Kiranpreet K. Khurana, MD
Edmund S. Sabanegh, Jr., MD
BASICS
DESCRIPTION
• 3 categories: Benign, premalignant, malignant
• May be male genitalia-specific (primary) or associated with other cutaneous lesions or systemic disease (secondary)
• May occur at any age
EPIDEMIOLOGY
Incidence
Varies widely by etiology
Prevalence
• Depends on etiology
– Pearly penile papule found in 14–48% of postpubertal males
– Genital warts found in 0.1–1% of men
RISK FACTORS
Systemic disease, irritant or allergen, sexual contact, trauma, uncircumcised penis, family history, inflammation, infections, medications, local skin hygiene, obesity, age, smoking
Genetics
• Reiter syndrome: Associated with HLA-B27 haplotype
• Hailey–Hailey disease: Autosomal dominant
• Penile cancer: Associated with altered expression of P53, P21, c-ras, myc, Ki-67 genes
PATHOPHYSIOLOGY
• Idiopathic, allergic, infectious, autoimmune, inflammatory, systemic, sexual transmission, genetic
• Lesions appear similar; biopsy often needed for diagnosis
ASSOCIATED CONDITIONS
• Lesler–Trélat syndrome: Increase in size and number of seborrheic keratosis lesions sometimes signaling internal malignancy
• Stevens–Johnson syndrome and toxic epidermal necrolysis: Prodromal upper respiratory illness followed by life-threatening desquamating lesions due to medications, infections, or cancers
• Psoriasis: Lesions under preputial skin, glans, or prepuce
• Reiter syndrome (reactive arthritis): Urethritis, arthritis, conjunctivitis. Circinate balanitis
• Behçet disease: Painful ulcers found in 57–93% of patients, mostly scrotum (90%), but glans and shaft also affected
• Inflammatory bowel disease: Arterial thrombosis of penis, penile swelling, and noncaseating granulomas on biopsy; also pyoderma gangrenosum
• Hailey–Hailey disease: Vesiculobullous rash
• Diabetes: Phimosis
• HIV: Kaposi sarcoma, seborrheic dermatitis
GENERAL PREVENTION
• Circumcision helpful in some cases
• Proper hygiene
• Safe sex practices
• Avoid contact with allergens or irritants
DIAGNOSIS
HISTORY
• Age
• Symptoms: Pain, pruritus, burning, discharge
• Location: Scrotum, glans, shaft, preputial skin, urethral/bladder lining, other sites
• Duration
• Rate of onset: Acute or chronic
• Exposures: New bath/laundry soap, lotions, oils, travel (exotic plants, animals, insects, people), shared towels/clothes, new medications, industrial, chemical
• Sexual history: Sexual partner with lesions
• Trauma
• History of systemic diseases or cancers
• Allergies
• Family history
• Previous treatment
PHYSICAL EXAM
• Examine and describe lesion(s):
– Elevated, nonelevated
– Color of lesion
– Morphology of lesion
– Configuration of lesion (linear vs. serpiginous)
– Degree of margination
– Degree of firmness
– Examine genitalia: Circumcised, uncircumcised, proper placement of foreskin
– Describe primary lesion(s) (1)[A]:
Papule: ≤0.5 cm, solid, elevated
Plaque: >0.5 cm, solid, elevated
Nodule: >0.5 cm, solid, dome-shaped
Vesicle: ≤0.5 cm, fluid-filled, well-circumscribed
Bulla: >0.5 cm, fluid-filled, well-circumscribed
Pustule: Vesicle with purulent fluid, well-circumscribed
Wheal: Hive, edematous plaque
– Describe secondary lesion(s) (1)[A]:
Scale: Flakes on lesion surface
Crust/scab: Collected cellular debris
Atrophy: Thinning of skin causing depression
Scar: Connective tissue collection
Cyst: Lesion with wall and lumen
Erosion: Defect with red/moist base
Fissure: Thin linear defect
Ulcer: Deep defect
• Full dermatologic exam:
– Single or multiple lesions
– Organ-specific or generalized
• Lymph node exam
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis, Gram stain, culture
• Complete blood count
• Serum chemistry profile
• STD screening if suspected
Imaging
• If locally advanced lesion or internal lesions/tumors/malignancies suspected
• Workup for associated abnormalities
Diagnostic Procedures/Surgery
• Cytologic smears: Potassium hydroxide or periodic acid-Schiff staining for fungal infections
• Tzanck smear: Herpes, varicella, Molluscum contagiosum
• Microscopic exam: Scabies, pubic lice, pinworm, and other infections
• Gram stain, bacterial, and fungal cultures of lesion: Infections
• Excisional or incisional biopsy
Pathologic Findings
• Depth of lesion
• Exam of epidermis, dermis, and subcutaneous tissue and any changes noted
– Infiltration with other cells or infectious agents
DIFFERENTIAL DIAGNOSIS
• Common benign lesions (1)[A]
– Acrochordon: “Skin tag”
– Angiokeratoma of Fordyce: Red papules on penis, scrotum; ectasia of dermal blood vessels
– Epidermoid cysts: Most common cysts of genital area. Filled with keratin. Postsurgical after circumcision or hypospadias repair
– Fordyce spots: Sebaceous glands on genitalia
– Pearly penile papule: Small, white/flesh colored, multiple, on glans or corona
– Seborrheic keratoses: “Stuck on” appearance
– Vitiligo: Patchy depigmentation of skin
– Zoon balanitis: Nonelevated, erythematous, glistening plaques on glans in uncircumcised men. Biopsy to distinguish from SCC in situ
– Sclerosing lymphangitis: Cordlike lesion of coronal sulcus; after vigorous sexual activity
• Allergic dermatitis, eczematous lesion with erythema, discharge, excoriations (1)[A]
– Atopic dermatitis: Also known as lichen simplex chronicus, pruritic, red/scaly lesion on posterior scrotum. “Atopic triad” of eczema, allergic rhinitis, asthma
– Contact dermatitis: Irritant or allergic. Scaly with crust. Direct cytotoxic effect of irritant or local type IV hypersensitivity reaction
– Erythema multiforme: Red papules and target lesions, blisters. Minor or major. Major: Stevens–Johnson syndrome, toxic epidermal necrolysis
• Papulosquamous disorders, scaly lesion on erythematous base (2)[C]
– Psoriasis: Thick plaque with silver scales. Corona and glans lesions in circumcised, underneath preputial skin in uncircumcised
– Reiter syndrome: Circinate balanitis, urethritis, arthritis, ocular, oral, and skin lesions. History of infection with Chlamydia, Gonococcus, Ureaplasma, or GI bacteria
– Lichen planus: Idiopathic autoimmune reaction against basal keratinocytes; small, flat, shiny, violaceous papules on glans
– Lichen sclerosis: Pruritic pearly white papules and plaques on glans and inner prepuce that scar. Late stage called balanitis xerotica obliterans. Biopsy to exclude SCC
– Fixed drug eruption: Hypersensitivity reaction to medication 1–2 wk after starting. Lesions occur in same location after challenge
• Vesicobullous disorders, autoimmune blisters and erosions (1)[A]
– Pemphigus vulgaris: Extensive painful blisters and erosions. Difficult to treat and may be fatal
– Bullous pemphigoid: LgG mediated, typically in patients older than 70 yr
– Dermatitis herpetiformis: Associated with celiac disease; IgA mediated
– Hailey–Hailey disease: Familial, seen in 20–30s, blisters in axilla, inguinal, perianal areas
• Noninfectious ulcers, lesions extending to dermis (1)[A]
– Behçet disease: Painful oral and genital ulcers, uveitis and other systemic involvement
– Pyoderma gangrenosum: Chronic painful ulcer associated with Crohn’s, ulcerative colitis, collagen vascular disease
– Traumatic ulcers: Direct impact, sexual activity, body piercings, cleansing techniques
• Infections and infestations (1)[A]
– STDs: Herpes simplex, syphilis, chancroid, genital warts, granuloma inguinale, lymphogranuloma venereum, molluscum contagiosum, Chlamydia, gonorrhea, trichomoniasis
– Genital warts: HPV 6 and 11.4 variants: Condylomata acuminate, common warts, flat-topped papules/plaques, Buschke–Löwenstein tumor (giant condyloma). Biopsy for flat-topped and giant condylomas to rule out SCC
– Balanoposthitis: Inflammation of glans and foreskin in uncircumcised males. Can be due to bacteria, yeast, irritants, trauma
– Cellulitis: Infection of deep dermis and subcutaneous tissues due to Staphylococcus aureus and Streptococcus pyogenes
– Folliculitis: Infection of hair-bearing follicles
– Furunculosis: “Boil”
– Hidradenitis suppurativa: Painful, firm, red nodules with draining sinuses; chronic inflammation of gland-bearing skin, superinfection possible
– Fournier’s gangrene: Necrotizing fasciitis; progresses from cellulitis to blisters to foul-smelling necrotic lesions. Surgical emergency
– Infestation: Pubic lice (Pediculosis pubis) or scabies (Sarcoptes Scabiei mite); very pruritic
• Neoplastic lesions, see Section I “Bowen disease and Erythroplasia of Queyrat,” “Penis, cancer, general considerations,” “Penis, squamous cell carcinoma”
TREATMENT
GENERAL MEASURES
• Common benign lesions (1)[A]:
– No treatment if asymptomatic
– If inflamed or infected, treat with antibiotics
– Topical corticosteroids or emollient for symptomatic relief
– Recurrent infections or cosmetic reasons: Excise, remove with laser or cryotherapy
Zoon balanitis: Topical steroids for symptoms, circumcision for cure
Contact dermatitis: Remove offending agent
Psoriasis: Topical corticosteroids, clobetasol, or systemic treatment
Lichen sclerosis: Biopsy to exclude SCC. Long-term follow-up required. Circumcision curative.
Pemphigus vulgaris: Oral corticosteroids, immunosuppressive therapy
Behçet disease: Oral corticosteroids, immunosuppressive therapy
Genital warts: Topical 0.5% podofilox, 5% imiquimod, green tea polyphenol extract, 25% podophyllin or trichloroacetic acid, cryotherapy, electrosurgery, laser ablation, surgical excision
Balanoposthitis: Circumcision curative
Hidradenitis suppurativa: Skin care, topical clindamycin or oral clindamycin and rifampin. Surgical excision for recurrent lesions
Fournier’s gangrene: Broad-spectrum intravenous antibiotic coverage and emergent surgical debridement
Infestation with scabies or pubic lice: 5% permethrin cream overnight and repeated a week later
MEDICATION
First Line
• Varies with etiology (see above) (3)[B]
– Low-potency topical corticosteroids for symptoms, eg, Hydrocortisone 1%, 2.5%
– Specific antibiotics aimed at pathogen
Second Line
• Varies with etiology (3)[B]
– High-potency or oral corticosteroids
– Immunosuppressive mediations
– Intravenous antibiotics
SURGERY/OTHER PROCEDURES
• Excision of lesion(s) and surrounding tissue
• Laser ablation, electrocautery, cryotherapy
• Circumcision
• More extensive surgeries if neoplastic lesion
ADDITIONAL TREATMENT
Radiation Therapy
Limited role in nonneoplastic lesions
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Most cutaneous lesions have a good prognosis but should be addressed promptly
• Widespread lesions difficult to control
COMPLICATIONS
• See “Differential Diagnosis” section
• If left untreated, lesions may progress locally or distally and cause symptoms
FOLLOW-UP
Patient Monitoring
Follow patients to monitor response to intervention and any change in lesion
Patient Resources
• http://www.cdc.gov/std/general/default.htm
• http://www.aad.org/skin-conditions/dermatology-a-to-z
REFERENCES
1. Choi JM. Common benign dermatologic genital lesions: Diagnosis and treatment. AUA Update Series. 2011;30:367–371.
2. Gogstetter D and Mercurio MG. Common penile lesions: Tips to the differential. Med Aspects of Human Sexuality. 2001;1(2):45–51.
3. Teichman JM, Sea J, Thompson IM, et al. Noninfectious penile lesions. Am Fam Physician. 2010;81(2):167–174.
ADDITIONAL READING
• Buechner SA. Common skin disorders of the penis. BJU Int. 2002;90:498–506.
• Köhn FM, Pflieger-Bruss S, Schill WB. Penile skin diseases. Andrologia. 1999;31(suppl 1):3–11.
See Also (Topic, Algorithm, Media)
• Balanitis and Balanoposthitis
• Bowen Disease and Erythroplasia of Queyrat
• Chancroid
• Condylomata Acuminata (Venereal Warts)
• Genital Ulcers
• Penis, Cancer, General Considerations
• Penis, Cutaneous Lesion Image 
• Penis, Squamous Cell Carcinoma
• Phimosis and Paraphimosis
• Sexually Transmitted Infections (STIs) (Sexually Transmitted Diseases [STDs]), General
CODES
ICD9
• 078.11 Condyloma acuminatum
• 608.89 Other specified disorders of male genital organs
• 709.8 Other specified disorders of skin
ICD10
• A63.0 Anogenital (venereal) warts
• N48.89 Other specified disorders of penis
• R23.8 Other skin changes
CLINICAL/SURGICAL PEARLS
• Do a complete skin exam when genital cutaneous lesion found.
• Skin lesions appear similar and excisional or incisional biopsies are often necessary for diagnosis and to rule out cancer.
• Stevens–Johnson syndrome, toxic epidermal necrolysis, Fournier gangrene, pemphigus vulgaris can be life-threatening.