Sex differences in dermatologic conditions

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This is part 1 of a series of articles on sex differences in dermatology. The next part will appear in the October/November 2023 issue of Contemporary OB/GYN.

Introduction

Several dermatologic conditions have notable differences between the sexes in terms of prevalence and manifestation. For example, autoimmune dermatoses, pigmentary disorders, and hair disorders occur more often in female individuals, whereas predominance of infectious and malignant skin diseases is seen in male individuals.¹ Female individuals are more commonly affected by skin diseases in general.² The reasons for these differences have yet to be determined and are likely complex, with factors such as hormones, genetics, skin physiology, and lifestyle playing a part.^1,3 In this first part of our series, we discuss differences between the sexes in the manifestation of atopic dermatitis and psoriasis.

Atopic dermatitis

Atopic dermatitis (AD) is the most common chronic inflammatory skin condition, characterized by impairment of the skin barrier and pruritus.⁴ Results from a study of patients older than 15 years with AD found no significant differences in AD duration or disease severity between male and female patients; however, female patients reported AD more frequently than male patients in all anatomical locations except the feet.⁵ The greatest difference between male and female patients was AD being located in the usually visible areas of the head, neck, and hands; 78.3% of female patients reported that AD was present in these areas compared with 55.7% of male patients.⁵ AD located in the areas that are usually visible (head, neck, and hands) led to decreased quality of life in female patients more than in male patients.⁵ There was a significant positive correlation between AD severity in female patients and impact on their quality of life but no such correlation in male patients.⁵ These data show that visible areas of AD may have a more significant impact on female individuals compared with male individuals.

Results from a study on hand eczema found that women and men had no differences on the Hand Eczema Severity Index.⁶ However, compared with men, it appeared that women had more variability in severity.⁶ AD severity has been shown to increase with age in both men and women.^6,7 Women had a statistically significant higher mean score for burden of disease.⁶ They also reported more itching and eczema-related fatigue than men, which may contribute to their higher scores for burden of disease.⁶ Additionally, results from another study found that women with hand eczema had higher levels of anxiety than men (P=.029).⁸

Although no sex differences in eczema prevalence have been found in newborns,^9-11 the prevalence of AD is moderately higher in boys than in girls during early childhood.¹² This sexual difference is later reversed, with a higher prevalence of eczema in girls compared with boys in the preschool ages all the way to adolescence.^12-15 In addition to differences in sexual hormones, gender differences in indoor vs outdoor activity may be related to these findings. Girls have been found to play indoors more than boys,¹⁶ and the prevalence of eczema is nearly twice as much in children who play more indoors than outdoors.^17,18 Within children aged 5 to 7 years, it has been shown that girls have a higher skin surface pH and decreased stratum corneum hydration compared with boys,¹⁶ both of which are factors associated with an increased tendency for children to develop acute atopic eczematous lesions.¹⁹

Compared with girls, boys have eczema and concomitant respiratory allergies more often.²⁰ In contrast, nonatopic eczema, characterized by a low level of total IgE and undetectable specific IgE antibodies,^20,21 is present twice as often in girls compared with boys (5.9% vs 3.1%).¹⁸

Psoriasis

Psoriasis is a chronic inflammatory condition that can affect the skin, nails, and joints. The prevalence of psoriasis for US adults is estimated to be 3.2%, and prevalence is similar in men and women.²² Findings from studies have shown that severe forms of psoriasis are more common in men compared with women after controlling for various possible confounders.^23,24 Results from a large Swedish cross-sectional study of 5438 patients with moderate to severe psoriasis found that across all ages, men had a higher median Psoriasis Area and Severity Index (PASI) score compared with women (7.3 vs 5.4; P<.001).²⁴ Women had significantly lower PASI scores than men in every body location except the head, where PASI scores were equal for women and men.²⁴ Results from a Swiss study that included 1979 patients with psoriasis found that more female patients were affected by psoriatic pruritus than male patients (36% vs 25.3%; P<.001).25 Pruritus was identified by 39.7% of patients with psoriasis as the most quality of life–limiting or bothersome factor of their disease.²⁵

Genital psoriasis can cause significant physical and emotional distress as well as negative impacts on quality of life and sexual health.^26,27 Anywhere from 33% to 63% of patients with psoriasis experience genital psoriasis during their disease course.²⁶ Results from a cross-sectional study conducted in Germany found that genital psoriasis was more prevalent in men compared with women (65.0% vs 52.5%; P=.021).²⁷ In results from another study, the scrotum was found to be the most common genital area involved in male patients and the labia majora was the most common genital area involved in female patients.²⁸ Findings from studies show that male sex, increased psoriasis severity, increased disease duration, and involvement of the scalp, flexure surfaces, and nails were associated with genital psoriasis.^28,29

Results from most studies have found no gender bias in pediatric psoriasis.^30,31 The median age of diagnosis in children has been reported to be 10 to 11 years, with no significant difference between male patients and female patients.^30,32,33 Findings from studies have shown that among pediatric patients with psoriasis, 17% to 29% have nail involvement and 18% to 50% have scalp involvement.^30,34-36 Results from a multicenter, cross-sectional study found that nail psoriasis was significantly more common in boys and scalp involvement was significantly more common in girls.³⁷

Key points

• Between the sexes, differences exist in the prevalence and manifestation of dermatologic conditions.
• The reasons for differences between sexes in dermatologic conditions have yet to be determined and are likely complex, with factors such as hormones, genetics, skin physiology, and lifestyle playing a part.
• Patient care should not drastically change simply because of a patient’s gender; it should be tailored to each patient’s specific needs.
• Many of the studies reviewed in this article were not randomized, controlled clinical trials; thus, findings may not be readily generalizable.
• Further investigation of sex-specific differences in dermatologic conditions and their causes is needed.

Conclusion

Our review of the literature has identified sex differences in some common dermatologic conditions that can help inform future patient care decisions. Nonetheless, patient care should not drastically change simply because of a patient’s sex. Management of these conditions should be tailored to each individual patient’s specific needs. Many of the studies reviewed were not randomized, controlled clinical trials; thus, findings may not be readily generalizable. Further investigation of sex-specific differences in dermatologic conditions and their causes is needed.

References

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