Data has indicated an increased prevalence of atopic dermatitis among female patients compared to male patients.
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.
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 (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 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
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.
1. Chen W, Mempel M, Traidl-Hofmann C, Al Khusaei S, Ring J. Gender aspects in skin diseases. J Eur Acad Dermatol Venereol. 2010;24(12):1378-1385. doi:10.1111/j.1468-3083.2010.03668.x
2. Andersen LK, Davis MDP. Sex differences in the incidence of skin and skin-related diseases in Olmsted County, Minnesota, United States, and a comparison with other rates published worldwide. Int J Dermatol. 2016;55(9):939-955. doi:10.1111/ijd.13285
3. Tamir E, Brenner S. Gender differences in collagen diseases. Skinmed. 2003;2(2):113-117. doi:10.1111/j.1540-9740.2003.02189.x
4. Kim BE, Leung DYM. Significance of skin barrier dysfunction in atopic dermatitis. Allergy Asthma Immunol Res. 2018;10(3):207-215. doi:10.4168/aair.2018.10.3.207
5. Holm EA, Esmann S, Jemec GBE. Does visible atopic dermatitis affect quality of life more in women than in men? Gend Med. 2004;1(2):125-130. doi:10.1016/S1550-8579(04)80017-2
6. Mollerup A, Veien NK, Johansen JD. An analysis of gender differences in patients with hand eczema - everyday exposures, severity, and consequences. Contact Dermatitis. 2014;71(1):21-30. doi:10.1111/cod.12206
7. Agner T, Andersen KE, Brandao FM, et al; EECDRG. Hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients. Contact Dermatitis. 2008;59(1):43-47. doi:10.1111/j.1600-0536.2008.01362.x
8. Boehm D, Schmid-Ott G, Finkeldey F, et al. Anxiety, depression and impaired health-related quality of life in patients with occupational hand eczema. Contact Dermatitis. 2012;67(4):184-192. doi:10.1111/j.1600-0536.2012.02062.x
9. Illi S, von Mutius E, Lau S, et al; Multicenter Allergy Study Group. The natural course of atopic dermatitis from birth to age 7 years and the association with asthma. J Allergy Clin Immunol. 2004;113(5):925-931. doi:10.1016/j.jaci.2004.01.778
10. Kerkhof M, Koopman LP, van Strien RT, et al; PIAMA Study Group. Risk factors for atopic dermatitis in infants at high risk of allergy: the PIAMA study. Clin Exp Allergy. 2003;33(10):1336-1341. doi:10.1046/j.1365-2222.2003.01751.x
11. Wadonda-Kabondo N, Sterne JAC, Golding J, Kennedy CTC, Archer CB, Dunnill MGS. A prospective study of the prevalence and incidence of atopic dermatitis in children aged 0-42 months. Br J Dermatol. 2003;149(5):1023-1028. doi:10.1111/j.1365-2133.2003.05605.x
12. Kanda N, Hoashi T, Saeki H. The roles of sex hormones in the course of atopic dermatitis. Int J Mol Sci. 2019;20(19):4660. doi:10.3390/ijms20194660
13. Butland BK, Strachan DP, Lewis S, Bynner J, Butler N, Britton J. Investigation into the increase in hay fever and eczema at age 16 observed between the 1958 and 1970 British birth cohorts. BMJ. 1997;315(7110):717-721. doi:10.1136/bmj.315.7110.717
14. Mortz CG, Lauritsen JM, Bindslev-Jensen C, Andersen KE. Prevalence of atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents: the Odense adolescence cohort study on atopic diseases and dermatitis. Br J Dermatol. 2001;144(3):523-532. doi:10.1046/j.1365-2133.2001.04078.x
15. Weiland SK, von Mutius E, Hirsch T, et al. Prevalence of respiratory and atopic disorders among children in the East and West of Germany five years after unification. Eur Respir J. 1999;14(4):862-870. doi:10.1034/j.1399-3003.1999.14d23.x
16. Möhrenschlager M, Schäfer T, Huss-Marp J, et al. The course of eczema in children aged 5-7 years and its relation to atopy: differences between boys and girls. Br J Dermatol. 2006;154(3):505-513. doi:10.1111/j.1365-2133.2005.07042.x
17. Schäfer T, Krämer U, Vieluf D, Abeck D, Behrendt H, Ring J. The excess of atopic eczema in East Germany is related to the intrinsic type. Br J Dermatol. 2000;143(5):992-998. doi:10.1046/j.1365-2133.2000.03832.x
18. Dao H Jr, Kazin RA. Gender differences in skin: a review of the literature. Gend Med. 2007;4(4):308-328. doi:10.1016/S1550-8579(07)80061-1
19. Seidenari S, Giusti G, Bertoni L, Magnoni C, Pellacani G. Thickness and echogenicity of the skin in children as assessed by 20-MHz ultrasound. Dermatology. 2000;201(3):218-222. doi:10.1159/000018491
20. Tay YK, Kong KH, Khoo L, Goh CL, Giam YC. The prevalence and descriptive epidemiology of atopic dermatitis in Singapore school children. Br J Dermatol. 2002;146(1):101-106. doi:10.1046/j.1365-2133.2002.04566.x
21. Rożalski M, Rudnicka L, Samochocki Z. Atopic and non-atopic eczema. Acta Dermatovenerol Croat. 2016;24(2):110-115.
22. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CEM. Psoriasis prevalence in adults in the United States. JAMA Dermatol. 2021;157(8):940-946. doi:10.1001/jamadermatol.2021.2007
23. Guillet C, Seeli C, Nina M, Maul LV, Maul JT. The impact of gender and sex in psoriasis: what to be aware of when treating women with psoriasis. Int J Womens Dermatol. 2022;8(2):e010. doi:10.1097/JW9.0000000000000010
24. Hägg D, Sundström A, Eriksson M, Schmitt-Egenolf M. Severity of psoriasis differs between men and women: a study of the clinical outcome measure psoriasis area and severity index (PASI) in 5438 Swedish register patients. Am J Clin Dermatol. 2017;18(4):583-590. doi:10.1007/s40257-017-0274-0
25. Murer C, Sgier D, Mettler SK, et al. Gender differences in psoriasis: a Swiss online psoriasis survey. Arch Dermatol Res. 2021;313(2):89-94. doi:10.1007/s00403-020-02066-1
26. Meeuwis KAP, Potts Bleakman A, van de Kerkhof PCM, et al. Prevalence of genital psoriasis in patients with psoriasis. J Dermatolog Treat. 2018;29(8):754-760. doi:10.1080/09546634.2018.1453125
27. Schielein MC, Tizek L, Schuster B, Ziehfreund S, Biedermann T, Zink A. Genital psoriasis and associated factors of sexual avoidance - a people-centered cross-sectional study in Germany. Acta Derm Venereol. 2020;100(10):adv00151. doi:10.2340/00015555-3509
28. Yi OS, Huan KY, Har LC, Ali NM, Chiang TW. Genital psoriasis: a prospective, observational, single-centre study on prevalence, clinical features, risk factors, and its impact on quality of life and sexual health. Indian J Dermatol. 2022;67(2):205. doi:10.4103/ijd.ijd_754_21
29. Ryan C, Sadlier M, De Vol E, et al. Genital psoriasis is associated with significant impairment in quality of life and sexual functioning. J Am Acad Dermatol. 2015;72(6):978-983. doi:10.1016/j.jaad.2015.02.1127
30. Tollefson MM, Crowson CS, McEvoy MT, Maradit Kremers H. Incidence of psoriasis in children: a population-based study. J Am Acad Dermatol. 2010;62(6):979-987. doi:10.1016/j.jaad.2009.07.029
31. Bronckers IMGJ, Paller AS, van Geel MJ, van de Kerkhof PCM, Seyger MMB. Psoriasis in children and adolescents: diagnosis, management and comorbidities. Paediatr Drugs. 2015;17(5):373-384. doi:10.1007/s40272-015-0137-1
32. Seyhan M, Coşkun BK, Sağlam H, Ozcan H, Karincaoğlu Y. Psoriasis in childhood and adolescence: evaluation of demographic and clinical features. Pediatr Int. 2006;48(6):525-530. doi:10.1111/j.1442-200X.2006.02270.x
33. Fan X, Xiao FL, Yang S, et al. Childhood psoriasis: a study of 277 patients from China. J Eur Acad Dermatol Venereol. 2007;21(6):762-765. doi:10.1111/j.1468-3083.2007.02014.x
34. Kwon HH, Na SJ, Jo SJ, Youn JI. Epidemiology and clinical features of pediatric psoriasis in tertiary referral psoriasis clinic. J Dermatol. 2012;39(3):260-264. doi:10.1111/j.1346-8138.2011.01452.x
35. Wu Y, Lin Y, Liu HJ, Huang CZ, Feng AP, Li JW. Childhood psoriasis: a study of 137 cases from central China. World J Pediatr. 2010;6(3):260-264. doi:10.1007/s12519-010-0213-0
36. Stefanaki C, Lagogianni E, Kontochristopoulos G, et al. Psoriasis in children: a retrospective analysis. J Eur Acad Dermatol Venereol. 2011;25(4):417-421. doi:10.1111/j.1468-3083.2010.03801.x
37. Mercy K, Kwasny M, Cordoro KM, et al. Clinical manifestations of pediatric psoriasis: results of a multicenter study in the United States. Pediatr Dermatol. 2013;30(4):424-428. doi:10.1111/pde.12072