• Users Online: 394
  • Print this page
  • Email this page


 
  Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 96-100  

Nonvenereal penile dermatoses: A retrospective study


1 University Clinic of Dermatology, Hospital de Santa Maria, Lisbon, Portugal
2 University Clinic of Dermatology, Hospital de Santa Maria; Institute of Molecular Medicine, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
3 University Clinic of Dermatology, Hospital de Santa Maria; Institute of Molecular Medicine, Faculdade de Medicina da Universidade de Lisboa; Institute of Hygiene and Tropical Medicine, Lisbon, Portugal

Date of Web Publication19-Mar-2018

Correspondence Address:
Ana Marcos-Pinto
University Clinic of Dermatology, Hospital de Santa Maria, Lisbon
Portugal
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_23_17

Rights and Permissions
   Abstract 


Context: A variety of nonvenereal diseases can affect the penis and diminish quality of life. Many present similar clinical features and a cutaneous biopsy may be necessary to clarify the diagnosis. Aims: To characterize nonvenereal penile dermatoses with histological confirmation in a southwestern Europe hospital during a 9-year period. Materials and Methods: A retrospective study was conducted. We reviewed all penile biopsies performed between January 1, 2007 and December 31, 2015 and studied the causes of the nonvenereal penile dermatoses. Results: The sample included a total of 108 patients, aged 62.9 (±17.8) years, between 16 years and 96 years of age. Eighteen dermatoses were identified. Inflammatory diseases were present in 65. 7% of patients (71/108) and neoplastic dermatoses in 34. 3% (37/108). Concerning inflammatory dermatoses, the most frequent were Zoon balanitis (27.8%, 30/108), followed by lichen sclerosus (15.7%, 17/108), psoriasis (11.1%, 12/108), and lichen planus (4.6%, 5/108). In patients with psoriasis, 10 had lesions only in the penis, similarly to all patients with lichen planus. The most frequent malignant tumor was squamous cell carcinoma (SCC) (15.7%, 17/108). The most common in-situ tumor was erythroplasia of Queyrat (8.3%, 9/108). A case of basal cell carcinoma (BCC) was found. Kaposi sarcoma and mycosis fungoides on penis were also diagnosed, as an additional form of presentation to their generalized disease. Conclusions: In this study, inflammatory diseases were the most frequently diagnosed dermatoses, while SCC was the most common malignant tumor found. In the majority of psoriasis and lichen planus cases, clinical lesions were only present in the genital area.

Keywords: Diagnosis, penile dermatoses, skin manifestations, therapeutics


How to cite this article:
Marcos-Pinto A, Soares-de-Almeida L, Borges-Costa J. Nonvenereal penile dermatoses: A retrospective study. Indian Dermatol Online J 2018;9:96-100

How to cite this URL:
Marcos-Pinto A, Soares-de-Almeida L, Borges-Costa J. Nonvenereal penile dermatoses: A retrospective study. Indian Dermatol Online J [serial online] 2018 [cited 2018 Apr 24];9:96-100. Available from: http://www.idoj.in/text.asp?2018/9/2/96/227792




   Introduction Top


A variety of nonvenereal diseases can affect the penis and may diminish quality of life or even, as with squamous cell carcinoma (SCC), have associated mortality. They may be classified into various groups based on their pathogenesis, but differential diagnosis is difficult if based only on clinical manifestations.[1] They may be of infectious origin such as candidiasis, inflammatory as psoriasis, lichen planus or lichen sclerosus, or neoplastic disorders, both benign and malignant.[1],[2],[3],[4] Therefore, its identification can be challenging and a cutaneous biopsy needed in order to clarify the diagnosis.

Objectives

The aim of this study was to assess all cases of nonvenereal penile dermatoses with histological confirmation over a 9-year period and to characterize the frequency, treatment, and evolution of the most frequent disorders.


   Patients and Methods Top


A retrospective study of all nonvenereal penile dermatoses with histological confirmation diagnosed in a southwestern Europe hospital between January 1, 2007 and December 31, 2015 was conducted. All penile biopsies performed during this period (a total of 171 penile biopsies) were reviewed and all cases of nonvenereal dermatoses with an etiological diagnosis and clinical information were included. The exclusion criteria were: sexually transmitted diseases (20), nonvenereal penile dermatoses without clinical information (27), and unspecific alterations in histological examination (16). Based on pathological findings, the dermatoses were classified into two types: inflammatory or neoplastic. Some of the inflammatory dermatoses were also categorized according to the anatomical distribution of the skin lesions: localized to penis or also involving other body areas. Patients gave informed consent for the photographs and the use of all clinical data. Data was analyzed using SPSS 22.0 software.


   Results Top


A total of 108 patients were included, medium age 62 (±17) years, between 16 years and 96 years of age. Eighteen dermatoses were identified [Table 1]. Inflammatory diseases were present in approximately 66% of the patients (71/108) and neoplastic dermatosis in 34% (37/108).
Table 1: Nonvenereal penile dermatoses

Click here to view


The most frequent inflammatory dermatoses were Zoon balanitis (27.8%, 30/108), followed by lichen sclerosus (15.7%, 17/108), psoriasis (11.1%, 12/108), lichen planus (4.6%, 5/108), unspecific balanitis (4.6%, 5/108), pemphigus vulgaris (0.9%, 1/108), and Fordyce disease (0.9%, 1/108).

In patients with Zoon balanitis, 29 were treated with topical corticosteroids and six of those were submitted to circumcision. One patient was treated with CO2 laser therapy, who had no relapse, as also all circumcised. Among the remaining patients who had been treated with corticosteroids, only one developed SCC, 2 years later after the histological diagnosis of Zoon balanitis.

Lesions of psoriasis were limited to the penis in 10 patients; two had generalized disease with lesions in other body areas. All diagnosed cases of lichen planus presented only with penile manifestations. In one patient with penile psoriasis, the lesion was excised, without relapse in a 3-year follow-up period, while all other patients with psoriasis and lichen planus were treated with topical corticosteroids with good response.

Every individual with lichen sclerosus had topical high potency corticosteroids applied, with circumcision being necessary in three of them. There were no cases of SCC during the follow-up period.

The majority of neoplastic dermatoses were malignant tumors. Among those, the most frequent was SCC (15.7%, 17/108), with only one case of basal cell carcinoma (BCC). In situ SCC, erythroplasia of Queyrat, was diagnosed in 8% (9/108). Kaposi sarcoma and mycosis fungoides were histologically diagnosed in one patient each.

The remaining patients had benign tumors such as seborrheic keratosis (2.8%, 3/108), angiokeratoma, angioma, lentigo, and milia cyst (0.9%, 1/108 each).

Partial or total penectomy was performed, respectively, in 14/17 (83%) and 3/17 (17%) of the 17/108 (15.7%) patients with SCC.

Erythroplasia of Queyrat was the etiological diagnosis in 9/108 cases, beings treated with CO2 laser in six. One patient was later submitted to partial penectomy because of relapse and evolution to an invasive SCC. Partial penectomy was done in other two cases as primary intervention and only one was treated with cryotherapy associated with imiquimod. There was not any other case of relapse during the follow-up. The unique penile BCC was excised and did not relapse.

All benign tumors were successfully treated and excised, except for one seborrheic keratosis, treated with CO2 laser therapy.


   Discussion Top


Since our study was based on nonvenereal pathology with histological confirmation, we expected most cases to be of neoplastic etiology. However, in our study and like in others,[1],[2],[3],[4] inflammatory diseases were the most diagnosed dermatosis. This could be due to the similar clinical appearance among various penile dermatoses and because some of them, like psoriasis or lichen planus that usually appear also in other body areas, rarely manifest themselves as a unique penile lesion, which makes the diagnosis more difficult.[5],[6]

Zoon balanitis was the most common inflammatory disease diagnosed histologically. Its a chronic disease of unknown etiology, described mainly in middle-aged or elderly uncircumcised man that begins as one or more roundish or polycyclic dark red patches with indistinct borders on the glans and/or internal preputial lamina [Figure 1].[7],[8] The differential diagnosis with erythroplasia of Queyrat and lichen sclerosus may be difficult and in those cases a skin biopsy must be performed. Development of SCC in this disease was described since 1999, but there was only one case of SCC in our series. In our study, 79% (26/30) of these patients responded well to corticosteroids, but in 21% (6/30) it was necessary circumcision with a successful rate of 100%, as it has been described previously.[6],[7] The CO2 laser therapy in one of our patients that did not relapse demonstrates that it can be an effective procedure in this disease as described by Retamar RA et al.[7]
Figure 1: Zoon balanitis – reddish plaque, well-defined, around the glans

Click here to view


Psoriasis is a chronic, inflammatory skin disease, with the genitalia being involved in up to 30% of psoriasis patients. In 2–5% of the patients, the lesions may occur only in this area. Lesions may appear on the glans and prepuce as small papules or large patches [Figure 2]. The location on the glans may be the first and only lesion.[5],[6]
Figure 2: Penile psoriasis – papules and plaques, salmon color, on the glans

Click here to view


Lichen planus has an estimated frequency of about 1% in the general population. The male genitalia is involved in 25% of cases, the glans penis being the most commonly affected with annular lesions frequently present. Fine white streaks are usually visible on the surface, the so-called Wickham's striae [Figure 3]. Like psoriasis, the majority of patients also have lesions in other areas.[6] In our study, lichen planus was only limited to the penis and among the 12 patients with penile psoriasis, only two also had lesions in other body areas. Several reports have cited the isolated occurrence of lichen planus and psoriasis on the glans penis.[5],[9],[10],[11] The explanation can be related with the Koebner phenomenon, after trauma, caused by sexual intercourse, tight clothes, chemical, such as contact with urine or related to sunburn.[5] The treatment of both diseases consists in topical corticosteroids as first line with our patients having had a satisfactory response with such topical therapy.
Figure 3: Lichen planus – whitish striae on the glans and foreskin

Click here to view


Genital lichen sclerosus is a chronic inflammatory skin disease responsible for male sexual dyspareunia and urological morbidity [Figure 4]. Early aggressive treatment may prevent disease progression and most patients achieved remission with ultrapotent topical corticosteroid in 75–90%[6], [12],[13],[14] as in our study, with an excellent response in 84% of those treated. Circumcision is recommended if maximal conventional medical treatment is not possible or fails. It was necessary only in three patients. Although, SCC can develop on lichen sclerosus, there were no cases of malignancy in our study.
Figure 4: Lichen sclerosus – white plaques on the glans and foreskin

Click here to view


In the neoplastic diseases of this body area, primary malignant penile cancer is uncommon in Europe, with an incidence of less than 1 per 100,000 males and with SCC accounting for more than 95% of the cases.[6] The clinical appearance of penile SCC varies from an erythematous plaque to more verrucous and exophytic lesions that may coalesce into an irregularly shaped mass [Figure 5]. As in other series, the most common neoplastic tumor was SCC. The diagnosis was made relatively early, allowing less invasive surgery (partial penectomy) in the majority of cases, with lower morbidity for the patients.
Figure 5: Squamous cell carcinoma – verrucous mass on the glans

Click here to view


Erythroplasia of Queyrat (SCC in situ on the glans) usually presents as a sharply, define borders, slightly raised erythematous plaque on the glans penis or the inner side of the foreskin. The surface may be somewhat smooth, scaly to frankly warty [Figure 6]. The progression of erythroplasia into SCC has been reported to occur in 10–33% of cases. Surgical excision is the treatment of choice, but topical 5-fluorouracil and CO laser may also be used.[6],[13]
Figure 6: Erythroplasia of Queyrat – reddish plaque on the glans with some periurethral nodules

Click here to view


In our series, there was a preferential treatment with CO2 laser therapy, with a success rate of 83%, similar to other studies.[15] Only one case of erythroplasia of Queyrat became an invasive carcinoma in an individual infected with HIV. Partial penectomy was necessary in only two patients as a primary intervention. There was no relapse in none of these.

Study limitations were that it was a retrospective study and only dermatoses with histological confirmation were included, excluding others clinically diagnosed. However, our findings may provide useful clinical data for an easier differential clinical diagnosis and treatment options of penile dermatoses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Puri N, Puri A. A study on non venereal genital dermatoses in North India. Our Dermatol Online 2012;3:304-7.  Back to cited text no. 1
    
2.
Saraswat PK, Garg A, Mishra D, Garg S. A study of pattern of nonvenereal genital dermatoses of male attending skin OPD at a tertiary care center. Indian J Sex Transm Dis 2014;35:129-34.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
You HS, Kim GW, Kim WJ, Mun JH, Song M, Kim HS, et al. Dermatoses of the glans penis in Korea: A 10-year single center experience. Ann Dermatol 2016;28:40-4.  Back to cited text no. 3
    
4.
Karthikeyan K, Jaisankar TJ, Thappa DM. Non venereal dermatoses in male genital region-prevalence and patterns in a referal center in south India. Indian J Dermatol 2001;46:18-22.  Back to cited text no. 4
  [Full text]  
5.
Meeuwis KA, de Hullu JA, Massuger LF, van de Kerkhof PC, van Rossum MM. Genital psoriasis: A systematic literature review on this hidden skin disease. Acta Derm Venereol 2011;91:5-11.  Back to cited text no. 5
    
6.
Andreassi L, Bilenchi R. Non-infectious inflammatory genital lesions. Clin Dermatol 2014;32:307-14.  Back to cited text no. 6
    
7.
Retamar RA, Kien MC, Chouela En. Zoon's balanitis: Presentation of 15 patients, five treated with a carbon dioxide laser. Int J Dermatol 2003;42:305-7.  Back to cited text no. 7
    
8.
Pastar Z, Rados J, Lipozencić J, Skerlev M, Loncarić D. Zoon plasma cell balanitis: An overview and role of histopathology. Acta Dermatovenerol Croat 2004;12:268-73.  Back to cited text no. 8
    
9.
Buechner SA. Common skin disorders of the penis. BJU Int 2002;90:498-506.  Back to cited text no. 9
    
10.
Karthikeyan K, Jeevankumar B, Thappa DM. Bullous lichen planus of the glans penis. Dermatol Online J 2003;9:31.  Back to cited text no. 10
    
11.
Alinovi A, Barella PA, Benoldi D. Erosive lichen planus involving the glans penis alone. Int J Dermatol 1983;22:37-8.  Back to cited text no. 11
    
12.
Bunker CB, Shim TN. Male genital lichen sclerosus. Indian J Dermatol 2015;60:111-7.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Eichmann AR. Dermatoses of the male genital area. Dermatology 2005;210:150-6.  Back to cited text no. 13
    
14.
Kirtschig G, Becker K, Günthert A, Jasaitiene D, Cooper S, Chi CC, et al. Evidence-based (S3) guideline on (anogenital) lichen sclerosus. J Eur Acad Dermatol Venereol 2015;29:e1-43.  Back to cited text no. 14
    
15.
Maranda EL, Nguyen AH, Lim VM, Shah VV, Jimenez JJ. Erythroplasia of Queyrat treated by laser and light modalities: A systematic review. Lasers Med Sci 2016;31:1971-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Patients and Methods
   Results
   Discussion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed370    
    Printed3    
    Emailed0    
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal