Noninfectious Penile Lesions

1. A 26-year-old man presents with a penile lesion that has existed at least 10 years without significant change and with no attendant symptoms. The lesion consists of four 1-to-1.5-mm soft, compressible purple papules, in aggregate measuring about 8 mm. No other lesions are seen on the genitals or on the body.

Diagnosis: The lesion proved to be angiokeratoma of Fordyce, a totally benign lesion. This type of angiokeratoma is ectatic, thin-walled vessels in the superficial dermis, with overlying epidermal hyperplasia that forms secondary to normal friction. When they are seen on the scrotum, vulva, or penis, they are usually referred to as angiokeratoma of Fordyce, a type of localized angiokeratoma, other types of which can appear on the legs or hands.

These totally benign lesions must be distinguished from generalized types of angiokeratomata, such as those seen in Fabry disease (angiokeratoma corporis diffusum), an inheritable metabolic disorder. With our patient’s history, his lesion was clearly benign.

Had his lesion been new or changing in any substantive way, additional testing, including a biopsy, might have been necessary to rule out entities such as squamous cell carcinoma (which is almost unknown in circumcised patients), condyloma, melanoma, the aforementioned Kaposi’s sarcoma, or even angiosarcoma.

For more information, see “Skin is skin, no matter the location.” Clinician Reviews. 2013 June;23(6):W5.

2. A 59-year-old uncircumcised man presents with a phimotic foreskin, which cannot be retracted without pain. Only a tiny opening remains through which the patient can urinate (with difficulty). The surface of the foreskin is atrophic, dry, and shiny with focal areas of purpura but little, if any, redness or swelling.

Diagnosis: This patient’s condition is lichen sclerosus, also called balanitis xerotica obliterans (BXO), a diagnosis of sufficient obscurity to almost guarantee initial misdiagnosis as “yeast infection” or “herpes.” One treatment failure after another eventually leads to referral to a provider familiar with BXO, which is the male version of lichen sclerosus et atrophicus (LS&A) and usually affects the glans, foreskin, and distal shaft.

The causes of these conditions are as yet unknown. However, much is known about how they present, how they look under a microscope, and how to treat them.

Treatment entails use of the most powerful topical steroid ointments, which are so effective that they have completely replaced previous treatment options (eg, testosterone ointment). While a cure is unlikely, control is a realistic goal.

BXO, as in this case, can also cause urinary obstruction, both from the overlying foreskin and from actual meatal stenosis. This is why advanced cases need referral to urology for possible circumcision. As with many penile diagnoses (eg, squamous cell carcinoma or condyloma), BXO is far more common in the uncircumcised.

For more information, see “Man has very uncomfortable problem.” Clinician Reviews. 2012 September;22(9):W4.

3. A 31-year-old man has a relatively asymptomatic penile rash that has repeatedly manifested and resolved over a period of months. A round, papulosquamous, bright pink patch on the distal right shaft of his circumcised penis measures > 3 cm in diameter and has a shiny appearance with slightly irregular margins. A similar rash is seen behind both ears, in the umbilicus, and patches of dandruff are noted. Despite good health, he has been under a great deal of stress recently.

Diagnosis: Seborrheic dermatitis (SD), also known as seborrhea, is an extremely common chronic papulosquamous disorder patterned on the sebum-rich areas of the scalp, face, and trunk. Although not directly caused by the highly lipophilic commensal yeast Malassezia furfur, it does appear to be related to increases in the number of those organisms, as well as to immunologic abnormalities and increased production of sebum. It can range from a mild scaly rash to whole-body erythroderma and can affect an astonishing range of areas, including the genitals.

SD, especially in this case, represents the perfect example of the need to “look elsewhere” for clues when confronted with a mysterious rash. Patients can certainly have more than one dermatologic diagnosis at a time, but a single explanation is considerably more likely and should therefore be sought. In this case, corroboration for the diagnosis of SD was readily found by looking for it in its known locations.

In this case, treatment comprised a combination of oxiconazole lotion and 2.5% hydrocortisone cream. Many other combinations have been used successfully, including pimecrolimus or tacrolimus combined with ketoconazole cream.

Whatever is used, a cure will not be forthcoming, since the condition is almost always chronic. The main value of an accurate diagnosis in such a case lies in easing the patient’s mind regarding the terrible diseases he doesn’t have.

For more information, see “Relatively Asymptomatic, but Still Problematic." Clinician Reviews. 2014 April;24(4):15-16.

4. This circumscribed inflammatory plaque on the glans penis of allegedly > 20 years' duration was refractory to circumcision and local treatment. Because of unresponsiveness of the lesion to circumcision and focal steroid infiltration, repeated biopsies were performed.

Diagnosis: One biopsy again showed the features of a plasmacellular inflammation, while the other finally revealed the histopathologic features of erythroplasia of Queyrat (carcinoma in situ or Bowen's disease of the glans penis). We assume that either the former biopsy specimens were taken from a plasma cell-rich reactive infiltrate around the neoplastic lesion, or that carcinoma in situ may have arisen due to the chronic inflammation of Zoon's balanitis plasmacellularis. Radiotherapy was performed with good clinical response and subsequent histopathologic proof of complete remission of the lesion.

For more information, see “Bowen's Disease of the Glans Penis (Erythroplasia of Queyrat) in Plasma Cell Balanitis.” Cutis. 2000 June;65(6):395-398.

1. A 26-year-old man presents with a penile lesion that has existed at least 10 years without significant change and with no attendant symptoms. The lesion consists of four 1-to-1.5-mm soft, compressible purple papules, in aggregate measuring about 8 mm. No other lesions are seen on the genitals or on the body.

Diagnosis: The lesion proved to be angiokeratoma of Fordyce, a totally benign lesion. This type of angiokeratoma is ectatic, thin-walled vessels in the superficial dermis, with overlying epidermal hyperplasia that forms secondary to normal friction. When they are seen on the scrotum, vulva, or penis, they are usually referred to as angiokeratoma of Fordyce, a type of localized angiokeratoma, other types of which can appear on the legs or hands.

These totally benign lesions must be distinguished from generalized types of angiokeratomata, such as those seen in Fabry disease (angiokeratoma corporis diffusum), an inheritable metabolic disorder. With our patient’s history, his lesion was clearly benign.

Had his lesion been new or changing in any substantive way, additional testing, including a biopsy, might have been necessary to rule out entities such as squamous cell carcinoma (which is almost unknown in circumcised patients), condyloma, melanoma, the aforementioned Kaposi’s sarcoma, or even angiosarcoma.

For more information, see “Skin is skin, no matter the location.” Clinician Reviews. 2013 June;23(6):W5.

2. A 59-year-old uncircumcised man presents with a phimotic foreskin, which cannot be retracted without pain. Only a tiny opening remains through which the patient can urinate (with difficulty). The surface of the foreskin is atrophic, dry, and shiny with focal areas of purpura but little, if any, redness or swelling.

Diagnosis: This patient’s condition is lichen sclerosus, also called balanitis xerotica obliterans (BXO), a diagnosis of sufficient obscurity to almost guarantee initial misdiagnosis as “yeast infection” or “herpes.” One treatment failure after another eventually leads to referral to a provider familiar with BXO, which is the male version of lichen sclerosus et atrophicus (LS&A) and usually affects the glans, foreskin, and distal shaft.

The causes of these conditions are as yet unknown. However, much is known about how they present, how they look under a microscope, and how to treat them.

Treatment entails use of the most powerful topical steroid ointments, which are so effective that they have completely replaced previous treatment options (eg, testosterone ointment). While a cure is unlikely, control is a realistic goal.

BXO, as in this case, can also cause urinary obstruction, both from the overlying foreskin and from actual meatal stenosis. This is why advanced cases need referral to urology for possible circumcision. As with many penile diagnoses (eg, squamous cell carcinoma or condyloma), BXO is far more common in the uncircumcised.

For more information, see “Man has very uncomfortable problem.” Clinician Reviews. 2012 September;22(9):W4.

3. A 31-year-old man has a relatively asymptomatic penile rash that has repeatedly manifested and resolved over a period of months. A round, papulosquamous, bright pink patch on the distal right shaft of his circumcised penis measures > 3 cm in diameter and has a shiny appearance with slightly irregular margins. A similar rash is seen behind both ears, in the umbilicus, and patches of dandruff are noted. Despite good health, he has been under a great deal of stress recently.

Diagnosis: Seborrheic dermatitis (SD), also known as seborrhea, is an extremely common chronic papulosquamous disorder patterned on the sebum-rich areas of the scalp, face, and trunk. Although not directly caused by the highly lipophilic commensal yeast Malassezia furfur, it does appear to be related to increases in the number of those organisms, as well as to immunologic abnormalities and increased production of sebum. It can range from a mild scaly rash to whole-body erythroderma and can affect an astonishing range of areas, including the genitals.

SD, especially in this case, represents the perfect example of the need to “look elsewhere” for clues when confronted with a mysterious rash. Patients can certainly have more than one dermatologic diagnosis at a time, but a single explanation is considerably more likely and should therefore be sought. In this case, corroboration for the diagnosis of SD was readily found by looking for it in its known locations.

In this case, treatment comprised a combination of oxiconazole lotion and 2.5% hydrocortisone cream. Many other combinations have been used successfully, including pimecrolimus or tacrolimus combined with ketoconazole cream.

Whatever is used, a cure will not be forthcoming, since the condition is almost always chronic. The main value of an accurate diagnosis in such a case lies in easing the patient’s mind regarding the terrible diseases he doesn’t have.

For more information, see “Relatively Asymptomatic, but Still Problematic." Clinician Reviews. 2014 April;24(4):15-16.

4. This circumscribed inflammatory plaque on the glans penis of allegedly > 20 years' duration was refractory to circumcision and local treatment. Because of unresponsiveness of the lesion to circumcision and focal steroid infiltration, repeated biopsies were performed.

Diagnosis: One biopsy again showed the features of a plasmacellular inflammation, while the other finally revealed the histopathologic features of erythroplasia of Queyrat (carcinoma in situ or Bowen's disease of the glans penis). We assume that either the former biopsy specimens were taken from a plasma cell-rich reactive infiltrate around the neoplastic lesion, or that carcinoma in situ may have arisen due to the chronic inflammation of Zoon's balanitis plasmacellularis. Radiotherapy was performed with good clinical response and subsequent histopathologic proof of complete remission of the lesion.

For more information, see “Bowen's Disease of the Glans Penis (Erythroplasia of Queyrat) in Plasma Cell Balanitis.” Cutis. 2000 June;65(6):395-398.

1. A 26-year-old man presents with a penile lesion that has existed at least 10 years without significant change and with no attendant symptoms. The lesion consists of four 1-to-1.5-mm soft, compressible purple papules, in aggregate measuring about 8 mm. No other lesions are seen on the genitals or on the body.

Diagnosis: The lesion proved to be angiokeratoma of Fordyce, a totally benign lesion. This type of angiokeratoma is ectatic, thin-walled vessels in the superficial dermis, with overlying epidermal hyperplasia that forms secondary to normal friction. When they are seen on the scrotum, vulva, or penis, they are usually referred to as angiokeratoma of Fordyce, a type of localized angiokeratoma, other types of which can appear on the legs or hands.

These totally benign lesions must be distinguished from generalized types of angiokeratomata, such as those seen in Fabry disease (angiokeratoma corporis diffusum), an inheritable metabolic disorder. With our patient’s history, his lesion was clearly benign.

Had his lesion been new or changing in any substantive way, additional testing, including a biopsy, might have been necessary to rule out entities such as squamous cell carcinoma (which is almost unknown in circumcised patients), condyloma, melanoma, the aforementioned Kaposi’s sarcoma, or even angiosarcoma.

For more information, see “Skin is skin, no matter the location.” Clinician Reviews. 2013 June;23(6):W5.

2. A 59-year-old uncircumcised man presents with a phimotic foreskin, which cannot be retracted without pain. Only a tiny opening remains through which the patient can urinate (with difficulty). The surface of the foreskin is atrophic, dry, and shiny with focal areas of purpura but little, if any, redness or swelling.

Diagnosis: This patient’s condition is lichen sclerosus, also called balanitis xerotica obliterans (BXO), a diagnosis of sufficient obscurity to almost guarantee initial misdiagnosis as “yeast infection” or “herpes.” One treatment failure after another eventually leads to referral to a provider familiar with BXO, which is the male version of lichen sclerosus et atrophicus (LS&A) and usually affects the glans, foreskin, and distal shaft.

The causes of these conditions are as yet unknown. However, much is known about how they present, how they look under a microscope, and how to treat them.

Treatment entails use of the most powerful topical steroid ointments, which are so effective that they have completely replaced previous treatment options (eg, testosterone ointment). While a cure is unlikely, control is a realistic goal.

BXO, as in this case, can also cause urinary obstruction, both from the overlying foreskin and from actual meatal stenosis. This is why advanced cases need referral to urology for possible circumcision. As with many penile diagnoses (eg, squamous cell carcinoma or condyloma), BXO is far more common in the uncircumcised.

For more information, see “Man has very uncomfortable problem.” Clinician Reviews. 2012 September;22(9):W4.

3. A 31-year-old man has a relatively asymptomatic penile rash that has repeatedly manifested and resolved over a period of months. A round, papulosquamous, bright pink patch on the distal right shaft of his circumcised penis measures > 3 cm in diameter and has a shiny appearance with slightly irregular margins. A similar rash is seen behind both ears, in the umbilicus, and patches of dandruff are noted. Despite good health, he has been under a great deal of stress recently.

Diagnosis: Seborrheic dermatitis (SD), also known as seborrhea, is an extremely common chronic papulosquamous disorder patterned on the sebum-rich areas of the scalp, face, and trunk. Although not directly caused by the highly lipophilic commensal yeast Malassezia furfur, it does appear to be related to increases in the number of those organisms, as well as to immunologic abnormalities and increased production of sebum. It can range from a mild scaly rash to whole-body erythroderma and can affect an astonishing range of areas, including the genitals.

SD, especially in this case, represents the perfect example of the need to “look elsewhere” for clues when confronted with a mysterious rash. Patients can certainly have more than one dermatologic diagnosis at a time, but a single explanation is considerably more likely and should therefore be sought. In this case, corroboration for the diagnosis of SD was readily found by looking for it in its known locations.

In this case, treatment comprised a combination of oxiconazole lotion and 2.5% hydrocortisone cream. Many other combinations have been used successfully, including pimecrolimus or tacrolimus combined with ketoconazole cream.

Whatever is used, a cure will not be forthcoming, since the condition is almost always chronic. The main value of an accurate diagnosis in such a case lies in easing the patient’s mind regarding the terrible diseases he doesn’t have.

For more information, see “Relatively Asymptomatic, but Still Problematic." Clinician Reviews. 2014 April;24(4):15-16.

4. This circumscribed inflammatory plaque on the glans penis of allegedly > 20 years' duration was refractory to circumcision and local treatment. Because of unresponsiveness of the lesion to circumcision and focal steroid infiltration, repeated biopsies were performed.

Diagnosis: One biopsy again showed the features of a plasmacellular inflammation, while the other finally revealed the histopathologic features of erythroplasia of Queyrat (carcinoma in situ or Bowen's disease of the glans penis). We assume that either the former biopsy specimens were taken from a plasma cell-rich reactive infiltrate around the neoplastic lesion, or that carcinoma in situ may have arisen due to the chronic inflammation of Zoon's balanitis plasmacellularis. Radiotherapy was performed with good clinical response and subsequent histopathologic proof of complete remission of the lesion.

For more information, see “Bowen's Disease of the Glans Penis (Erythroplasia of Queyrat) in Plasma Cell Balanitis.” Cutis. 2000 June;65(6):395-398.