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LETTER TO THE EDITOR
Year : 2017  |  Volume : 8  |  Issue : 6  |  Page : 503-505  

Pseudoverrucous papules and nodules in an infant with penoscrotal hypospadiasis


Department of Dermatology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India

Date of Web Publication14-Nov-2017

Correspondence Address:
Munisamy Malathi
Department of Dermatology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry (JIPMER), Dhanvantari Nagar, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_410_16

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How to cite this article:
Kamat D, Malathi M, Prabhakaran N, Thappa DM. Pseudoverrucous papules and nodules in an infant with penoscrotal hypospadiasis. Indian Dermatol Online J 2017;8:503-5

How to cite this URL:
Kamat D, Malathi M, Prabhakaran N, Thappa DM. Pseudoverrucous papules and nodules in an infant with penoscrotal hypospadiasis. Indian Dermatol Online J [serial online] 2017 [cited 2019 Jun 16];8:503-5. Available from: http://www.idoj.in/text.asp?2017/8/6/503/218342



Sir,

A 10-month-old male child presented with itchy, reddish, raised lesions over the scrotum of 4 months duration. The baby was born with penoscrotal hypospadias with doubling of urethra. In addition to the normal urethral orifice at the glans penis, the child had another urethral opening on the ventral aspect of the shaft of the penis. Though there was no history of continuous dribbling of urine, urine flow through the proximal ventral urethral opening was causing maceration of the skin around external genitalia.

Cutaneous examination revealed multiple minimally erythematous papules with overlying erosions as well as ulcerations distributed in close proximity to the penoscrotal urethral orifice. The lesions were distributed on and either side of the median raphe but more so on the left side. Few erosions showed evidence of partial healing [Figure 1]. The child was treated earlier for scabies and intertrigo without any improvement. Based on the history and clinical examination, the child was diagnosed to have pseudoverrucous papules and nodules (PPN). As the lesions were in the genitalia, the mother was not willing for biopsy. On advising topical clobetasone 0.05% cream twice daily along with frequent wiping of the area, there was significant improvement within 1 week; 2 weeks later, there was near complete resolution of the skin lesions [Figure 2]. The parents were asked to follow these precautions and advised to use zinc cream till definitive surgery was done.
Figure 1: Multiple erythematous, erosive papules and nodules involving the scrotum

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Figure 2: Complete resolution of lesions after topical steroid application

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PPN is a rare form of diaper dermatitis occurring due to prolonged wetness.[1] It presents as gray or erythematous, erosive/verrucous papules, plaques and nodules in the genital and peristomal sites of all ages.[2] Chronic urinary and stool incontinence secondary to urogenital anomalies, occult spinal dysraphism, and various urological and gastroenterological procedures lead to severe irritation of the diaper region causing PPN.[3],[4]

The pathogenesis is similar to that of other forms of irritant contact dermatitis occurring in the diaper area. The most important factor is moist environment, over hydration of skin causing maceration, increased permeability of the skin, and ammonia from urine. Scrotal skin has a higher chance of developing irritant reaction.[2],[4] Although our patient did not have continuous dribbling of urine, the lesions developed on scrotum as urine from ventral aspect of penis was in frequent contact with the skin on under surface of the scrotum.

Granuloma gluteale infantum has morphological and histological overlap with PPN, and Jacquet's erosive dermatitis is also considered to be a part of the same clinical spectrum as PPN, representing chronic irritant contact dermatitis.[5],[6] Therefore, a new term “erosive papulonodular dermatosis” was coined to include all the three variants of irritant contact dermatitis.[7]

PPN mimics certain serious dermatoses such as condyloma lata, condyloma acuminata, cutaneous metastasis, and cutaneous Crohn's disease. Other differential diagnoses include bacterial infections, candidiasis, pemphigus vegetans, and halogenodermas.[3],[6]

As PPN is a chronic irritant reaction, histopathology shows psoriasiform epidermal hyperplasia and reactive acanthosis without significant dermal inflammatory infiltrate in most cases.[3],[4],[8] However, microscopic examination is rarely required for the diagnosis.[2]

Treatment is mainly aimed at removal of precipitating factor and prevention of secondary infections.[4] Zinc cream as barrier and topical steroids are used to treat PPN.[6] Some authors have mentioned urinary alkanization with oral ascorbic acid and acetic acid soaks.[8]

We are reporting this case as one must be aware of this entity, not just in the setting of peristomal dermatitis but also in case of any chronic irritation caused by urine and feces so that unnecessary investigations can be avoided.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Chang MW. Neonatal, Pediatric and Adolescent Dermatology. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K editors. Fitzpatrick's Dermatology in General Medicine. 8th ed. New York: McGraw Gill.2012; p. 1198.  Back to cited text no. 1
    
2.
Garrido-Ruiz MC, Rosales B, Luis Rodriguez-Peralto J. Vulvar pseudoverrucous papules and nodules secondary to a urethral-vaginal fistula. Am J Dermatopathol 2011;33:410-2.  Back to cited text no. 2
    
3.
Coppo P, Salomone R. Pseudoverrucous papules: An aspect of incontinence in children. J EurAcad Dermatol Venereol 2002;16:409-10.  Back to cited text no. 3
    
4.
Dandale A, Dhurat R, Ghate S. Perianal pseudoverrucous papules and nodules. Indian J Sex Transm Dis 2013;34:44-6.  Back to cited text no. 4
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5.
Nelson J, Maroon M. Pseudoverrucous papules. N Engl J Med 2011;364:e50.  Back to cited text no. 5
    
6.
Douri T, Shawaf AZ. Pseudoverrucous papules and nodules: A case report. Dermatol Online J 2012;18:14.  Back to cited text no. 6
    
7.
Robson KJ, Maughan JA, Purcell SD, Petersen MJ, Haefner HK, Lowe L. Erosive papulonodular dermatosis associated with topical benzocaine: A report of two cases and evidence that granuloma gluteale, pseudoverrucous papules, and Jacquet's erosive dermatitis are a disease spectrum. J Am Acad Dermatol 2006;55:74-80.  Back to cited text no. 7
    
8.
Lyon CC, Smith AJ, Griffiths CE, Beck MH. The spectrum of skin disorders in abdominal stoma patients. Br J Dermatol 2000;143:1248-60.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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