The localization of the psoriatic lesions to the inter-
triginous areas affects the clinical presentation. The most
evident difference between classical plaque-type psoriasis
and inverse psoriasis is the lack of, or less, scaling at the
intertriginous areas. The lesions are well demarcated,
erythematous, and often presenting with a shiny/glazed
appearance. This is caused by the moist, warm milieu at
the flexural body sites characterized by harboring conglom-
erations of follicles and sebaceous glands in conjunction
with numerous apocrine and eccrine glands (in particular
the axillae and groin) that might lead to friction and
maceration.3,7 This renders the inverse areas more suscep-
tible to Koebner phenomenon. Genital skin differs in some
respects from flexural skin, with the vulvar and penile skin
starting as stratified, keratinized squamous cell epithelium
on the outer parts and converting to mucosal lining at the
inner parts, with an intermediate transition zone. At the more
keratinized surfaces of the genital skin, scales might be
seen.8 On the histopathologic level, the lessened scaling is
reflected by similarly decreased presence of epidermal
hyperplasia, and more pronounced spongiosis in inverse
psoriasis is also a histologic characteristic.9
Associations with other diseases
Inverse psoriasis has been found more commonly in
patients with nail involvement compared with psoriatic
patients without affection of the nails in a questionnaire-
based survey with nearly 1500 responders10; otherwise, no
correlation between inverse psoriasis and particular clinical
manifestations of psoriasis has been reported within the time
scope of this review. Attempts to find a correlation between
HLA-Cw6 and inverse psoriasis have not been successful,2
and in subtyping of psoriasis by the use of statistical
methodology identifying six different clusters, inverse psori-
asis did not contribute significantly in any of the clusters.11
Psoriasis, in general, has been associated with comorbidities,
such as cardiovascular disease, metabolic syndrome,12 and
lymphoma.13 Currently, no work has been published on
comorbidities associated with inverse psoriasis.
458
The clinical presentation of psoriasis in HIV patients has
been reported to be more often of the inverse type, despite the
fact that the incidence of psoriasis in general in this
population equals the background population. 14 In a
retrospective study of 50 HIV patients with psoriasis, 36%
had flexural involvement and 26% had involvement of the
genitalia,15 and severe psoriasis presented in intertriginous
areas might be the first symptom of HIV infection.16
Development of inverse psoriasis has been reported
as a paradoxical side effect to treatment with infliximab
for Crohn's disease17 and hidradenitis suppurativa. 18 The
localization of both hidradenitis and inverse psoriasis to
intertriginous areas and the possible affliction of a moist,
warm milieu in inverse body sites could suggest a
correlation between these skin diseases, but it appears not
to be the case.19
Lifestyle and body habitus have an impact on the
manifestations of chronic plaque-type psoriasis, with obese
individuals being more likely to present with severe psoriasis.
Inverse psoriasis has been observed to be more common in the
obese population with the extremely obese having a trend
toward inverse psoriasis.20 To date, no study has investigated
the influence of being overweight in relation to isolated inverse
psoriasis, and the link between inverse psoriasis and adiposity
remains unclear.
Correlation between inverse psoriasis
and microbiology
An association between streptococcal pharyngitis and
guttate psoriasis is well described in the literature, and
infection with streptococci can both trigger and exacerbate
preexisting chronic plaque-type psoriasis.21
An impact of bacterial or fungal overgrowth in the
pathogenesis of flexural psoriasis has also been speculated
due to the moist environment in the flexural sites. In 100
psoriasis patients, of whom 31 had inverse psoriasis,
specimens for candidal study were collected from the axillae
and groin without increased prevalence of Candida in the
intertriginous areas of psoriatic patients compared with
healthy controls and patients with atopic dermatitis. Candida
on the tongue was more common in psoriatic patients
compared with those with atopic dermatitis but without
correlation to clinical manifestations; the investigators
concluded that it was clinically irrelevant.22 A 2003 study
examining colonization of Candida in patients with inter-
triginous psoriasis did not detect Candida in either
intertriginous psoriasis or control groups.23
In an immunohistochemical study comparing inverse
and chronic plaque psoriasis to investigate a possible
pathogenetic difference, a decrease of CD161+ cells in the
dermis of flexural psoriasis patients was found. The authors
speculate it to be caused by a microbial overgrowth in
flexural psoriasis thereby affecting NK cells, 24 but this
remains speculative.
S.H. Omland, R. Gniadecki
In conclusion, no studies have reported bacterial or fungal
overgrowth of inverse psoriasis within the time limits for
this review.
Quality of life
It is well known that psoriasis has a great impact on
quality of life, but there is limited knowledge about sexual
health and quality of life in terms of inverse/genital psoriasis.
A questionnaire-based study from 2011 found that sexual
health is diminished in patients with psoriasis and that
women with genital affliction are particularly affected with
sexual distress.25 This has recently been confirmed.26
Inverse, or in particular genital, psoriasis seems to be
underreported and undertreated in the clinic; almost half of
patients with genital psoriasis never spoke to their physician
about the genital lesions, and only a quarter found their
physician to pay relevant attention to it. Nearly 70% did not
treat the genital lesions.27 This reflects the psychological
aspect of inverse/genital psoriasis but might also reflect lack
of knowledge about the frequency of the problem.
Treatment
From a pharmacologic point of view, application of topical
treatment in the intertriginous areas can be considered as
treatment under occlusion due to enhanced hydration and
increased percutaneous absorption. The inverse areas are
considered more sensitive and prone to side effects from
topical steroids (ie, due to thinner skin at these locations).28
Treatment with steroids should probably be done with caution
to avoid side effects; however, no data comparing steroid
side effects in inverse and extensor sites have confirmed a
higher rate of corticosteroid-induced implications.29 The
thinner skin and lack of scaling of the psoriatic lesions at the
intertriginous areas can also assist in the treatment. Topical
calcineurin inhibitors with limited efficacy in classic plaque-
type psoriasis30,31 have proven efficient in inverse psoriasis.
Two double-blind studies comparing tacrolimus with either
placebo32 or topical calcitriol33 reported tacrolimus to be
superior. Two double-blind studies investigated pimecrolimus,
either compared with calcipotriol, betamethasone dipronate,
and placebo34 or compared with placebo.35 Betamethasone
dipronate was significantly more effective than pimecrolimus,
although no significant difference was found between
calcipotriol and betamethasone dipronate and between calcipo-
triol and pimecrolimus.34 In the study comparing pimecrolimus
and placebo, pimecrolimus was significantly superior to
placebo.35 Five open prospective studies36–40 all reported the
efficacy of topical tacrolimus 0.1%, and one retrospective study
of 13 children reported complete clearance in 12 of 13 children
after 2 weeks of treatment with topical tacrolimus.41
Different vitamin D3 analogues have also been compared.
A double-blind left-right study conducted in 2003 compared
calcitriol and calcipotriol in the treatment of psoriasis localized
Psoriasis inversa: A separate identity or a variant of psoriasis vulgaris? 459

in facial, hairline, retroauricular, or flexural psoriasis.
Calcitriol was found to be superior in both safety and efficacy
with most pronounced improvement for the flexural areas.42 In
an open-label study with 11 patients treated with calcipotriol
50 μg/mg twice daily for 6 weeks, 10 experienced complete
remission after the end of treatment (Table 1).43
The combination of tacrolimus and excimer therapy was
efficient in a patient resistant to prior treatment of inverse
psoriasis44; adalimumab was effective on inverse psoriasis in
a patient with psoriatic arthritis45; oral dapsone followed by
topical calcineurin resulted in complete remission of inverse
psoriasis46; topical coal tar 2% foam as monotherapy led
to complete clearance of axillary psoriasis47; efalizumab
treatment resulted in complete and sustained remission
during maintenance therapy in a patient with severe inverse
psoriasis48; excimer laser 308 nm has been tried with
success49; and, finally, botulinum toxin lead to improvement
of inverse psoriasis in a patient with hyperhidrosis.50
The efficacy of botulinum toxin in the treatment of
inverse psoriasis has further been tested in a small clinical
open-label trial with improvement in 13 of 15 patients.51
A literature review grading the efficacy of topical
treatments in treatment of facial and flexural psoriasis,
ranging from A1 to D, concludes that topical steroids,
vitamin D3, and calcineurin inhibitors are equal as first-line
treatment with individualization of the patient.52 A treatment
guide from the Medical Board of the National Psoriasis
Foundation from 2009 recommends low-potency topical
steroids as the first-line treatment for the short term, but with
a shift to vitamin D3 or calcineurin inhibitors when there is
need of treatment for more than 4 weeks.53
Conclusions
Inverse psoriasis historically has been categorized as
chronic plaque-type psoriasis located in inverse areas. To
date, no separate pathogenic mechanism has been found, and
attempts to prove a role for bacteria or fungi in correlation to
inverse psoriasis or a correlation to a specific HLA subtype
have not been sustained. Inverse psoriasis did not contribute
significantly when trying to cluster psoriasis into different
subtypes. This supports the hypothesis that inverse psoriasis
is not a disease entity in itself.
Inverse psoriasis might be more common in people with
HIV, possibly indicating a different immunologic interplay.
A tendency toward an overrepresentation of inverse psoriasis
in the obese could suggest friction/maceration as a triggering
factor of psoriasis at intertriginous sites as well. Correlation
between nail psoriasis and inverse psoriasis might indicate a
certain disease pattern. The different histologic appearance
of inverse skin with less epidermal hyperplasia and the
corresponding lack of scaling in these areas could suggest
divergent mechanisms in the development of inverse

Table 1 Schematic overview of clinical trials and inverse psoriasis

Publication Study type Method Psoriasis type Conclusion
Lebwohl et al (2001) Double blinded 0.1% tacrolimus vs Facial and intertriginous Tacrolimus was superior to vehicle
vehicle (n = 167) psoriasis early (P b .004) and at end of
treatment (P b .001)
Liao et al (2007) Double blinded Tacrolimus 0.3% vs Facial and genitofemoral Both were efficient, tacrolimus
calcitriol (n = 50) psoriasis superior to calcitriol (P b .05)
Kreuter et al (2006) Double blinded Pimecrolimus 1% vs Intertriginous psoriasis Efficacy of all three topical;
calcipotriol 0.005% vs betamethasone and calcipotril
betamethasone 0.1% vs were superior to pimecrolimus
vehicle (n = 80) (P b .05%)
Gribetz et al (2004) Double blinded Pimecrolimus 1% vs Intertriginous psoriasis Pimecrolimus was superior to
vehicle (n = 57) vehicle (P = .0007)
Rallis et al (2005) Open prospective Tacrolimus 0.1% (n = 10) Facial and anogenital psoriasis Improvement in all patients
Martin Ezquerra et al Open prospective Tacrolimus 0.1% (n = 15) Facial, intertriginous, genital, Improvement in all patients
(2006) and plaque type
Brune et al (2007) Open prospective Tacrolimus 0.1% (n = 11) Facial and intertriginous Improvement in all patients
psoriasis in children
Bissonnette et al Open prospective Tacrolimus 0.1% (n = 12) Male genital psoriasis Improvement in all patients
(2008)
Freeman et al (2003) Open prospective Tacrolimus 0.1% (n = 21) Facial and intertriginous 17/21 had complete clearance at
psoriasis day 57 (end of study)
Ortonne et al (2003) Double blinded, left-right Calcitriol vs calcipotriol Facial, hairline, retroauricular, Calcitriol superior to calcipotriol
comparison (n = 75) and flexural psoriasis (P b .002)
Duweb et al (2003) Open prospective Calcipotriol (n = 11) Flexural psoriasis 10/11 had complete clearance after
6 weeks
Zanchi et al (2008) Open prospective Botulinum toxin type A Inverse psoriasis Improvement in 13/15
50-100 U (n = 15)
460
psoriasis compared with psoriasis located in extensor sites.
This is reflected in the different treatment options, where
calcineurin inhibitors with modest efficacy in chronic
plaque-type psoriasis play a bigger role in the treatment of
inverse psoriasis.
Psoriasis in intertriginous areas might be an underestimated
problem with a great impact on the quality of life. There has
been little attention paid to inverse psoriasis, and literature
dealing with isolated inverse psoriasis is sparse. This probably
reflects the current opinion that inverse psoriasis is part of
chronic plaque-type psoriasis and not a separate disease entity.
There is no evidence that inverse psoriasis is a separate disease
entity, although present literature is sparse, and future
epidemiologic, investigative, and clinical studies might reveal
different pathogenic and etiologic mechanisms. The problem is
probably underrated and should be considered by all
physicians treating psoriasis patients.
Disclosures
Robert Gniadecki has board membership with AbbVie,
Pfizer, and Merck Sharp and Dohme (MSD) (advisory boards);
consultancy fees from AbbVie, Pfizer, Janssen, MSD, Leo
Pharma, Pfizer, Janssen, MSD, and Therakos; and payment for
development of educational presentations from Janssen.
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