Diagnosis and Clinician–Patient Conversations

This discussion outlines best practices for the physical diagnosis of genital and intertriginous psoriasis, including the role of comprehensive skin examinations and considerations for biopsy in cases of diagnostic uncertainty. Experts also share practical strategies to normalize sensitive-site conversations, improve patient comfort, and support accurate detection and documentation.

Watch the full series: Genital and Intertriginous Psoriasis Expert Panel Video Series

Shehla Admani, MD: All right, so that was a really great discussion. Let’s move on to our next chapter, and that’s physical diagnosis and clinician–patient conversations. So, we already talked about this need for an ICD-10 code, right? We need to have an official diagnosis. We need to assess the true need. Without that, it leaves us, as the healthcare providers, to really tease out, “Does this patient have genital psoriasis?” That’s not always very easy to do. Initially, you go into the room, you start the conversation, you take your history. How do you start that conversation? I don’t know if you want to maybe get us started on that. 

John Zampella, MD, FAAD: Yeah. I mean, if someone’s coming in specifically for psoriasis, for me, it’s a very easy segue, especially because, again, I’m trying to build a rationale for what treatment I’m going to use. It’s easy to ask, “Hey, where else do you have it? Is it in your scalp? Is it in your ears? Is it in your groin? Does it happen in your butt?” Those kind of give me the in to ask the questions and then obviously look. 

At the men’s center, I have a lot of patients who come in with just a genital rash, and 3% to 5% of patients can have genital-only psoriasis. In those scenarios, it actually gets a little challenging to make the diagnosis. So, those patients, you invariably have to look. Actually, even looking sometimes could be a challenge to make the diagnosis. So, sometimes you say, “Okay, we’re going to treat this empirically and let’s see what happens.” 

Admani: Yeah. So, once you start the conversation, letting them know, “Hey, psoriasis can occur on any part of the body. It can be on your scalp, it can be on your nails, it can be on the butt crack.” If you just normalize some of that conversation, I think it can be so helpful. When you’re doing the exam, Melodie, I don’t know if you can share with us, do you have some sort of standardized approach as to who gets a more comprehensive exam? What is a comprehensive exam in your clinic? 

Melodie Young, MSN A/GNP-c: For psoriasis specifically, if they’re coming in for that or some sort of rash and we haven’t yet established the diagnosis, I do the same thing that he does. They show me, “I have psoriasis because this looks like the photos they’ve seen online,” but they don’t equate some of the other things, the nail pits, being psoriasis, or genital or flexural. So, I will kind of ask the questions. Rarely do I not find something additional to what they’ve shown me, so I know to go to the hotspots, the ears, the scalp, not just the elbows and knees.  

Then, I start asking the questions, being a little bit more politely intrusive: “Do you have it at the top of your butt crack?” I don’t use the proper technical, the gluteal cleft. Then, “Do you have any there? Well, does it ever hurt? Is it red?” Because sometimes it won’t be there at the time that they’re there for the visit. Then, move on to the other places. “What about in the groin? What about in the genitalia area? Do you have redness or rash or any things that may look different than what you see in other areas?” I just bring that up and then will say, “If you don’t right now, you may. It’s very common. At some point, you’re going to see something, and I just want you to know that is very likely psoriasis. It’s okay to take a picture of it, bring me the photo, and then let me see, because it’s very important that we give you the right therapy, the right diagnosis, and that you not use the medicines that you have at home on that area.”  

So, I kind of go about the same way. Then, if they want to show me something, I will often tell them, “You can just drop trou and let me look.” You get your little light, start the exploration, or just say, “Just scoot over.” If they’re shy, just scoot over and show me just a little bit. Then, if I think that’s what it is, I might need to see more, but just let me have a little sneak peek. 

Michael Payette, MD, MBA, FAAD: I’m curious, do you guys have all of your psoriasis patients undress on the first exam into a gown, or do you allow them to come in in their street clothes and then sort of work through it? 

Young: We ask them if they want to, and then usually we’ll say okay. When they get clear or are doing well, then I’ll say, “Now’s when we really need to do the exam,” because they need to see once all that plaque is gone what else is going on with your skin. Do you have them stripped down? 

Payette: I think I should. I think sometimes where I’m guilty is that patient who comes in with limited psoriasis on the extremity, on the scalp, maybe the upper back, and they just want to show you that spot. I know I need to examine the whole patient. It’s much easier if they get undressed into a gown versus pulling an arm out, undoing their belt, dropping their pants, turning this way, turning that way. 

Part of why we’re having this conversation is to encourage our peers to remember that a comprehensive exam needs to be done, because sometimes if you don’t get them undressed into a gown at that first visit, then at a subsequent visit, you can do it. I think sometimes it’s a very uncomfortable experience for a patient, especially a new patient who’s never met you before, to get fully undressed. 

Zampella: I don't always have my patient get undressed, especially on the first visit. I agree, but it's funny because why don't we have them get undressed? We think it's going to be faster to just show me the spots. But then like you said, after they show your elbow, they're like, oh, okay, then show me over here. By the time you’ve actually seen all the spots they point out to you, you might as well have just had them get undressed. It would've been faster.  

Payette: Yeah. The irony is they get undressed when they go see their primary care physician anyway, and then they're just getting their heart listened to and their lungs listened to. But for some reason, I don't think derms... we just don't do it enough. I think a big point of what we're trying to establish here is that whether you do it on the first visit or you do it on that subsequent visit, make sure at some point you do that comprehensive exam. On top of that, you have to then do that comprehensive exam again. I find a lot of times when my patients come back for that second or third visit, they're like, "Well, you already know what I have. We're just here to talk about the treatment." And I'm like, "Well, yeah, but I need to assess how that treatment has worked where it needs to have to look."  

Zampella: It's always so funny to me, too, because some of the patients will come in, and say you've given them a treatment, and I'm like, "Oh, how's it going?" And [they’ll say], "It's great." From their perspective, it may be great because it was way worse before, but then when you actually look at it like, "Well, I don't think that's that great. I think we could do better than that." So, that's another reason to look because if you just ask in that regard, you're maybe undertreating the patient exactly because the patient's point of view is, “Yeah, this is way better than it was,” but they don't know that we can even make it better than that, maybe.  

Young: We need to drive the exam and not let the patient drive the exam to say, "I want you to look at a spot. I want you to look at something." You have to be a salesman, and you have to be really good at reading people and developing relationships with people and kind of meeting where they are with them.  

Zampella: One of my mentors used to say, "No peekaboo dermatology. No peekaboo. No peekaboo. We are looking at your skin."  

Admani: That's right.  

Young: Yeah.  

Admani: Right. I love that. I think with genital psoriasis, we all know it looks different. It feels different. We can't just let our patients volunteer that information. We know that there are so many things that we have to do on a regular basis. Like our pap smears, our colonoscopies, we do so many things that are routine and uncomfortable. So, if we work to make this full physical exam more routine, our patients are going to get better care. You're exactly right. They don't always know when things are better, and so it is important for us to look. Setting that stage, Melodie, I think is so great, letting them know that it can happen on the genital skin. If it's not there right now, if it comes up, you let me know. I am your go- to person.  

Payette: What I'm taking away from this is we should do propofol to do our general exams.  

Zampella: Everybody gets your little benzodiazepine on the way in.  

 Young: Or martinis or something. 

Zampella: Exactly. 

Admani: Okay. So the dreaded genital biopsy. Who do you biopsy? When do you biopsy? Talk me through it.  

Payette: Yeah, no, it's a great point. I think that most of the time, even genital psoriasis is a clinical diagnosis, especially if you have other supporting features. You have a family history of psoriasis, you've got psoriasis in other locations. We kind of all roughly know what it looks like. It's going to have more of that sort of pinkish red, maybe some light scale, but you're never going to see that micaceous scale that you see with traditional psoriasis. So, I generally don't biopsy if it's very suggestive of general psoriasis. When I do biopsy is when I've instituted a therapy and something hasn't responded the way I thought. Or, if I'm looking at it and I'm like, I'm not really sure. I teach my medical students and residents that biopsy is not just, "Oh, this is a basal cell. I'm going to biopsy it to get insurance coverage." A biopsy was really designed to be a diagnostic tool to help you in your differential.  

There are things we have to consider down there. Yes, you can have sexually transferred diseases, you can have extramammary Paget’s disease, you can have even intertrigo. So, I think in those scenarios where you're not 100% sure what you're seeing or you've instituted some therapy where it hasn't responded the way you expected, then it's appropriate to introduce that topic. The irony, and again, I take care of mostly men with genital disease, but they're terrified of that experience. It's actually not that bad. Most of them, you could probably agree that after they've had a biopsy done, they're like, oh, I was way more worried about that than I needed to be. Obviously, there are certain areas of the genitalia, like the head of the penis, for example, where if I don't ever have to bias it on my lifetime, great. Along the shaft of the penis or the scrotum, or even in the intertriginous creases there, those biopsies are not particularly painful. Although the anxiety component for a patient, I think, prepares them for this horrible experience. 

Zampella: I actually would take out the dreaded biopsy. I would take out dreaded because I actually have a little paper that we wrote on this. You can go look it up. I tell my patients genital biopsy is the least painful biopsy I do. Even the head of the penis, in fact. In my little paper, if you want to go read it, what we did was essentially just: if you go into your cabinet, into your refrigerator, and you get your 23% lidocaine, tetracaine that you use for your cosmetic patients. Maybe you're not doing that with your pediatric patients, but go next door to your cosmetic person. Grab a little jar of their high-strength lidocaine. You say, "Are you in a rush to get out of here?" Usually, they're not if you're talking about doing a biopsy. You circle your spot, you put a dab of that on there for 5, 10 minutes, the genitals numb topically exceedingly well and exceedingly fast. You can almost go do the biopsy without even injecting any lidocaine at that point, but I always do. They will walk away, exactly like Mike said, that that was not bad at all.  

Admani: Yeah. I think also you don't have to be that fancy because I'll use lidocaine 4% cream on my vulvar biopsies.  

Zampella: Could do.  

Admani: I think it works beautifully, and oftentimes the patients will be like, "This process was so much better than with my gynecologist,” because they don't always get the numbing with other providers. So, we definitely do have that tool and we should utilize it.  

Zampella: For sure. That alleviates a lot of the anxiety around it, too. If you tell them this is not going to be painful.  

Admani: Yeah. So, one thing we didn't talk about, you want to biopsy when you're thinking about other things, when you're not 100% certain this is psoriasis, it's not responding how you want it to. We also have to make sure that we're doing our physical exam in a way that we're ruling out other differentials.  Generally, when I'm approaching a vulvar exam, I have this standardized method that I do working through all the different structures in my mind, and I go through it. I look at the mons, the inguinal creases, labia majora, labia minora, the introitus, the perineum, perianal area, everything. That way, I know that I'm not missing subtle signs of another disease. I don't know if you guys have a similar approach that you use in your male genital clinics of some standardized way of how you approach the exam.  

Zampella: I do something very similar to you. I have the patients show me, and then actually, it varies a little bit whether a patient's circumcised or uncircumcised. If they're uncircumcised, it's a little bit easier. Depending on what you feel comfortable with, I'll usually let the patients manipulate themselves and say, "Can I see this side? Can I see that side? Can you lift up your scrotum?" If they're uncircumcised, I'll say, "Can you retract the foreskin? Can I look?" And go about it that way. But I agree, having a standardized way to go about that to make sure you're hitting all the parts is important.  

Payette: Can I ask you guys also, do you take photos?  

Young: Yes, that is really interesting. The lady I work with, Dr Jennifer Cather, she is so funny. She's sort of a Southern California hippie. I joked about [how] she can get a picture; she gets more pictures of genitalia than anybody I know, where I'm more shy about it and try to say, would you mind? I think now that we take photos of everything in our clinic, it seems much more commonplace. The first thing that we're doing, if, "Hey, I want to take a picture of your genitalia," I probably would kind of ask if it's okay and then try to give them a little bit of modesty, try to protect some things and just take the photo of what I need.  

Payette: I think it's super important because we take photos of everything, and especially if you're going to do a biopsy, if you don't have that photo, I mean, that biopsy is essentially incomplete, right? What we try to do is using the same blue surgical towels that you use if you're doing surgery, is we will essentially drape the patient to only expose the genitalia. So, it's basically de-identifying. You don't want to take a picture from 4 feet back. That's not going to help you, but I think it's important that we do that. I think it's important that our peers be comfortable doing that too, but obviously doing it in a way that's respectful for the patient.  

One of the things I also wanted to touch on real quickly, getting back to the biopsy for a second, is I have the privilege of having a nurse who works with me, and she does all of my anesthesia for surgeries and for biopsies and whatnot. So, when I'm talking about doing a biopsy on a patient, I have to let them know that I have a nurse who's here. “Are you comfortable if she comes in and does the biopsy? And if you're not comfortable, I'm more than happy to do all the” ... I mean, not the biopsy, the numbing part. “If you're not comfortable, I'm more than comfortable to do it for you.” I think sometimes that if you don't do that and you're expecting your doctor to come back in and your doctor is now of the opposite gender, then patients are like, "Ooh, I don't want to now. " That was one of the things I just wanted to...  

Admani: That is a really good point. In our clinic as well, the nurse does the numbing, but I numb all my vulvar biopsies myself.  

Payette: Oh, you do?  

Admani: I feel like it took me some effort to make that relationship and to get the buy-in for moving forward with the biopsy, and I just feel like personally, I owe it to them to do it start to finish, but I don't think that necessarily has to be the case. The key with anything that involves a genital area is consent, right? Having a conversation and asking them. You ask for permission to do the photos, you ask for permission for the biopsy. If you're involving anyone else in their care, you ask for permission for that as well. We can't make any assumptions as to what a patient is or isn't going to be okay with. We just have to ask. 

Young: That's a great point. One of the things I wanted to go back to related to biopsies because you were talking about male genitalia. With female genitalia, if it's anywhere around a structure that I'm going to be concerned about, I'm actually going to refer that out. I have sent it to derm surgeons to have a biopsy done, or I've sent to a gynecologist to say, because I've just seen and heard of situations. I think it's perfectly acceptable to say, "This needs to be biopsy. We need to know what that is, and it's in an area where I'm not comfortable.” Now, that's mostly not going to be dealing with psoriasis of the genitalia, but if you're looking there and you find something, I think you need to know whether or not it's something you're comfortable doing or you need to get some extra assistance as someone who does that regularly and really understands all the structures, all the nerves, all the things.  

Admani: It's never wrong to phone a friend for help.  

Zampella: Yeah. I find that something, I agree, even in men, something really close to the urethral meatus or something right over the urethra, like the skin right over the urethra, sometimes that gets a little dicey. So, I agree. You got to have your friends on speed dial.  

Admani: Yeah. We talked a little bit earlier about pediatric patients, right? So, that unique population and that consent process, having that conversation, asking. With the adolescents, if you ask them if you can do a genital exam and they say no, how do you move forward from that?  

Payette: I would even expand on that. Even say cultural differences in terms of how people dress, and what their faith may be, because this comes up not infrequently. I can actually think of an unrelated case of a Muslim lady I have who has vitiligo, but I have no idea to this day what the extent of that vitiligo is because it's against her faith to show me. So, I think it can be really challenging, but at the end of the day, we have to be respectful of our patient's choices as long as they're not doing something that in some way causes harm. We have to be respectful of that. If they decline, then what I will do in my note is, I will just say, patient declined that exam or declined that biopsy because I want it to be documented, but also, I'm not going to do something that they don't want. That's a great question.  

Zampella: I was going to say for me, half my patients at the Center for Men's Health are women actually. So, I do see a lot of both female genitals, but also females in my practice. I've had patients who I can tell they're uncomfortable with either talking about or showing me their private areas and stuff. I say, "Listen, I'm happy to take care of you, but we have a women's center. If you would feel more comfortable with somebody else, because you need this, you deserve to feel comfortable going to see your doctor, I'm happy to put a referral in." We work together all the time in our department with other people. So yeah, not being afraid to, again, phone a friend, getting people to the care that they need.  

Payette: John, maybe you can comment on this, but we do the same thing too, because I obviously take care of a lot of women as well, and I offer them that opportunity. What I find is that just offering the opportunity makes them feel more comfortable to just proceed with what you're doing today.  

Young: You showed respect. The beautiful thing is that you're starting the conversation, you're letting them know this needs to be done. We want to be done, right? It shows respect.  

Admani: Yeah. 

Payette: Yeah. I find a lot of times though, they actually like to relax a little bit and like, this person really cares about me, and so now I'm actually going to let them proceed with the exam.  

Admani: Yeah. So, I think the big takeaway is that we don't force genital exams. Right? If they're not ready, you don't need to move forward that day. Maybe you're not going to be the person who does that for them, but I think it's also important to remember that just because we're not examining the area doesn't mean that we can't offer treatment, right? It is totally okay to go based on just their symptoms and maybe offer a little empiric treatment to get started. Then, maybe when they come back, they'll feel more comfortable. Or, like Melodie, you were saying, maybe they'll be comfortable taking a photo and showing you that photo later on. We can still help them, and we still should help them.  

Young: Someone is going to treat it, and it may be something that they get because psoriasis is very familial. So, all of those things, it's going to be treated. You can either be the one to diagnose it and come up with the appropriate treatment or say, "If you don't want to show me now, I'm going to give you this, and you try this for a couple of weeks, then if it doesn't work, come back and see me." Pick something that's not likely to be harmful and hopefully will be helpful.  

Zampella: The photo thing is interesting. That's definitely a generational thing. Maybe it's like an Instagram or a social media phenomenon.  

Young: Tinder. Tinder. 

Zampella: Something because I have young patients, even adolescents, they don't want to show me in real life, but like, “Oh, I have a photo album hidden on my phone,” and bring up all their photos and show them.  

Young: When you're asking about the photos, when we were trying to get more photos 10 years ago, Lilly was looking to bring a biologic for psoriasis in the genitalia and there's [audio unclear]. I was like, "No, I really don't." Then, I started talking with the girls in my office, "How are we going to get people to let us take pictures of the genitalia so we can learn about this? " They said, "Just find out if they have a Tinder account or just find out."  

Payette: That's hilarious.  

Young: So yeah, ask them, and then most of them joke about it.  

Zampella: I think most patients are mostly okay with photos. We always ask. Certainly a biopsy, I say you have to have a photo because God forbid. Actually, this has happened to me, and this goes back to actually, when do you do biopsy? I had a patient was treated on the outside of my clinic for a year for genital psoriasis, and it wasn't getting better. I was like, "Are you sure it hasn't gotten any better?" He's like, "Not any better." So, the biopsy ended up being like a Bowen's disease, like a squam cell in site 2.  

Young: That follows up with what he said about doing the exam after there's a pink scaly patch. The patient may think it's just untreated psoriasis that hasn't cleared. You want to be very specific about knowing what medicine is supposed to do to what area.  

Zampella: You can't forget that patients can't, probably don't know this, but you can have 2 things, right? Oh, here's that. You're going to have psoriasis and then still get a squamous cell in the genitals.  

Young: Absolutely. And a lot of them have done phototherapy through the years in their genitalia. Seen that a lot.  

Zampella: Do you all do phototherapy for genitals?  

Payette:  No.  

Young: No, but I have seen it.  

Payette: I don't have a booth anymore.  

Zampella: Okay.  

Young: Yeah. I've been around long enough that I've seen it with even grenz treatment.  

Payette: Yeah. I mean, I've definitely diagnosed many squamous, maybe not many, but more than double digits of squamous cells on a penis that people have interpreted as being something else.  

Zampella: I do. I use phototherapy for genitalia, and I have eczema laser. I agree. You have to use it kind of in a limited fashion, but it's nice for, I think we're going to get into this a little bit later too, but older patients who might not be able to take a medication or have polypharmacy. You can say like, okay, this is not a medication that is still pretty efficacious.  

Admani: Yeah. And I just wanted to end really quick back to the photos. We shouldn't make any assumptions as to if someone is going to allow it or not. It's always good practice to just ask. Surprisingly, I have a huge number of lovely postmenopausal women who send me photos of their vulva on a regular basis. I want to know.  

Young: Lucky you. 

Admani: They want to know if things are getting better. People love to have objective evidence of improvement before and after. 

Young: That's the thing. That's the thing. That’s a compliment to you. It is.