Erectile dysfunction in dermatology: A silent epidemic

By Warren R. Heymann, MD, FAAD
Oct. 15, 2025
Vol. 7, No. 41

A privilege of being a physician is having intimate conversations with patients that would never occur in any other circumstances. Although I do not focus on sexual health during my patient encounters, it is discussed when obvious and appropriate, such as dyspareunia in women with lichen sclerosus. But what about men who may be afflicted with erectile dysfunction (ED) when the cause is not so apparent? ED is defined as the consistent inability to attain and maintain an erection sufficient to perform satisfactory sexual intercourse. ED is a common problem. In the United States, the incidence of ED is 25.9 per 1000 people, increasing with age, affecting > 70% of men over 70 years old. (1)

The letter to the editor “Erectile dysfunction in patients with seborrheic dermatitis” by Rabbin-Birnbaum et al. (2) sparked my curiosity, not only for the subject matter (see below) but rather the realization that practically the only times I speak with patients about ED is in the context prescribing a 5-alpha-reductase inhibitor (5-ARIs) such as finasteride. (Sexual dysfunction in patients receiving 5-ARIs is a controversial subject, and may be related to comorbidities including obesity, nicotine dependence, diabetes mellitus, hypertension, mood and anxiety disorders.) (3) I have prescribed the phosphodiesterase 5 inhibitor sildenafil on multiple occasions — for Raynaud phenomenon, never for ED. Why not? Honestly, the thought never crossed my mind. Rabbin-Birnbaum et al. made me realize that I have not been addressing a situation that can adversely affect quality of life. Discussing ED is a two-way street. Just as I would never have thought about asking a patient with seborrheic dermatitis (SD) about ED, I imagine that most patients with SD would not think about asking their dermatologist about ED, either out of embarrassment or the expectation that ED is not in our scope of practice. What is the connection between ED and dermatology?

For a thorough understanding of ED in dermatology, I encourage you to read the outstanding review of the topic by Tanasov and Tiplica. The following is the article’s abstract. “Erectile dysfunction (ED) is an often undiagnosed but significantly prevalent condition among male dermato-venereological patients, characterized by a complex pathophysiology and a substantial impact on quality of life. This review aimed to synthesize recent literature on the increased risk of ED in skin diseases, the underlying pathogenic mechanisms — including vasculogenic, endocrine, neurogenic, psychogenic and immunologic pathways — as well as the dermatologist’s role in managing patients’ sexual health. Inflammatory conditions (e.g. psoriasis, atopic dermatitis, lichen simplex chronicus, and chronic hand eczema), infections (viral, bacterial, and fungal, including sexually transmitted infections), autoimmune conditions (e.g. scleroderma and pemphigus) and disorders of the apocrine and eccrine glands (such as hidradenitis suppurativa) have all been linked to ED. The multi-systemic nature of many dermatologic diseases has become increasingly evident due to their associations with cardiovascular and metabolic comorbidities (atherosclerosis, hypertension, metabolic syndrome, and vitamin D deficiency), central and peripheral neuropathies, endocrine disorders (hypogonadism and diabetes mellitus) or genito-urinary sequelae of sexually transmitted infections, while psychogenic ED further highlights the major mental health burden of skin conditions. Dermatologists are in the unique position to evaluate patients’ sexual function and risk factors, investigate potential causes through accessible routine tests, prescribe impotence medication, consider erectile and overall sexual function in the dermatologic treatment choice, and provide integrative lifestyle recommendations. Addressing sexual health in dermatologic practice offers significant benefits for both patients and health care systems, improving compliance, reducing logistical challenges and optimizing financial outcomes.” (4)

Using the All of Us database, Rabbin-Birnbaum et al. performed a matched, cross-sectional analysis by identifying cases with SD and controls with nearest neighbor propensity score matching by age and race/ethnicity. The authors identified 2,906 cases of SD and 8,718 matched controls [median age 66 years]. SD was significantly associated with ED in both univariable analysis (odds ratio, OR 2.2, 95% CI 2.0–2.4) and multivariable analysis (OR 1.8, 95% CI 1.6–2.0), adjusting for potential confounders, such as smoking history and hypertension. These findings “may provide additional evidence to support the hypothesis that it is chronic inflammation rather than psychogenic stressors that contributes to the association of ED with inflammatory skin dermatoses.” (2)

Zhonag et al. utilized data from 3,601 men in the National Health and Nutrition Examination Survey (NHANES) to investigate the association between the systemic immune-inflammation index (SII) and ED in adult males. The SII is derived from the counts of neutrophils, lymphocytes, and platelets in the peripheral blood and is a comprehensive indicator of the immune response and inflammation levels. Covariates such as age, race, marital status, education, smoking, alcohol consumption, BMI, hypertension, and diabetes were considered. The prevalence of ED was 6.28%. After adjusting for confounding factors, a significant association was observed between high levels of the SII and ED, with a 1.45 OR for ED in individuals with high SII levels. Although the precise pathomechanism linking inflammation to ED is unclear, with ongoing inflammation, nitric oxide bioavailability is compromised, resulting in impaired vasodilation. (5)

Managing ED includes recommendations for a healthy lifestyle (exercise, balanced nutrition, stress management, and proper sleep) and PDE5 inhibitors (sildenafil, tadalafil, vardenafil, and avanafil) as first-line therapy. Other treatments (intracavernosal injection of vasoactive drugs such as papaverine and prostaglandin E; hormone replacement therapy [testosterone]; vacuum erection device; penile prosthesis implantation; low-intensity extracorporeal shock wave; and stem cell injections) are beyond the scope of practice for dermatologists. (1,4)

While many dermatologists — myself included — will probably not become experts on sexual health, we can all be more aware that the chronic inflammatory dermatoses we treat may be responsible for ED. If we do not ask our patients about it, the issue that may be causing such distress will likely be left unaddressed. We can do our patients a tremendous service, even if all we do is determine if they are experiencing ED and refer them to those with expertise in sexual health.

Point to Remember: Erectile dysfunction (ED) is associated with chronic inflammatory disorders, including psoriasis, seborrheic dermatitis, hidradenitis suppurativa, atopic dermatitis, and others. Dermatologists can help ED patients by acknowledging these associations and assisting them in receiving appropriate therapy.

Our expert’s viewpoint

John Zampella, MD, FAAD
Dermatologist, Associate Professor of Dermatology
NYU Grossman School of Medicine
Physician, Preston Robert Tisch Center for Men’s Health

Men, skin, and sexual health

Working at the Preston Robert Tisch Center for Men’s Health has given me a unique lens into how men interact with the health care system — or, more often, how they don’t. It’s well-documented that men use fewer health care resources compared to women. Whether it’s due to cultural norms, stigma, or simple inertia, men engage with health care less frequently than women across specialties. Dermatology is no exception. Despite being at higher risk for serious diseases like melanoma, men visit the dermatologist only about two-thirds as often as women. (6) If our male patients are arriving late, and less often, it raises the question: What else are we missing?

A pivotal interaction came when I saw a patient with genital psoriasis who was distraught because he was unable to maintain an erection. I was fortunate that he brought it up, otherwise, I would never have thought to ask. I was able to discuss the association of psoriasis with erectile dysfunction (ED) (5) and recent evidence that treating psoriasis may improve sexual function. (7,8) I was also able to educate the patient that the mechanism behind this association is multifactorial and likely includes both systemic inflammation and psychosocial effects.

Understanding ED requires appreciating its complexity. Erectile function depends on a well-orchestrated balance of neurologic signaling, vascular integrity, hormonal support, endothelial function, and mental health. Diseases that impact any one of these systems can lead to ED. Above, Dr. Heymann eloquently summarizes several studies assessing the links between dermatologic conditions and ED. We recently reported an association between seborrheic dermatitis and ED using a large dataset to control for factors such as obesity, smoking, and depression and demonstrated a persistent association between ED and seborrheic dermatitis, lending evidence that there is a systemic inflammatory response that may be a proximate factor. (9) Our findings were compelling and further highlight the possibility that erectile dysfunction may be more closely associated with dermatologic disease than previously recognized.

Which begs the question, where does dermatology fit into all this? As Dr. Heymann mentions, we as dermatologists are not likely to begin prescribing sildenafil to treat ED or administer testosterone therapy, but we may be the only physicians treating chronic inflammatory skin conditions in men. As we learn more about how skin diseases affect erectile function and how treating these conditions may improve sexual health, discussing sexual function may need to become a more routine part of our patient conversations. I was lucky that day the patient brought up his concern for ED. If we don’t ask, we miss an opportunity to help a patient. Men are already less likely to seek dermatologic care. When they do, there may be more motivating their visit than just their skin, we just need to ask the question.

References

1. Wang CM, Wu BR, Xiang P, Xiao J, Hu XC. Management of male erectile dysfunction: From the past to the future. Front Endocrinol (Lausanne). 2023 Feb 27;14:1148834. doi: 10.3389/fendo.2023.1148834. PMID: 36923224; PMCID: PMC10008940.

2. Rabbin-Birnbaum C, Khodadad K, Shah JT, Zampella JG. Erectile dysfunction in patients with seborrhoeic dermatitis. J Eur Acad Dermatol Venereol. 2025 May;39(5):e388-e390. doi: 10.1111/jdv.20305. Epub 2024 Aug 22. PMID: 39171429.

3. Lauck KC, Limmer A, Harris P, Kivelevitch D. Sexual dysfunction with 5-alpha-reductase inhibitor therapy for androgenetic alopecia: A global propensity score matched retrospective cohort study. J Am Acad Dermatol. 2024 Jul;91(1):163-166. doi: 10.1016/j.jaad.2024.03.019. Epub 2024 Mar 28. PMID: 38552905.

4. Tanasov A, Tiplica GS. Erectile dysfunction in dermatology and venereology: From aetiopathogenic mechanisms to practical considerations for dermato-venereologists. J Eur Acad Dermatol Venereol. 2025 Mar 8. doi: 10.1111/jdv.20618. Epub ahead of print. PMID: 40055994.

5. Zhong L, Zhan X, Luo X. Higher systemic immune-inflammation index is associated with increased risk of erectile dysfunction: Result from NHANES 2001-2004. Medicine (Baltimore). 2023 Nov 10;102(45):e35724. doi: 10.1097/MD.0000000000035724. PMID: 37960751; PMCID: PMC10637557.

6. Steuer AB, Cohen JM, Zampella JG. Top dermatologic diagnoses by gender in the United States. Int J Dermatol. Published online November 26, 2019:ijd.14736. doi:10.1111/ijd.14736

7. Molina-Leyva A, Salvador-Rodriguez L, Martinez-Lopez A, Ruiz-Carrascosa JC, Arias-Santiago S. Association between Psoriasis and Sexual and Erectile Dysfunction in Epidemiologic Studies: A Systematic Review. JAMA Dermatol. 2019;155(1):98-106. doi:10.1001/JAMADERMATOL.2018.3442.

8. Yüksek T, Ataş H, Kartal SP, Aygar GT, Karakoyunlu AN. Impact of adalimumab on erectile dysfunction, sperm parameters and hormonal profile in male psoriasis patients: a six-month observational study. Arch Dermatol Res. 2025;317(1). doi:10.1007/S00403-024-03520-0,

9. Gerdes S, Ostendorf R, Süß A, et al. Effectiveness, safety and impact of guselkumab on sexuality and perceived stigmatization in patients with psoriasis in routine clinical practice: Week 28 results from the prospective German multicentre G‐EPOSS study. Journal of the European Academy of Dermatology and Venereology. 2024;39(Suppl 1):15. doi:10.1111/JDV.19927