7.1 Balanitis and Balanoposthitis
Inflammation of glans penis (balanitis) and prepuce (balanoposthitis). May be bacterial (Pediatr Dermatol
1994;11:168), intertrigo, irritant dermatitis, maceration injury, or candidal (most common) in etiology (Genitourin Med
Common condition affecting 11% of male gu
clinic attendees in one study (Genitourin Med
1993;69:4003). More common in uncircumcised males. May be seen in children and adults. Most often occurs in males with poorly retractile foreskin.
Si/Sx: Redness, edema, discharge, pain, may be associated with voiding difficulties.
Neoplasm, psoriasis, Zoon’s balanitis, papillomavirus, other sexually transmitted diseases (Genitourin Med
prep; Tzanck prep; fungal, bacterial, or viral cultures as dictated by clinical examination
Eliminate irritants, improve personal hygiene, topical antifungals if fungal related, short crs
of low-potency topical steroids, retraction of foreskin to allow glans and prepuce to dry after cleansing, circumcision if recurrent.
7.2 Lichen Sclerosis
Exact cause is uncertain, but genetic predisposition, infections, and autoimmune factors have been implicated. It may be related to abnormal regulation of IL-1 (Hum Genet
Occurs commonly on genital skin. Females more than males. In males, more common in older males (J Am Acad Derm
1992;26:951); may occur in children. High prevalence of autoimmune disease. In males, referred to as balanitis xerotica obliterans. In females, affects the genital skin and may affect any age group but more common in elderly women (Am J Clin Dermatol
Pathophys: Lesions well circumscribed white macules or plaques. Epidermis often atrophic and prone to ulceration. More common on moist skin of foreskin and in females in the vulva and perianal area. May lead to scar formation and destruction and contraction of foreskin, clitoral prepuce, and vulva. In males, white plaques noted on glans and often involves prepuce, which becomes thickened and nonretractile (Lancet 1999;353:1777). Histology shows a thickened epidermis, followed by atrophy and follicular hyperkeratosis.
Squamous cell carcinoma reported in pts with balanitis xerotica obliterans. Malignant changes less common than in lichen sclerosis et atrophicus in females (J Dermatol Surg Oncol
1978;4:556; Br J Vener Dis
1978;54:350). There is a 5% risk of developing squamous cell carcinoma of the vulva in females with vulvar lichen sclerosis (Am J Clin Dermatol
2004;5:105); urethral stenosis in males.
May be asx
but often associated with itching and burning. Males may note pain with urination or erection.
Diff Dx: Vitiligo, postinflammatory hypopigmentation, scar, genital herpes, syphilis, fixed drug eruption, Reiter’s syndrome, squamous cell carcinoma, and erythroplasia of Queyrat
Dx often made by physical examination. If question, bx
In males, rx
is circumcision; may be needed if phimosis present. High-potency topical steroids are the treatment of choice in males with balanitis xerotica obliterans. Intralesional corticosteroid injections have also been used. If there is urethral involvement and stenosis, meatotomy or urethral dilation may be needed. In females, high-potency topical steroids (ie, clobetasol 0.05% ointment) are effective (J Reprod Med
1993;39:25). Because of the risk of developing squamous cell carcinoma, pts need regular f/u
visits (J Acad Dermatol
7.3 Fixed Drug Eruption
Cutaneous eruption that can be reproduced at the same site(s) by the same drug(s) (J Pediatr
1999;135:396). Predilection for the glans penis.
Epidem: More commonly related to therapy with antibiotics such as tetracyclines and sulphonamides. Other causes include salicylates, phenacetin, phenolphthalein, and some hypnotics (Lancet 1999;353:1777).
T-cell independent ag-specific triggering of mast cells or keratinocyte cytokine release (TNF-alpha, IL-2, IL-6) after administration of causative drug (Dermatology
Sx: May be painful
Genital lesions usually solitary, well-demarcated, inflammatory; may be bullous and subsequently ulcerated. Shaft and glans of penis are common sites. Recurrent with repeat medication exposure
at same site; postinflammatory hyperpigmentation common in recurrent lesions.
Crs: Most lesions fade spontaneously without treatment but may leave an area of residual hyperpigmentation.
Lab: Bx: papillary-dermal mononuclear cell infiltrate near dermoepidermal junction
Rx: Discontinue offending medication; topical care; rarely systemic steroids
7.4 Zoon’s Balanitis
Cause: Plasma-cell mediated. Etiology is unknown; may be related to chronic infection with Mycobacterium smegmatis.
Epidem: Uncircumcised males only. Lesions found on glans or prepuce.
Pathophys: Histopathol: band of plasma cells in dermis; may be chronic
but may have pain, irritation, and discharge
Solitary, orange-red, distinct borders; may be erosive; up to 2 cm
in size (Urol Int
Diff Dx: Squamous cell carcinoma in situ, other forms of balanitis
Bx helpful to confirm dx
Often chronic and poorly responsive to topical treatment but can resolve completely with circumcision (Br J Dermatol
1982;105:585; Genitourin Med
7.5 Behçet’s Syndrome
Cause: Systemic vasculitis of small and large vessels
Genetic? Associated (27%) with HLA
B51 and 27; viral? though isolated occurrence argues against it. Male-to-female ratio: 1.7:1 in eastern Mediterranean type, 1:2 in United States at Mayo Clinic. Although rare, may be increasing.
Pathophys: Immune complex with small vessel vasculitis
Sx: Onset in 20s
Recurrent: oral ulceration primary criterion for illness. Ulcerations either aphthous type, deep, painful, numerous, may scar; or herpetic type, especially in females, 1-2 mm
, will respond to tetracycline oral rinse rx
. Recurrent, painful. Painful genital ulcers occur in most, which is one of four secondary criteria for dx
(J Am Acad Derm
1995;32:968); does not always occur concurrently with oral lesions; may involve scrotum, prepuce, or glans; may be herpetiform, major (< 1 cm
), or minor. Uveitis.
Each attack lasts 1-4 wk
disease has bad prognosis. Males have a more severe crs
Blindness (Bull Rheum Dis
often titrated to the uveitis), multiple cardiac (Ann Intern Med
1983;98:639), inflammatory arthritis with polys
< 200,000, aseptic meningitis, thrombophlebitis, colitis, skin pustules and delayed hypersensitivity reaction to saline or any shot
Diff Dx: Aphthous ulcers, syphilis, herpes simplex, chancroid
elevated. Serol: increased acute phase reactants. Skin tests: (1) delayed hypersensitivity reaction to a saline shot is diagnostic; 1/3 pts have thrombophilia.
Rx of genital lesions is both local and systemic. Local: moisture-retaining dressings, intralesional injection of corticosteroids, topical anesthetics. Systemic: (1) ASA
, indomethacin, or pentoxifylline 300 mg po bid
(Ann Intern Med
1996;124:891); (2) high-dose steroids; (3) azathioprine (N Engl J Med
1990;322:281), cyclophosphamide, or chlorambucil; (4)
thalidomide 100 mg po qd
(Ann Intern Med
1998;128:443). Cmplc: teratogenicity in pregnant female, polyneuropathy. Other therapies include colchicine, FK
506, hydroxychloroquine (J Ocul Pharmacol
1994;10:553; Curr Opin Rheum
1994;6:39). Interferon alpha has demonstrated promising results in clinical trials (Arch Dermatol
2002;138:467; Br J Ophthalmol
2003;87:423). Dapsone and rebamipide have also been used in small series and have demonstrated efficacy in treatment of the mucocutaneous lesions (J Dermatol
7.6 Sclerosing Lymphangitis
Cause: Local trauma
Males 20-40 yr
1987;59:194). Associated with vigorous sexual activity (Br J Vener Dis
Pathophys: Thrombosed lymphatic vessels
Sx: Usually painless
Translucent, flesh/red-colored lesion on shaft/glans of penis (Arch Dermatol
1991;47:421). Swelling proximal and parallel to the corona (J Urol
Usually remits within 4-6 wk
Avoidance of vigorous sexual activity. If persists, excise (J Urol
7.7 Erythema Multiforme
Many drugs (sulfonamides, penicillin, phenytoin, phenylbutazone) have been reported to cause erythema multiforme (J Invest Dermatol
1994;102:285; N Engl J Med
1994;331:1272). May occur secondary to opiates, NSAIDs, IVP
dye (steroids protect), thiamine, curare, dextrans, hormonal fluctuations. Associated
infectious agents include Mycoplasma pneumoniae, Histoplasma capsulatum, Coccidioides immitis, Yersinia enterocolitica,
echovirus, Coxsackie virus, Epstein-Barr, influenza virus, herpes simplex.
Epidem: Affects all cutaneous skin surfaces. Stevens-Johnson syndrome more severe form.
Pathophys: With herpes infection, lesions appear 7-12 d after viral eruption.
Sx: Sore throat, malaise
Red iris or target lesions 1-2 cm
in diameter. Stevens-Johnson syndrome: targetoid lesions, blisters, mucosal membrane involvement. Toxic epidermal necrolysis: Sloughing of the epidermis and blistering.
Usually resolves over 3-6 wk
but may be recurrent
Epidermal detachment of mucous membranes, locally in Stevens-Johnson syndrome with 5% mortality or extensively in toxic epidermal necrolysis with 30% mortality (N Engl J Med
R/o systemic diseases like SLE
, dermatomyositis, scarlet fever.
Eliminate causative agent, rx
denuded skin, systemic immunosuppression controversial
7.8 Tuberculosis of the Penis
Cause: Mycobacterium tuberculosis
Rare manifestation of TB
in adults; may be primary or secondary
of penis occurs after sexual contact with organism present in female genital tract or by contamination from infected clothing (J Urol
1976;48:274). Rarely, may develop secondary to inoculation through an infected ejaculate.
Superficial ulcer of glans or solid penile nodule (J Urol
Cmplc: Tubercular cavernositis
Diff Dx: Malignant penile lesions
Bx of lesion to confirm dx
Rx: Antituberculosis chemotherapy
7.9 Molluscum Contagiosum
Dermatol Online J 2003;9:2
Cause: Virus belonging to the DNA pox family
Worldwide incidence of 2-8%. Genitalia commonly involved but can affect other areas of body; confined to skin and mucous membranes. Higher incidence in children, sexually active adults, and those who are immunodeficient. Transmitted primarily through direct skin contact, but fomites have been suggested as another source of infection. Incubation period usually 2-7 wk
, up to 6 mo
Usually a self-limiting, benign skin lesion (Dermatology
1994;189:65); can be more severe in immunocompromised
Sx/Si: Small, firm umbilicated skin papules, discrete, smooth, and dome shaped; skin colored with an opalescent character
Excise, freeze, burn, or laser lesions. Topical therapies include 0.05 mL
of 5% podofilox in lactate-buffered ethanol bid
for 3 d (Dermatol Ther
2000;13:285); Cantharidin (0.9% solution of collodion and acetone) applied to area for at least 4 hr
, repeated every week until lesions clear (J Am Acad Dermatol
2000;43:503), can cause blistering; iodine solution and salicylic acid plaster (Int J Dermatol
1990;29:443); tretinoin 0.05-0.1% cream; aqueous solution 5-10% KOH
; imiquimod 5% cream; cidofovir 3% cream (Pediatr Dermatol
7.10 Pearly Penile Papules
Cause: Possibly viral origin or phylogenetic residua
Epidem: Occurs in 30% of men (Cutis 1977;19:54); more frequently found in young adults and uncircumcised (J Dermatol Surg Oncol 1989;15:552)
Histopathol: acralangiofibromas (Arch Dermatol
Appears as 1- to 2-mm pink/white/yellow or transparent papules that encircle corona and are more prominent on dorsal surface (GU Med
Crs: Lesions may resolve with age.
Diff Dx: Condyloma acuminatum, molluscum contagiosum
not necessary; if bothersome, may remove or rx
laser (Dermatol Surg
1999;25:124; J Dermatol Surg Oncol
7.12 Basal Cell Carcinoma
7.13 Extramammary Paget’s Disease of Genitalia
7.14 Kaposi’s Sarcoma
Table 7.1 Nonsquamous Cell Carcinomas of the Penis
Basal Cell Carcinoma
Extramammary Paget’s Disease of the Genitalia
Malignant intraepidermal process
Human herpes-8-virus (HHV-8) coinfection
Uncommon: may occur on shaft of penis, scrotum, or glans
Rarely involves male genitalia but can affect penis
Women, men; up to 80% of those with extramammary Paget’s have subjacent or visceral malignancy; penile disease may occur in men with bladder Ca treated with radiation therapy
Most common malignancy in AIDS pts; 3% of men with AIDS and Kaposi’s sarcoma may present with genital lesion
Macule or papule with irregular border; may be pigmented (red, blue, black, or brown)
Papular lesion, pearly colored with telangiectasia; often ulcerate
Pruritic erythematous plaque with well-demarcated borders; may be excoriated and crusted
Subcutaneous, nontender, nonpruritic nodules. Lesions may be red or blue, may become exophytic and bleed. Lymphedema may occur. May have fever, weight loss, night sweats
Bx of lesion
Bx to confirm dx
Bx may confirm dx if physical exam not definitive
Determined by depth of lesion. In general, poor prognosis with penile lesions
Remove plaque and treat underlying malignancy. Radiation therapy and 5-FU have been used to treat plaque. For extensive disease of penis and scrotum may use Nd:YAG laser
Treatment of lesions depends on whether part of AIDS or isolated lesions in HIV-neg cases. In HIV-pos pts, may regress using highly active antiretroviral therapy (HAART) alone, but aggressive palliation can be offered with combined HAART and radiation therapy. Conservative surgical excision offers excellent palliation. Photoablation using CO2 or Nd:YAG laser also has been effective in genital lesions. If extensive lesions of the penis, rx with suprapubic cystostomy.
Abbreviation: Nd:YAG laser, neodymium doped yttrium aluminum garnet.
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