Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases

BACKGROUND: Penile intraepithelial neoplasia (PIN) is the term used to describe erythroplasia of Queyrat (EQ), Bowen's disease (BD) and bowenoid papulosis (BP). These conditions are distinct clinical entities and have different epidemiological and aetiological associations and prognostic implications. OBJECTIVES: To describe the presentation and treatment of patients with PIN. METHODS: Thirty-five patients presenting with PIN over a 7-year period are described. RESULTS: Our observations include: (i) patients with BP are younger than those with EQ or BD and sometimes have a history of immunosuppression; (ii) patients with BP usually have a history or clinical evidence of previous genital human papillomavirus infection; (iii) patients with EQ often have a concurrent penile dermatosis (lichen sclerosus or lichen planus); (iv) patients with PIN are usually uncircumcised; and (v) response to treatment of BP depends on the integrity of the immune system. CONCLUSIONS: We recommend vigorous treatment of all patients with PIN, including circumcision. Smoking should be actively discouraged. Patients should have life-long follow-up and partners of patients with BP should be screened for other forms of intraepithelial neoplasia (cervical and anal).     

Clinical outcomes in a specialist male genital skin clinic: prospective follow‐up of 600 patients

It is important to assess outcomes for medical interventions in order to focus scarce resources on outcomes with a known positive benefit. An open, observational study was performed to assess the clinical outcomes of 600 male patients with a genital skin problem attending a specialist secondary care dermatology facility. Patients were mainly referred by general practitioners and genitourinary medicine physicians. Outcome was measured at 3 and 6 months, and was determined by clinical examination and assessment of patient symptoms. The mean age of the group was 45.3 years. The commonest diagnoses were lichen sclerosus (30.5%), balanitis (17.3%), eczema (12.8%), lichen planus (7.3%), psoriasis (7.2%) and benign lesions (5.5%). The commonest presenting symptoms were genital rash (43%), genital soreness, pain or burning (17.5%), and penile lesions (15.7%). Lichen sclerosus and all forms of balanitis were more common in uncircumcised patients, whereas lichen planus was more common in circumcised males. Short‐term outcome was excellent, with 11.5% of patients being reassured and discharged on their first visit, and after 6 months 58% of all patients were clear and 12% had improved. Only 4.5% reported no improvement in symptoms. Diagnostic biopsy demonstrated malignant or premalignant lesions in nearly a fifth of those having a procedure. Close working with urological and genitourinary medicine colleagues is important to manage the various aspects of male health.     

Plasma Cell Balanitis Presenting in a Patient with a History of Syphilis

Plasma cell balanitis (PCB), also knows as Zoon balanitis, is a benign asymptomatic but chronic and erosive inflammatory condition of the glans penis and prepuce that generally affects uncircumcised men in later years. Clinical presentation involves a single, shiny, well defined reddish patch. We describe the first case of PCB ever reported in a patient with a previous history of syphilis, and include a review of the current literature. A 57-year-old Hispanic man with a remote history of syphilis presented with a 6-month nonhealing, granulating ulcer of the foreskin and glans penis that had been repeatedly mistaken for syphilis and treated unsuccessfully with circumcision 3 weeks previously. Biopsy of the glans penis demonstrated sections with denuded chronic granulation tissue showing a fibrotic stroma with numerous blood vessels and a mixed inflammatory infiltrate including scattered plasma cells. It is important to differentiate PCB from a syphilitic chancre in a patient presenting with a nonhealing penile lesion. This case report demonstrates that these entities may be seen in the same patient at different times.     

An argument for circumcision. Prevention of balanitis in the adult

A cross-sectional study and a retrospective study were performed to determine the frequency of balanitis in a randomly selected group of dermatology patients. A total of 398 subjects were included in the cross-sectional study, 213 (53.5%) of whom had been circumcised. Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men. In patients with diabetes mellitus, balanitis occurred with a prevalence of 34.8% in the uncircumcised population, compared with 0% in the circumcised population. Balanitis did occur with increased frequency in the diabetic population (16%), regardless of circumcision status, compared with the nondiabetic population (5.8%). Of 63 circumcisions performed at our institution between 1987 and 1989, 28.6% were for the treatment of balanitis; 44.4%, for phimosis (which was probably induced by chronic balanitis); 19% in preparation for placement of penile prostheses; and 8% for miscellaneous reasons. No complications of circumcision were reported. In this group of patients, balanitis was more frequent in diabetic than in nondiabetic uncircumcised men (50% vs 15.4%).     

Thalidomide in plasma cell balanitis refractory to conventional topical treatment

Zoon’s plasma cell balanitis is a chronic genital inflammatory dermatosis that affects uncircumcised men, especially the elderly. It’s characterized by painless erythematous plaques of orange hue, located on the glans penis and foreskin. Circumcision is the most effective treatment; however, it can be hard for patients to accept. As an alternative, topical calcineurin inhibitors are used, with good response. This article reports the case of a 32-year-old patient, HIV carrier, diagnosed with Zoon’s plasma cell balanitis. Treatment with topical tacrolimus was administered, without improvement. A 6-week course of thalidomide resulted in complete remission of the lesions, without recurrence after eight months of follow-up.     

Traumatic neuroma of the penis after circumcision - Case report

Traumatic neuromas are tumors resulting from hyperplasia of axons and nerve sheath cells after section or injury to the nervous tissue¹. We present a case of this tumor, confirmed by anatomopathological examination, in a male patient with history of circumcision. Knowledge of this entity is very important in achieving the differential diagnosis with other lesions that affect the genital area such as condyloma acuminata, bowenoid papulosis, lichen nitidus, sebaceous gland hyperplasia, achrochordon and pearly penile papules.     

尖锐湿疣和鲍温样丘疹病中Livin,Caspase-3的表达及相关性分析

目的探讨尖锐湿疣(CA)和鲍温样丘疹病(BP)中凋亡抑制蛋白(Livin),半胱氨酸蛋白酶-3(Caspase-3)的表达,并进行相关性分析。方法选取CA,BP皮损和正常成年人包皮组织各30例,采用免疫组化法检测Livin,Caspase-3蛋白的表达。结果 Livin在BP组中阳性率(3.833±1.533)高于CA组(3.033±1.866)及正常对照组(2.733±1.112),Caspase-3在正常对照组中阳性率(3.833±1.556)高于CA组(1.733±1.856)及BP组(2.000±1.640),差异均有统计学意义(P均<0.05)。在CA,BP及正常对照组中Livin与Caspase-3的表达均无相关性(P均>0.05)。结论 Livin,Caspase-3可能在HPV感染相关的皮肤增殖性疾病中发挥一定作用。     

Lichen planus: an unusual cause of phimosis.

We report on a 47-year-old man with oral and genital lichen planus. After some months of the disease, increasing phimosis developed which had not been present before. Retraction of the foreskin was now impossible and sexual intercourse was painful. Treatment with triamcinoloneacetonide and etretinate ameliorated the phimosis but the patient was still not comfortable and circumcision was performed. Histology from the foreskin revealed the typical picture of lichen planus. No features of lichen sclerosus et atrophicus were present. This is the first published observation of phimosis as a result of lichen planus.     

Final Diagnosis of 112 Girls Presenting With Genital Mucocutaneous Symptoms and Signs: The Mayo Clinic Experience

Pediatric genital mucocutaneous diseases are rare. A retrospective review was performed of children presenting with symptomatology of genital dermatoses to a hospital‐based dermatology service. This study highlights that the range of genital diseases in children is not as broad as in adults. The diagnosis of genital mucocutaneous disease in children is usually genital lichen sclerosus, but other diagnoses should be considered.     

Association of penile lichen sclerosus and oncogenic human papillomavirus infection

BACKGROUND: Data on the prevalence of human papillomavirus (HPV) infection in patients with penile lichen sclerosus (LS) are scant and controversial. AIM: To investigate the prevalence of HPV infections in patients with penile LS. METHODS: HPV infection was assessed by polymerase chain reaction (PCR) in paraffin-embedded penile biopsies obtained from the glans or inner foreskin of 46 adult patients with penile LS, and in brush cytology smears of penile healthy mucosa from an equal number of randomly selected control males matched for age. Statistical evaluation was performed using conditional logistic regression analysis. RESULTS: PCR disclosed the presence of HPV infection in 17.4% of LS patients (HPV 16, six cases; HPV 18, one case; HPV 45, one case). Amongst the controls, HPV infection occurred in 8.7% of patients (HPV 16, two cases; HPV 53, one case; HPV 70, one case). Statistical regression analysis confirmed that the rate of HPV infection was higher amongst patients with genital LS than amongst healthy controls [odds ratio (OR), 2.55; 95% confidence interval (CI), 0.73-8.89]. CONCLUSIONS: Infection with oncogenic "high-risk" HPV types in patients with genital LS may enhance the risk of penile cancer arising on LS.     

Immunohistochemical evaluation of androgen receptors in genital and extragenital lichen sclerosus: evidence for loss of androgen receptors in lesional epidermis.

BACKGROUND: Reduction of lichen sclerosus has been seen with topical testosterone, and spontaneous resolution has been attributed to increasing androgen levels. OBJECTIVE: Our purpose was to investigate the role of androgens in lichen sclerosus by studying lesional skin and site-specific normal skin for the presence of androgen receptors. METHODS: Immunoperoxidase staining for androgen receptors was performed on lesional tissue from 31 patients and microscopically compared with site-specific normal skin. RESULTS: Androgen receptors were present in normal genital and extragenital skin. Lesional genital and extragenital areas showed decreased staining compared with site-specific controls. Finally staining was decreased in histologically well-developed lesions compared with early lesions. CONCLUSION: This study provides evidence for the loss of androgen receptors with disease progression in both genital and extragenital skin affected by lichen sclerosus. These findings support a hormonal pathogenesis of lichen sclerosus and may be significant in the treatment of the disease.     

Histology of lichen sclerosus varies according to site and proximity to carcinoma.

To investigate why vulvar but not extragenital lichen sclerosus is associated with squamous cell carcinoma, we performed a histologic study of extragenital lichen sclerosus, vulvar lichen sclerosus without carcinoma, and vulvar lichen sclerosus with carcinoma adjacent to and distant from the carcinoma. We compared epidermal thickness, rete ridge length, mitotic activity, atypia, dermal collagen change, dermal inflammation, and presence of other dermatoses in 30 women in each group. Extragenital lichen sclerosus showed thinner epidermis (mean thickness of 0.13 mm versus 0.41 mm; P < 0.0005), shorter rete ridges (P = 0.0001), more dermal edema (P = 0.16), and absence of associated dermatoses of spongiotic dermatitis and lichen planus (P < 0.005) compared with vulvar lichen sclerosus. The epidermal thickening seen in vulvar lichen sclerosus was indistinguishable from lichen simplex chronicus. Vulvar lichen sclerosus without carcinoma was generally similar to that distant from carcinoma. Vulvar lichen sclerosus adjacent to carcinoma showed increased epidermal thickness (0.61 mm versus 0.26 mm; P < 0.005), more dermal fibrosis (P < 0.0005), more inflammation (P < 0.0005), and more simplex (differentiated) vulvar intraepithelial neoplasia (18 cases versus 1 case; P < 0.0005) compared with that distant from carcinoma. We concluded that (1) the classic histologic features of lichen sclerosus are seen in both vulvar and extragenital sites; (2) vulvar lichen sclerosus without associated carcinoma has a mean epidermal thickness more than three times that of extragenital lichen sclerosus; (3) the epidermal thickening is histologically indistinguishable from lichen simplex chronicus; (4) there is a tendency for vulvar lichen sclerosus to have a more sclerotic and inflamed dermis; (5) lichen sclerosus 10 mm from cancer is more similar to vulvar lichen sclerosus without carcinoma than lichen sclerosus 1 mm from carcinoma; and (6) lichen sclerosus adjacent to carcinoma tends to show exaggerated epidermis thickness, basal atypia, and loss of the edematous-hyaline layer.     

Extragenital bowenoid papulosis associated with atypical human papillomavirus genotypes

BACKGROUND: Bowenoid papulosis typically appears as grouped violaceous or red-brown papules in the genital or perianal regions and clinically resembles condylomata acuminata. Isolated extragenital bowenoid papulosis is rare and has been reported in only a few case reports. OBJECTIVES: A 51-year-old immunocompetent, healthy woman had two solitary papules on the elbow; a 41-year-old HIV-positive man had a solitary cutaneous plaque on the abdomen. No genital, periungual, or other extragenital sites of involvement were noted in either patient. The diagnosis was confirmed histologically in both cases. Lesional skin from the female patient was tested with the Digenehybrid HPV DNA assay and was positive for a mixture of low-risk HPV subtypes (6, 11, 42, 43, 44). Lesional skin from the male patient was tested with polymerase chain reaction (PCR). Consensus primers targeted for the HPV L1 region, which is a highly conserved sequence common to more than 20 HPV subtypes encoding a viral capsid protein, were used. PCR using the consensus primers was positive, but type-specific probes for HPV types 6, 11, 16, 18, 45, 31, 33, 35, and 39 were negative. CONCLUSIONS: To our knowledge, our male patient represents the first case of isolated bowenoid papulosis of the abdominal skin. Isolated upper-extremity bowenoid papulosis in our female patient is also a unique case in both location and involvement of low-risk HPV types (6, 11, 42, 43, 44), which have not been previously associated with extragenital bowenoid papulosis.     

Ultrapotent topical corticosteroid treatment of childhood genital lichen sclerosus.

OBJECTIVE: To observe the clinical effects of short-term application of ultrapotent topical corticosteroid on symptomatic genital lesions of lichen sclerosus in pediatric patients. DESIGN: Case series of 10 prepubertal girls with genital lichen sclerosus. Ultrapotent topical corticosteroids were applied twice daily for 6 to 8 weeks and patients were reexamined at completion of treatment. Long-term follow-up over 6 months to 3 years. SETTING: Pediatric dermatology clinic (referral center). PATIENTS: Ten prepubertal girls with typical clinical features of genital and/or perianal lichen sclerosus. INTERVENTION: Topical ultrapotent corticosteroid ointment was applied sparingly to affected areas for 6 to 8 weeks. MAIN OUTCOME MEASURE: Improvement of erythema, whitening erosions, and atrophy. Subjective improvement of symptoms. RESULTS: All patients showed partial or total subsistence of signs and symptoms of lichen sclerosus. Frequency and severity of recurrences varied, but patients responded within a few days to reapplication of ultrapotent topical corticosteroid. No significant adverse effects were noted after the initial 6- to 8-week course of therapy or during the 6-month to 3-year follow-up period. CONCLUSION: A 6- to 8-week course of ultrapotent topical corticosteroid is a safe and effective treatment for genital lichen sclerosus in pediatric patients.     

Treatment of genito-anal lesions in inflammatory skin diseases with PUVA cream photochemotherapy: an open pilot study in 12 patients

BACKGROUND: Localized skin lesions of the genito-anal region such as in lichen sclerosus et atrophicus or in lichen planus are a burden for many patients, and therapeutic efforts, including therapies with potentially hazardous side-effects, are often unsatisfactory. Recently, PUVA bath photochemotherapy has been proven highly effective in the treatment of various inflammatory skin diseases, including localized scleroderma. Another form of topical PUVA therapy, 8-methoxypsoralen-containing cream or gel preparations, has been proven to be as effective as PUVA bath therapy for palmoplantar dermatoses. OBJECTIVE: We evaluated the clinical effects of PUVA cream photochemotherapy in patients with genital lesions of inflammatory skin diseases. METHODS: Twelve patients with lichen sclerosus et atrophicus, lichen planus, vulvar eczema and pruritus vulvae were included in the study. PUVA cream therapy was performed up to 4 times a week. RESULTS: PUVA cream photochemotherapy induced a significant clinical improvement of genital lesions in most patients, as revealed by clinical examination. Clinical improvement (reduction in size of lesions of erythema, and/or of pruritus) was achieved in most patients after 10-20 treatments and was reduced in patients that had only received 5-15 treatments. Cumulative doses ranged between 4.5 and 180 J/cm(2); all patients tolerated PUVA cream phototherapy well without any side-effects. CONCLUSION: PUVA cream phototherapy represents a highly effective therapy that should be further investigated as an alternative treatment for patients with genital lesions of inflammatory skin diseases.     

Male genital lichen planus: A retrospective study of 89 cases

BackgroundUnlike other types of lichen planus (LP), there are no series concerning male genital LP.ObjectiveTo describe the clinical characteristics, diagnosis, and response to treatment of male genital LP.Patients and methodsA retrospective study of male patients with genital LP consulting a dermatologist specialized in anogenital diseases between January 2010 and 2019. Demographic data, history, functional signs, clinical characteristics, pathology, complications, and treatment efficacy were collected.ResultsEighty-nine patients were included at four centers. The median age was 51 years. Most patients were uncircumcised and asymptomatic. In 88.8% of cases, only the genital mucosa was involved. Erythema (71%), papules (21.3%), lacy network (15.7%), atrophic lesions (15.7%), erosions (14.6%), and post-inflammatory hyperpigmentation (2.2%) were less frequently observed. Biopsy results confirmed LP in 61.3% of cases but could not rule out other inflammatory genital dermatoses in other cases. Anatomic complications were observed in 30.3% of patients. Topical corticosteroids (TCS) induced remission in most cases. Tacrolimus efficacy was comparable to that of TCS.ConclusionMale genital LP is a rare inflammatory disorder chiefly affecting uncircumcised men. It is found predominantly on the mucosal component of the penis and presents as non-erosive inflammatory balanitis in most cases, with frequent partial or complete remission on treatment with TCS.     

Low prevalence of penile wetness among male sexually transmitted infection clinic attendees in London

OBJECTIVE: To determine the prevalence of penile wetness among STI clinic attenders in London. STUDY DESIGN: A total of 480 consecutive men were examined clinically to detect whether penile wetness, defined as the clinical observation of a uniform diffuse layer of moisture on the surface of the glans and coronal sulcus, was present. RESULTS: Penile wetness was observed in 30 (6.3%), including 29 (8.3%) of uncircumcised and 1 (0.8%) of circumcised men (Relative risk 10.54 (95% CI 1.45-76.6, P = <0.001) (Fisher's Exact test) and in 14/34 (41.2%) of men with balanitis. Penile wetness was observed in 9.2% Asian, 7% Caucasian, 3% of black men, and 6.3% of homosexuals, and in 14/34 (8.2%) of men with clinical balanitis compared with 8/244 (3.3%) with no STI diagnosis (P = <0.001). CONCLUSIONS: The prevalence of penile wetness was low in this population of STI clinic attenders in London, much lower than in Durban, South Africa. Further studies of male genital hygiene are warranted.