pearly penile papules

Common penile lesions:
tips to the differential
Darin S. Gogstetter, MD, and Mary Gail Mercurio, MD
____________

The patient who comes to you for evaluation of a penile lesion is probably anxious, embarrassed, and afraid. No doubt, one of his biggest worries is whether he has contracted a sexually transmitted infection and, if so, has he infected his partner? As his p r i m a ry care physician, you may or may not be able to identify the underlying disorder and prescribe proper treatment. However, one of the most important aspects of your role is to be sensitive to the probable mental state of your patient by being nonjudgmental and committed to helping him. The history Your first step is to review aspects of the patient’s history, specifically questioning him about recent sexual exposures, recent travels, hygienic habits, whether the lesion is pruritic or painful, and about the possible pre e x i stence of other skin disorders. When considering the factors that may play a role in the development of a penile lesion, some physicians may consider the issue of circ u m c i s i o n to be a very important one. There are mixed opinions as to the benefits and disadvantages of circumcision, with some, including the authors, believing that uncircumcised men are at a greater risk than circumcised men for many conditions that cause penile lesions.

Questions to consider After taking a thorough history, carefully examine the lesion and note its characteristics. Ask yourself the following questions to try to describe it vis u a l l y. What color is it? Where is it located? Is it inflamed or atro p h i c ? This method can help narrow the diff e rential diagnosis of common causes of penile lesions to reach the proper diagnosis. Treatment considerations Because of the large number of penile lesions that are responsive to tre a tment with topical cort i c o s t e roids, remember that the genital skin is thinner than other areas on the body, and that foreskin, acting as an occlusive, can 4 5 Common penile lesions: tips to the differential Darin S. Gogstetter, MD, and Mary Gail Mercurio, MD Darin Gogstetter, MD Clinical Instructor Department of Dermatology University of Rochester School of Medicine Rochester, New York Mary Gail Mercurio, MD Assistant Professor of Dermatology Department of Dermatology University of Rochester School of Medicine Rochester, New York Penile lesions are always a cause for intense concern — and embarrassment—for the patient, who may there f o re delay seeking medical attention. The diff e rential diagnosis ranges fro m benign conditions to those that currently have no cure. The history and appearance are keys to the diagnosis: the authors re v i e w the many clinical images and provide practical diagnostic tips as well as treatment updates. A B S T R A C T February 2001 Practice Ti p s l Be sensitive to the delicate mental state of the patient who p resents with a penile lesion. l Take a thorough history, focusing on recent sexual e x p o s u res, recent travels, hygienic habits, whether the lesion is p ruritic or painful, and the possible preexistence of other skin disord e r s . l As a general rule, when p rescribing steroids for the t reatment of penile lesions use only low-potency topical stero i d s. naturally enhance penetration of cort i c o s t e roids topically applied to the glans. Exercise caution when prescribing these drugs; use of an inappropriately potent s t e roid can have adverse effects, including atro p h y, striae, and telengiectasias. As a general rule, when prescribing steroids for the treatment of penile lesions (with the exception of lichen sclerosus, see discussion below) use only low-potency topical steroids, such as hydroc o rtisone 1% and 2.5% (class VII) and desonide or aldometasone dipropionate (class VI). Zoon’s balanitis This common benign inflammatory condition is also known as plasma cell balanitis, balanitis circumscripta plasmacellularis, or plasma cell mucositis. The clinical signs ( F i g u re 1) include oozing erythematous patches or plaques on the glans and/or on the inner surface of the pre p u c e of uncircumcised men.1 Z o o n ’s balanitis is a largely asymptomatic condition, although mild itching can occur, so it is not unusual for a patient to have this condition anyw h e re from a few weeks to a few years before seeking medical care. Treatment consists of mild topical cort ic o s t e roids, such as class VI and VII agents. Recurrences may be common.

Because in situ squamouscell carcinoma can have a v e ry similar clinical pre sentation, resistant lesions should be biopsied. Lichen sclerosus Lichen sclerosus (LS) is an atrophic condition of unknown cause. Much more common in women than in men, LS is seldom found on parts of the body other than the genitals. Lesions which often evolve over years, can be flat, slightly raised or slightly depressed, and are usually pink or hypopigmented (Figure 2). Alt h o u g h commonly asymptomatic, symptoms can include pru r itus, dysuria, painful erections, decreased sensation of the glans, and decreased caliber of the urinary stream. M alignant transformation has also been re p o rted in penile LS.2 - 3 Advancing and re f r a c t o ry cases should be ref e rred to a dermatologist. End-stage LS, known as balanitis xerotica obliterans, is identified by a thickened, contracted prepuce that cannot be manually retracted over the glans. In this situa- Common penile lesions 4 6 February 2001 Z o o n ’s balanitis The signs of Zoon’s balanitis include oozing ery t h e m a t o u s patches or plaques on the glans. FIGURE 1 Lichen sclero s u s Lichen sclerosus lesions can be slightly depressed, atro p h i c , and hypopigmented. FIGURE 2 Lichen planus Polygonal, shiny, flat-topped papules which are ery t h e m a t o u s to violet in color, are Lichen planus lesions. FIGURE 3 Zoon’s balanitis is a largely asymptomatic condition so it is common for a patient to have this condition anywhere from a few weeks to a few years before seeking medical care. tion, re f e rral to a dermatologist can expedite diagnosis. No effective treatment is available, although topical application of ultra-potent steroids (Class I), such as clobetasol propionate or halobetasol propionate, early in the disease may partially reverse the sclerotic component. Lichen planus A common inflammatory condition, lichen planus (LP) can affect mucous membranes, skin, and nails; it is a benign disease with remissions and exacerbations. As seen in Figure 3, LP lesions are polygonal, shiny, flat-topped papules that are faintly erythematous to violet in color. A fine whitish, reticulated scale re f e rred to as Wi c kh a m ’s striae (Figure 4) can be seen on the surface of LP lesions. The annular and erosive genital LP are uncommon variants.

Typical penile LP is asymptomatic and commonly resolves with residual hyperpigmentation while erosive LP can be painful and persist for many years. Low-potency topical stero i d c reams can be beneficial.The classic form of LP is thought to be idiopathic where a s other forms are associated with drugs (eg, allopurinol, ACE inhibitors, NSAIDS). The diff e rential diagnosis of the classic idiopathic type of penile LP includes psoriasis, and for the erosive variant the diff e rential diagnosis includes plasma cell balanitis, ery t h roplasia of Queyrat, and a fixed drug eru p t i o n . Psoriasis The penis is a common location for psoriasis (Figure 5), and, in some cases, it is the sole area of involvement. Psoriatic lesions on the penis are typically red, scaly, papules or raised plaques on the glans and/or shaft, with the exception of uncircumcised men who often lack the scale when lesions are located on the glans. Psoriatic patches on other body parts usually facilitate the diagnosis. Supportive findings include red scaly plaques on the elbows, knees, gluteal cleft, scalp and periumbilicus, as well as so-called oil-drop spots (yellowish subungual spots on the fingers and toes) and pitting of the nail plates. Treatment for penile lesions—which can take weeks to improve—consists of low-potency topical steroids. Penile psoriasis is marked by exacerbations and remissions, so new lesions are likely to develop. Balanitis circinata Balanitis circinata is a penile rash that is the most common cutaneous finding in Reiter’s syndrome (a characteristic clinical triad consisting of arthritis, urethritis, and conjunctivitis). The disease occurs mostly in young men with HLA-B27 haplotype. A well-demarcated erosion with a slightly raised border is the sign of balanitis circinata. The cutaneous findings can be exaggerated in HIV-associated Reiter’s syndrome. Distinction between Reiter’s syndrome and psoriasis can sometimes be extraordinarily difficult, because the similarity in clinical presentation and histological findings may lead us to the wrong diagnosis. The treatment includes antiinflammatory agents, and immunoregulatory or immunomodulatory agents. February 2001 47 Lichen planus Genital lichen planus can also take annular or erosive form s . FIGURE 4 P s o r i a s i s The penis is a common location for erythematous, scaly, psoriatic plaques. FIGURE 5 Psoriatic lesions on the penis are typically red, scaly, papules or raised plaques on the glans and/or shaft. Fixed drug eruption This condition is a localized response to a systemic medication. These genital lesions frequently begin as solitary or multiple blisters that erode or ulcerate and eventually become a hyperpigmented patch (Figure 6). Lesions tend to recur in the same site if there is re e x p o s u re to the offending medication. Drugs known to cause these eru ptions include NSAIDs, sulfonamides, phenolphthalein, tetracycline, and barbiturates. The only treatment for fixed d rug eruption is discontinued use of the offending dru g , although a drug with similar indications can be pre s c r i b e d . Lichen simplex chronicus Repetitive rubbing or scratching of the scrotal skin can result in lichen simplex chronicus, which leads to the thickening and accentuation of the scrotal rugae (Figure 7). A pruritic condition may have initiated the pro c e s s , but persistent habitual scratching creates a vicious itch–scratch–itch cycle. Treatment is directed toward b reaking this cycle with systemic antihistamines. Wi t h p roper treatment, the physical changes will re s o l v e .

Scabies The signs of scabies are pruritic papules, vesicles, cru s t s , or nodules on the glans and shaft (Figure 8), caused by the scabies mite, Sa r coptes scabi.e Iif penile lesions are seen in the setting of severe pruritus and a derm a t o s i s e l s e w h e re on the body, there is usually a scabetic infestation. Papules or erosions on the finger webs, wrists, a x i l l a ry folds, popliteal fossae, waistband area, and knees can aid the diagnosis. A definitive diagnosis can be made with micro s c o p i c visualization of the mite, ova, or fecal material. Scabies can be spread through sexual contact as well as other types of contact such as shared toweling or bedding. First-line treatment is with topical permethrin cre a m ( E l i m i t e®) 5%, which is applied at bedtime and washed o ff in the morning. A single application is often suff icient; a second application a week later will increase the clearance rate in severe infestations (as in patients with HIV or other immunocompromised conditions). S e c o n d a ry bacterial infection is common in scabetic infestations and can be treated with systemic antibiotics. A significant amount of residual itching can last weeks to months after treatment, but an oral antihistamine or a low-potency topical steroid can offer relief. Persistent Common penile lesions 4 8 February 2001 Fixed drug eru p t i o n Hyperpigmented patches, like this one found on the glans, a re a result of fixed drug eru p t i o n s . FIGURE 6 Lichen simplex chro n i c u s C h ronic scratching of the scrotal skin results in lichen simplex c h ronicus, which results in the thickening and accentuating of the scrotal ru g a e . FIGURE 7 S c a b i e s The signs of scabies can include crusted papulonodules on the glans, shaft, and scro t u m . FIGURE 8 penile lesions can become violaceous and papulonodul a r. It is important to address and if needed treat anyone who may have been exposed to prevent reinfection. Molluscum contagiosum Molluscum contagiosum is a common infection caused by poxvirus. It is typically asymptomatic, but mild itching is not unusual; visible signs include the domeshaped umbilicated papules shown in Figure 9. An eczematous dermatitis may surround the lesions re s u l ting from the associated pruritus. Genital lesions often arise from sexual contact; however, molluscum contagiosum can also be spread by autoinoculation, re s u l ting in a more linear distribution of lesions. Diagnosis can be confirmed noninvasively by expressing the papule contents and perf o rming a Giemsa stain. Tre a tment options include cryotherapy with liquid nitro g e n , physical removal with a sharp curette, and chemical ablation. Once eradicated, molluscum rarely re c u r s . Condyloma Penile condyloma is the most common sexually transmitted disease. Most condyloma are caused by human papillomavirus (HPV) types 6 and 11. Intere s ti n g l y, most of the cases of genital HPV infection are s u b c l i n i c a l .4

Penile condyloma (Figure 10) appear as papules and plaques that have a pebbled surface and are often the same color as the surrounding skin. Large le- February 2001 49 Molluscum contagiosum Molluscum contagiosum is typically asymptomatic, but mild itching along with dome-shaped umbilicated papules, can o c c u r. FIGURE 9 Condyloma Penile condyloma, the most common sexually transmitted disease, is identified by papules and plaques which have a pebbled s u rface and are often the same color as the surrounding skin. FIGURE 10 C o n d y l o m a L a rge condyloma lesions can become pedunculated and caulif l o w e r- l i k e . FIGURE 11 Pearly penile papules Pearly penile papules, a common asymptomatic condition, are identified by 2-3 mm colored, dome-shaped papules aro u n d the coronal sulcus. FIGURE 12 sions, such as those in Figure 11, may become pedunculated and cauliflowerlike, occurring on any surface of the penis, including the urethra. If large condyloma are p resent, it may be beneficial to surgically debulk prior to topical treatment. Condyloma therapies include liquid nitrogen cry o s u rg e ry, podophyllin (10-25%), podofilox (Condylox®) (0.5%), trichloroacetic acid, imiquimod cream (Aldara®), intralesional interf e ron, CO2 l a s e r, and cold steel excision. The partner of a man with condyloma should be evaluated, as an associated oncogenic HPV strain can predispose to the development of cervical cancer5 or to anal carc i n o m a .6 Benign conditions Pearly penile papules. This common, asymptomatic f o rm of angiofibroma of unknown etiology is clinically marked by rows of white-pink, 1- to 2-mm papules located around the coronal sulcus, as shown in Figure 12. They are often not noticed by the patient and re q u i re no treatment. However, penile papules are often mistaken, by both patients and physicians, for condyloma acuminatum. No medical treatment is warranted. Follicular cysts. F i g u re 13 shows follicular cysts that a re dome-shaped subcutaneous papules or nodules that arise from the hair follicles on the scrotum and less commonly on the penis. Also known as epiderm a l inclusion cysts and steatocystomas, follicular cysts are benign cystic lesions. Although no treatment is warranted, they do not typically re s o l v e . Angiokeratomas of fordyce. This common benign condition is caused by distended dermal blood vessels, which increase in incidence with age. It is characterized by 1- to 2-mm purple, compressible papules, seen in F i g u re 14, which bleed spontaneously or during the trauma of intercourse. Treatment is unnecessary unless a lesion bleeds rec u rre n t l y. In this case, lesions can be ablated by elec-

Common penile lesions 5 0 February 2001 Squamous-cell carc i n o m a This moist, friable, exophytic plaque involving the meatus and inferior glans is squamous cell carc i n o m a . FIGURE 15 E ry t h roplasia of Queyrat E ry t h roplasia of Queyrat, an in situ carcinoma, appears as a s o l i t a ry, glistening, erosive plaque. FIGURE 16 Follicular cysts These dome-shaped subcutaneous papules or nodules are follicular cysts. FIGURE 13 Angiokeratomas of Ford y c e These violaceous, dome-shaped papules on the scrotum are indicative of angiokeratomas of Ford y c e . FIGURE 14 t rodesiccation or laser. Be sure to consider the diagnosis of Fabry ’s disease, a rare, x-linked systemic storage disease caused by deficiency of the enzyme alpha-galactosidase- A. If you suspect Fabry ’s disease, look for multiple angiokeratomas on the penis and scrotum as well as groin, inner thighs, and lower abdomen. In situ carcinomas B o w e n ’s disease. B o w e n ’s disease is the most common type of carcinoma in situ of the penis.7 Usually located on the penile shaft, it presents as a pink, well-demarc a t e d , d ry patch or plaque that may be scaly. Treatment options include excision, carbon dioxide laser, and topical fluorouracil. Untreated, this disease can culminate in invasive squamous-cell carcinoma, (Figure 15), which can be definitively diagnosed by biopsy. E rythoplasia of queyrat. E ry t h roplasia of Queyrat involves the penile skin—glans, inner surface of prepuce, coronal sulcus—that appears as the solitary, glistening, erosive plaque seen in Figure 16. Like Bowen’s disease, ery t h roplasia of Queyrat has the potential to t r a n s f o rm into squamous cell carc i n o m a . Bowenoid papulosis. Bowenoid papulosis is an H P V-associated carcinoma in situ. HPV-16 is the most common and types 16,18, and 33 are considere d the most oncogenic with greatest potential for development into invasive squamous-cell carc i n o m a .8 Bowenoid papulosis usually occurs on the penile shaft and is characterized by multiple, slightly elevated, re d or brown papules which may be verrucous or scaly.

These penile neoplasms, although infrequent, can re p resent a significant diagnostic and therapeutic challenge, as they can masquerade as other penile dermatoses. Also, complete yet conservative removal is imperative given their location. Depending on the extent of disease, treatment options range from tissuesparing topical chemotherapy to surgical excision. R e f e re n c e s 1 . Davis DA, Cohen PR. Balanitis circumscripta plasmacellularis. J Uro l 153; 424–426, 1 9 9 5 . 2 . Weber P, Rabinovitz H, Garland L. Ve rrucous carcinoma in penile lichen sclero s i s et atrophicus. J Dermatol Surg Oncol 13: 529–532, 1987. 3 . Pride HB, Miller OF III, Tyler WB. Penile squamous cell carcinoma arising fro m balanitis xerotica obliterans. J Am Acad Derm a t o l 29: 469–473, 1993. 4 . Sonnex C, Sholefield JH, Kocjan G, et al. Anal human papillomavirus infection in heterosexuals with genital warts: prevalence and relation with sexual behavior. B M J 303: 1243, 1991. 5 . S c h i ffman MH. New epidemiology of papillomavirus infection and cervical neoplasia. J Natl Cancer Inst 87: 1345–1347, 1995. 6 . Shah KV. Human papillomaviruses and anogenital cancers. N Engl J Med 3 3 7 : 1386–1388, 1997. 7 . Micali G, Innocenzi D, Nasca MR, et al. Squamous cell carcinoma of the penis. J Am Acad Derm a t o l 35: 432–451, 1996. 8 . Johnson TM, Saluja A, Fader D, et al. Isolated extragenital bowenoid papulosis of the neck. J Am Acad Derm a t o l 41: 867–870, 1999.

blog