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Investigation
Classification of
male genital
dermatoses
Skin diseases
affecting the
genitals
Authors’ case
studies
Male
genital
dermatoses
The authors
DR ADRIAN LIM
dermatologist and phlebologist;
board member of the Australasian
College of Phlebology; director of
training of the Australasian
College of Dermatologists;
consultant dermatologist, Royal
North Shore Hospital, Sydney and
in private practice in Sydney and
Kogarah, NSW.
Background
GENITAL skin is an extension of the
general skin surface and, therefore,
shares the usual non-genital-specific
skin diseases such as eczema, psoriasis
and skin cancer. In addition, the distinct male genital anatomy makes the
genitals susceptible to skin diseases
not commonly encountered elsewhere. As a sexual organ, the penis is
a conduit for many STIs.
The psychosexual aspects of male
genital skin disease should not be underestimated. It is a frequent source of great
emotional and psychosexual morbidity.
This article will focus on common skin
diseases localised on the male genitalia,
as well as less common, but important
genital-specific skin conditions.
Figure 1: Penis surface anatomy.
pubis
shaft
coronal
sulcus
glans
meatus
scrotum
Surface anatomy of the male
genitalia
For the purposes of this article, the
term ‘male genitalia’ refers to the
penis and scrotum. However, many
conditions affecting the male genitalia may also affect the adjacent
areas such as the pubic area (superior), groin, genitocrural folds (lateral), perineum and anus (inferior).
The penis is the external and pendulous component of the male genitalia (figure 1). It starts from the
pubic wall and comprises the body
(shaft) that joins the head (glans)
distally. The urethra opens as a slit
(meatus) at the most distal point of
the glans. The dorsal vein of the
penis can sometimes be seen running along the dorsal surface. The
ventral surface is contiguous with
the scrotum. The coronal sulcus is
the groove between the glans and
the shaft of the penis. The prepuce
(foreskin) covers the glans in the
uncircumcised flaccid penis. In the
circumcised penis, the glans is
exposed, and consequently develops a reactive thickening (keratinisation) of the surface epithelium.
Male circumcision is indicated as
treatment for certain genital conditions such as foreskin stricture
(phimosis) and a number of inflammatory conditions of the glans.
Male circumcision is also performed for various social and religious indications. There is debate
about the ethics and/or justification
for the practice of non-medical circumcision.
An argument against circumcision is the fact that surface keratinisation post circumcision makes
the glans penis less sensitive and
supplementary lubricants may be
required for sexual intercourse and
masturbation. In support of circumcision is evidence that circumcision
is protective against a number of
inflammatory, neoplastic and infectious penile diseases.
cont’d page 25
ASSOCIATE PROFESSOR
STEPHEN SHUMACK
dermatologist; board member of
the Australasian College of
Phlebology, Skin and Cancer
Foundation Australia, and Epiderm
(Australian Dermatology Research
and Education Foundation);
consultant dermatologist, Royal
North Shore Hospital, Sydney;
medical director of the Skin and
Cancer Foundation Australia; and
in private practice in Sydney and
Kogarah, NSW.
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25 May 2012 | Australian Doctor |
23
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Investigation
PATIENT history and examination, along with relevant investigations are the cornerstones of
managing male genital dermatoses
(table 1). Practitioners must show
sensitivity and tact when dealing
with genital disorders and recognise the frequent link between
sexual dysfunction and psychological issues.
The guiding principle when
dealing with male genital dermatoses is to exclude STI, rule out
malignancy and not to neglect the
urological system, represented by
the penile urethra.
History
The patient’s age is helpful in
assessing likely male genital dermatoses. STIs are more common
Table 1: Clinical approaches to male genital dermatoses
History
Age
Circumcision
Eczema/psoriasis/
allergies
Presenting problem
Sexual history
Medications
Examination
Investigation
General (non-genital) skin
and mucous membrane
Genital: penis and scrotum
Perineum and anus
in men in early adulthood; older
males are more prone to skin
cancer; and, foreskin-related
problems (eg, phimosis) are more
common in the paediatric and elderly age groups.
Evidence of general skin diseases, such as eczema and psoria-
Dermoscopy
Swabs
Skin scrapings
Bloods
Biopsy
sis, should be sought and a thorough sexual history obtained
where relevant. A detailed medication history including a timeline should be established in suspected drug-related genital
eruptions. Urogenital symptoms
such as dysuria, frequency and
urethral discharge may indicate
urological disease.
ing pubic lice while a dermatoscope
is helpful for pigmented lesions.
Examination
Investigation
The genitalia need to be examined
closely with particular focus on the
penis, foreskin, scrotum, perineum
and anus.
Foreskin pathology such as phimosis should be confirmed. Any genital
rash or eruption should be noted with
reference to morphology, site and distribution. Non-genital skin including
oral mucosa (blistering disorders),
hair-bearing areas (lice) and nails
(psoriasis, lichen planus) should also
be examined. The perineum and anus
should be examined for pathology
such as lichen sclerosus.
Visual aids such as a magnifying
lens can assist greatly in visualis-
Bacterial and viral swabs should
be taken from any ulcers and discharge, and should then be
processed for microscopy, culture
and PCR that looks for herpes,
chlamydia or gonorrhoea. Scrapings for microscopy can confirm
fungal infections and can sometimes confirm scabies.
Additional STI screening with
serology for syphilis, viral hepatitis and HIV may be indicated. A
skin biopsy may be necessary to
establish the diagnosis, however,
this is generally performed after
specialist opinion, given the sensitive location.
Classification of male genital dermatoses
SKIN diseases of the male genitalia
can be broadly grouped into the
following categories (table 2):
• Normal anatomical variants.
• STIs.
• Non-genital-specific skin diseases.
• Skin diseases usually associated
with the genital region.
Normal anatomical variants
Adolescent and young adults may
become concerned about certain
normal features of their genitals
after having noticing them for the
first time. Prominent normal
anatomical structures such as veins,
sebaceous glands and hair follicles
are common reasons for presentation at a doctor’s clinic.
Prominent sebaceous glands are
known as Fordyce spots — commonly seen on the scrotum as
translucent yellowish papules. Similar structures may be present on the
labial (lip) mucosa. Confusingly similar sebaceous prominences on the
glans penis are referred to as Tyson’s
glands. Pearly penile papules are
anatomical variants found on the
coronal sulcus, and frequently mistaken for warts. In all these cases,
reassurance and patient education
is all that is required.
Table 2: Classification of male genital dermatoses
Normal anatomical STIs
variants
Non-genital-specific skin diseases Skin diseases usually associated
with the genital region
• Prominent veins
• Pearly penile
papules
• Prominent hair
follicles
• Prominent
sebaceous gland
• Inflammatory
- Eczema
- Psoriasis
- Seborrhoeic dermatitis
- Lichen planus
• Pigmentary
- Vitiligo
- Melanosis and lentiginosis
• Infective/microbial
- Candidiasis/tinea
- Boils/folliculitis
- Erythrasma
• Neoplastic
- Squamous cell carcinoma
(Bowen’s disease/erythroplasia of
Queyrat)
Bowenoid papulosis
- Extramammary Paget’s disease
• Drug related
- Fixed drug eruption
- Stevens–Johnson syndrome
• Viral
- Warts/Bowenoid
papulosis
- Molluscum
contagiosum
- Herpes
• Infestation
- Scabies
- Lice
• Other venereal
diseases
• Inflammatory
- Lichen sclerosus
- Zoon’s balanitis
- Genital ulcers (Behçet’s disease,
pyoderma gangrenosum,
cicatricial pemphigoid
• Fibrosis/stricture
- Phimosis
- Paraphimosis
- Peyronie’s disease
• Tumour/cysts
- Angiokeratomas
- Scrotal calcinosis
• Idiopathic
- Chronic idiopathic oedema
- Dysaesthesia/pruritus (ani)
Figure 2: A: Genital scabies. B: Scabies in the digital cleft.
A
B
STIs
Skin-to-skin contact during sexual
intercourse facilitates transmission
of several well-known diseases such
as viral warts, herpes, scabies
(figure 2), pubic lice and nits
(figure 3) and molluscum contagiosum. Although these infections can
occur on non-genital sites, the sexually acquired subtypes often show
phenotypic and genetic adaptation
to the genital region. For example,
the herpes simplex virus (HSV 2)
and certain genital verrucal sub-
types have a greater predilection
for genital skin.
Pubic lice (Pediculosis pubis)
are also physically adapted to the
pubic region with their crab-like
body and prominent ‘claws’ to
attach to the pubic hair shafts. By
comparison, head lice have a
Figure 3: Pubic lice and nits.
more slender structure, better
adapted to scalp hair.
Despite these adaptations,
transmission can also occur onto
non-genital sites, for example,
HSV 2 developing on the lip
through orogenital sex, and pubic
lice spreading to eyelashes and
axillary hair. Scabies acquired
non-sexually can often localise as
genital scabetic nodules that are
diagnostic of the condition.
Other STIs affecting the genitals
and genitourinary tract include
syphilitic chancres, non-syphilitic
chancroid (Haemophilus ducreyi),
lymphogranuloma venereum
(Chlamydia trachomatis), granuloma inguinale (Klebsiella granulomatis), gonorrhoea and chlamydia. Other causes of infective
urethritis and proctitis may also
present to the GP requiring appropriate investigation and management. Screening for sexually
acquired blood-borne diseases such
as HIV and viral hepatitis may be
necessary, especially in the context
of unprotected sex.
Non-genital-specific skin diseases
COMMON skin diseases such as
eczema and psoriasis frequently affect
the genitals. The morphology of the
rash is generally recognisable,
although scaly rashes, such as psoriasis, may appear less scaly, especially so
over the moist glans in the uncircumcised penis.
The presentation of a variety of
skin diseases localised to the glans
penis (especially in the uncircumcised)
can appear non-specific, posing diagnostic challenges.
Inflammatory conditions
Inflammatory diseases are by far the
most common group of disease seen
on the male genitalia. This group
includes eczema, psoriasis and seborrhoeic dermatitis.
The management principles revolve
around supportive measures with
gentle cleansers and use of non-soap
alternatives. The genital skin is more
sensitive than non-genital skin and any
specific treatment needs to take this
into account. For example genital psoriasis is not usually treated with phototherapy because of the greater susceptibility of skin cancer in this area.
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The use of higher potency topical
steroids on genital skin should also be
monitored closely with the rapid development of topical steroid changes,
such as striae, common in this area.
Eczema
As with eczema anywhere else on
the body, the condition is made
worse by over-cleaning, especially
with harsh soaps. Parts of the genital region, such as the glans in the
uncircumcised penis, are particularly sensitive to over-cleaning in
fastidious individuals.
In general, eczema severity tends
to be milder on genital skin and more
responsive to treatment than other
body sites. Low-potency topical
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HOW TO TREAT Male genital dermatoses
from previous page
steroids such as 1% hydrocortisone
cream are often quite effective in this
area. Mixed corticosteroid–anti-yeast
preparation such as hydrocortisone
with clotrimazole cream (eg, Hydrozole) can be used to limit any opportunistic secondary yeast overgrowth
in the genital area.
Contact dermatitis or eczema is
also seen in the genital areas with the
use of irritating topical agents such
as antiseptics causing irritant contact
dermatitis. Allergic contact dermatitis
can also occur with the use of perfumed products or products containing allergens such as preservatives.
Figure 4: Psoriasis.
Figure 5: Seborrhoeic dermatitis
affecting the glans penis and
scrotum.
Figure 6: Lichen planus affecting the
glans penis. (Photo: Dr Ian Hamann).
Figure 7: Vitiligo with focal pigment
loss on the penile shaft.
Figure 8: Penile melanosis on the
penile glans and shaft. A lesion
biopsy (glans) was performed to
exclude malignancy.
Figure 9: Erythrasma of the groin
and scrotum.
Figure 10: Bowen’s disease of the
penile shaft. (Photo: Dr Ian Hamann).
and candidiasis can also affect the
male genitals — especially the uncircumcised glans penis — and can be
considered the male equivalent of
vaginal thrush. Candidal transmission between sexual partners can also
occur. Treatment with topical antifungal creams can alleviate the
problem.
therapy may be viable options, but
will need informed patient consent
because of the increased possibility of local recurrence.
Psoriasis
This commonly affects the male
anogenital region, especially the
natal–gluteal cleft between the buttocks. Genital psoriasis can occur in
isolation or as part of the
skin–joint–nail complex of psoriasis
(figure 4).
The lesions can resemble psoriatic
lesions elsewhere with well-circumscribed erythematous plaques topped
with silvery scales. However, genital
psoriasis may have less or no scaling
especially under the foreskin. A psoriasiform rash can occur on the glans
penis in association with reactive
arthritis (Reiter syndrome) in genetically susceptible individuals after gastroenteritis or genitourinary infection
(eg, chlamydia). Mild- to moderatepotency topical steroids are the mainstay of treatment of this condition.
Seborrhoeic dermatitis
This is a form of dermatitis occurring in conjunction with an overgrowth of commensal skin yeast.
Apart from the typical areas of the
scalp, eyebrows and nasolabial crease,
groin and genital involvement can
occur (figure 5).
Candidiasis and tinea can occur in
the setting of excessive sweating or
dampness and poor personal hygiene.
Management involves keeping the
area dry with non-occlusive cotton
underwear and use of 1% hydrocortisone with 1% clotrimazole topical
preparations (eg, Hydrozole cream).
Lichen planus
This pruritic, papular, polygonal and
purple-coloured skin eruption can
affect the genitals (figure 6). It can
also be associated with nail, and/or
mucosal involvement with white lacy
streaks in the inner buccal mucosa.
The clinical appearance is usually
diagnostic and can be confirmed histologically with the characteristic
lichenoid inflammation at the junction between the epidermis and
dermis. Itch may be severe and often
requires moderate to high potent topical steroids such as betamethasone
for adequate control.
Pigmentary disorders
As a sexual organ, the male genital is
intimately linked with the person’s
psychosexual identity and self-image.
‘Harmless’ pigmentary conditions —
either increased or decreased pigmentation — can lead to significant emotional and psychosexual morbidity.
Vitiligo and lentiginosis are the two
more common pigmentary conditions encountered in clinical practice.
Vitiligo and
lentiginosis are the
two more common
pigmentary
conditions
encountered in
clinical practice.
tip areas (figure 7). Whether this pattern of distribution is as a result of
trauma or pressure is still debated.
The cosmetic impact of vitiligo is
greater in darker-skinned individuals,
and the exposed and visible areas
such as the face have management
priority.
Individuals sufficiently bothered by
their genital vitiligo can be carefully
prescribed potent topical steroids for
2-3 months at a time that is usually
the minimum time for pigment
restoration. An alternative immunosuppressive agent is tacrolimus compounded as a 0.1% ointment.
Patients with vitiligo may need to
have screening blood test for associated autoantibody conditions such as
thyroid disease, diabetes or pernicious
anaemia.
Lentiginosis
Darker-skinned individuals are also
more susceptible to hyperpigmented
macules (melanosis and lentiginosis)
that can affect the genitals (figure 8).
Like hypopigmented spots, hyperpigmented spots can be just as cosmetically distressing for patients.
The types of pigmented lesions
include naevi (moles), lentigines
(freckles) and post-inflammatory
hyperpigmentation.
It is important to ensure the pigmented lesion is not sinister (eg,
melanoma), and this can usually be
established with routine clinical and
dermatoscopic examination. If there
is any doubt about the diagnosis, a
biopsy is required.
Benign naevi or lentigines are best
left alone. Surgical excision can be
problematic in terms of scarring and
subsequent functional restriction.
Rarely, pigment-removing laser can
be used to lighten benign pigmented
lesions in self-conscious individuals.
Vitiligo
Depigmenting conditions such as
vitiligo have a predilection for the
genitals in the ‘lip-tip’ distribution
involving perioral, genital and finger
26
| Australian Doctor | 25 May 2012
Infective/microbial
Candidiasis/tinea
Fungal infection can occur as tinea
cruris (jock itch). Yeast overgrowth
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Boil/folliculitis
Bacteria such as Staphylococcus
aureus can cause troublesome folliculitis or boils (furuncles). Some individuals may be staph carriers with
reservoirs in the axillary or nasopharyngeal areas. Individuals with repeat
episodes of folliculitis and boils may
need swabs of the nostrils, axillae and
groin to exclude staphylococcal carriage. A 10-15 day course of topical
application of mupirocin and systemic antibiotics, such as
cephalosporin or flucloxacillin, may
help in this situation.
Erythrasma
This is a micrococcal organism of the
skin causing an erythematous rash of
the groin (figure 9) or a superficial
keratolytic change on the feet. Erythrasma is responsive to topical
antibiotics such as erythromycin 2%,
or topical 1% clindamycin. Topical
antifungals are also helpful in treating
any coexisting tinea.
Neoplastic
Skin cancers
The most common genital skin
cancer is squamous cell carcinoma
(figure 10), also known as Bowen’s
disease or erythroplasia of Queyrat.
As with any skin cancer, the key is
early detection followed by definitive treatment. Excision is generally preferred with clear margins
on histology. With some cases of
in situ SCC — where surgical morbidity may be significant — nonsurgical alternatives such as topical
5-fluorouracil
cream,
imiquimod cream or photodynamic
Bowenoid papulosis
This is an erythematous or slightly
pigmented papule or plaque, secondary to viral warts. These lesions are
premalignant and also know as penile
intraepithelial neoplasia, a male version of the better-known vulval or
cervical intraepithelial neoplasia.
Although these lesions are recognised
as premalignant, they often regress
spontaneously. Treatment is similar
to wart therapy and ranges from
liquid nitrogen or cautery to the use
of topical agents such as podophyllum and imiquimod.
Extramammary Paget’s disease
This condition can rarely present
in the anogenital region. This is an
adenocarcinoma that is analogous
to Paget’s disease of the nipple.
The diagnosis should prompt a
search for associated adenocarcinoma in adjacent organs such as
the bladder, genitourinary tract or
gastrointestinal tract.
Drug related
Fixed drug eruption
Some patients are susceptible to fixed
drug eruptions that localise to the
same body region with each exposure to the implicated drug (figure
11). The eruption tends to be erythematous and sharply demarcated with
occasional blisters, accompanied by
considerable burning and itching.
Sulphonamides, tetracyclines,
NSAIDs and codeine-containing
drugs or mixtures are some of the
more commonly associated medications that can trigger fixed
drug eruption. The genitals are a
common location for fixed drug
eruption. The blisters usually heal
without scarring, but may develop
prolonged post-inflammatory
hyperpigmentation. Identifying
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Figure 11: Fixed drug eruption on the
glans penis from sulfamethoxazole.
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affects mucosal surfaces such as the
lips, eyes and genitals (figure 12),
which may precede the skin rash.
Most patients have involvement of
several mucosal regions (oral, ocular,
anogenital) and hospitalisation may
be required for skin, eye, GI and respiratory care to minimise complications such as mucosal scarring and
strictures.
The role of immunosuppressants
such as prednisone and cyclosporine,
and immunomodulators such as IV
immunoglobulin, is beyond the scope
of this article, however, immediate
cessation of the implicated drug is
mandatory and can be life-saving.
and stopping the implicated drug
leads to resolution of the
problem.
Stevens–Johnson syndrome/toxic
epidermal necrolysis
This is a serious drug reaction with a
mortality of up to 30%. Although
drugs are the most common aetiologic factor, a minority of cases may
result from preceding infections (eg,
mycoplasma pneumonia, HSV).
An initial maculopapular rash is
followed by the characteristic targetlike lesions, which resemble blisters,
each with a dusky central ‘bullseye’.
Stevens–Johnson syndrome also
Figure 12: Stevens–Johnson
syndrome.
Skin diseases usually associated with the genital region
Inflammatory
Lichen sclerosus
ALSO known as balanitis xerotica
obliterans, this is an uncommon,
but important condition with a
predilection for the genital region
(figure 13). While lichen sclerosus
is more common in females, it also
occurs in males and children.
Although the cause is unknown,
there may be a link with autoimmune diseases such as vitiligo, thyroiditis, pernicious anaemia and
diabetes.
Lichen sclerosus may present initially as ivory-white papules and
plaques that progressively become
atrophic. The condition can be
itchy and/or painful. The skin eventually becomes thinned and parchment-like with irregularly
depressed areas. Purpura, erosions
and lichenification (thickening of
the skin from repeated scratching)
may complicate the clinical appearance. The glans and foreskin are
typically affected and lichen sclerosus is a leading cause of phimosis
(stricture of foreskin) making it
non-retractable and meatal stenosis.
The first-line treatment is potent
topical steroids applied until the
condition stabilises and remits.
Maintenance with mild- to moderate-potency topical steroids may be
necessary for a period of time (ie,
months). There is a low risk of
SCC transformation with genital
lichen sclerosus and long-term
follow-up is recommended.
Lichen sclerosus also occurs in
non-genital sites, but these areas
are not associated with malignant
change. Circumcision is protective
against lichen sclerosus and may
be required in cases where there is
secondary phimosis.
Zoon’s balanitis
Primary Zoon’s balanitis is an
inflammatory condition of the
glans penis of unknown cause,
affecting middle-aged and older
uncircumcised men (figure 14). The
glans becomes irritated as a result
of a dysfunctional foreskin leading
to retained secretions, epithelium,
urine and overgrowth of commensal organisms under the foreskin.
The foreskin itself may be too
tight or adherent, creating friction
and further irritation to the underlying glans. The condition is often
asymptomatic despite the appearance of shiny red patches occurring
on the glans penis and inner surface of the foreskin.
The condition affects mucosal
genitalia only and spares the kera-
Figure 13: Lichen sclerosus.
A: Lichen sclerosus with ivory white
plaques on the penile shaft.
B: Lichen sclerosus with white
plaques and erosions on the penile
glans and ventral shaft.
Figure 14: Zoon’s balanitis of the
penile glans and shaft.
(Photo: Dr Ian Hamann).
yeast is the mainstay of treatment.
The condition can be difficult to
treat and there may be frequent
relapses. With refractory Zoon’s
balanitis, circumcision is usually
curative.
Fibrosis and stricture
Phimosis and paraphimosis
(Photos: Dr Ian Hamann).
Genital ulcers
A
B
required for confirmation followed
by treatment with immunosuppressives such as systemic steroids and
cyclosporine.
Benign genital ulcers similar to oral
aphthous ulcers can occur in
response to acute systemic illness.
They are more common in females
than males. Unlike benign oral
ulcers (aphthae) where this can
generally be accepted as a clinical
diagnosis, genital ulcers should not
be labelled as benign until other
possibilities — especially STIs —
have been excluded.
Rare, but distinctive causes of
genital ulcers include Behcet’s disease, pyoderma gangrenosum, cicatricial pemphigoid and drug eruptions such as fixed drug eruption
and Stevens–Johnson syndrome.
Secondary Zoon’s
balanitis may result
from psoriasis,
seborrhoeic
dermatitis, lichen
sclerosus, lichen
planus, contact
dermatitis and even
skin cancers.
Behçet’s disease. This is a very
rare condition consisting of
painful ulcers affecting the mouth
and the anogenitalia. The cause
is unknown, but probably due to
abnormal cellular immunity
resulting in recurrent ulcers.
Behçet’s disease is also associated
with arthritis, uveitis, meningitis
and nerve palsies. The mucocutaneous disease is managed with
topical and intralesional steroids
while oral prednisone, azathioprine and other immunosuppressives are reserved for more severe
systemic disease manifestations.
Pyoderma gangrenosum. This is a
destructive ulcerating genital condition that is often misdiagnosed
as cancer or infection. The soft
tissue breaks down, forming deep
ulcers that can cause tissue
destruction. The condition often
worsens with physical injury or
inadvertent surgical procedures
such as aggressive debridement or
attempted excision. The key to
managing pyoderma gangrenosum
is immunosuppressive therapy
such
as
prednisone
or
cyclosporine, and investigation for
associated disorders such as malignancy, inflammatory bowel disease, rheumatoid arthritis and
viral hepatitis.
tinised outer foreskin, shaft and
scrotum. Zoon’s balanitis is also
called plasma cell balanitis because
of the presence of plasma cells on
skin histology.
Because of the non-specific
nature of the presentation, it is necessary to exclude concurrent primary genital dermatoses that may
be the cause of secondary Zoon’s
balanitis. Secondary Zoon’s balanitis may result from psoriasis, seborrhoeic dermatitis, lichen sclerosus,
lichen planus, contact dermatitis
and even skin cancers (Bowen’s disease). In fact, any condition from
the list of inflammatory, infective
or neoplastic groups of genital dermatoses can cause secondary
Zoon’s balanitis.
The management of primary
Zoon’s balanitis requires good genital and foreskin hygiene. Daily
gentle cleaning with water and
mild soap or cleanser is recommended. The use of topical steroids
(initially potent) with topical anti-
Cicatricial pemphigoid. This is an
autoimmune blistering disorder
that targets the oral, ocular and
anogenital mucous membrane and
frequently causes scarring, strictures and adhesions. A biopsy with
direct immunofluorescence is
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The foreskin is non-retractable at
birth (physiological phimosis), but
becomes gradually retractable with
age. Pathological phimosis occurs
when a previously retractable foreskin becomes non-retractable or
when the foreskin remains nonretractable after puberty.
Pathological phimosis is usually
a result of scarring of the foreskin
from chronic inflammation and
other disease processes such as
lichen sclerosus.
Paraphimosis refers to a
retracted foreskin that becomes
entrapped behind the coronal
sulcus.
Phimosis and paraphimosis are
diseases of uncircumcised males.
Many of the inflammatory genital
diseases — especially lichen sclerosus — can lead to scarring and subsequent phimosis.
Paraphimosis is less common and
occurs in the setting of forceful
retraction of the phimotic foreskin
— after vigorous sexual activity or
following acute swelling from contact dermatitis or urticaria or
angioedema of the genitals.
Paraphimosis is a medical emergency because the constriction
around the coronal sulcus restricts
blood supply to the glans penis that
can lead to irreversible penile
damage.
Phimosis can be treated with
potent topical steroids to reduce
inflammation and swelling while
paraphimosis can be managed with
various manual reduction techniques. Circumcision should be
considered when conservative
measures have failed and is
urgently indicated in strangulating
paraphimosis.
Peyronie’s disease
This is a fibrotic condition of the
penile shaft leading to distortion of
the penis especially during erection.
The erect penis with Peyronie’s disease typically curves, which can be
painful and impact adversely on
sexual function.
The fibrous plaques are often
palpable as lumps within the erectile tissue, and are more common
on the dorsal penis. The cause is
unknown, but there appears to be
a link with other fibrotic conditions — such as Dupuytren’s concont’d next page
25 May 2012 | Australian Doctor |
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HOW TO TREAT Male genital dermatoses
from previous page
Summary
tracture of the palms — in up to
10% of cases.
Peyronie’s disease can resolve
spontaneously, so waiting up to 1-2
years is advisable before considering
surgery. In the meantime, intraregional steroids or collagenase may
alleviate some of the symptoms,
while not being curative.
Male genital dermatoses can
present as:
• Normal anatomical variants
• STIs
• Non-genital-specific skin diseases
• Skin diseases usually associated
with the genital region
Tumours/cysts
Angiokeratomas
These vascular lesions present as
red to purple papules ranging
from 1-5mm in diameter. Patients
tend to present with multiple
lesions, although solitary lesions
are not uncommon, with greater
numbers with increasing age.
Older lesions are larger and more
keratotic. They mainly occur on
the scrotum, but can also be
found on the penile shaft.
Most are not associated with
any underlying metabolic disorders and are benign capillary malformations commonly known as
angiokeratoma of Fordyce.
Fordyce angiokeratomas should
be distinguished from angiokeratoma of Fabry — a rare genetic
metabolic disorder secondary to
alpha-galactosidase deficiency and
impaired glycosphingolipid
metabolism. Angiokeratoma of
Fabry presents in childhood with
multiple angiokeratomas, accompanied by organ dysfunction secondary to build-up of glycosphingolipids, especially in the skin,
eye, kidney, heart and CNS.
Patients with benign angiokeratomas have no symptoms, but
may present for cosmetic treatment.
Occasional bleeding may occur
from a scratched or traumatised
lesion. Genital angiokeratomas can
be effectively treated with gentle
hyfrecation or vascular lasers.
Scrotal calcinosis
This is a relatively common disorder presenting as firm whitish scrotal nodules that may be solitary or
multiple (figure 15). It is uncertain
whether the calcinosis is primary,
or results from underlying disorders such as epidermoid cysts, sebaceous cysts, eccrine cysts, dartos
muscle degeneration, foreign body
irritation or trauma.
The lesions can occasionally
become inflamed or infected, secondary to trauma. If desired by the
patient, treatment is by surgical
excision, although additional
lesions may continue to develop
with time.
Idiopathic
Chronic idiopathic genital oedema
This is a rare condition that can
result in significant psychosexual
and physical morbidity. The penile
and foreskin swelling is thought to
be the result of lymphoedema from
either primary lymphatic hypoplasia or secondary lymphatic damage
from recurrent infections. The lymphoedema is made worse by intercurrent episodes of cellulitis and
lymphangitis that can complicate
the clinical presentation. Phimosis
can result from chronic cases.
Chronic idiopathic genital
oedema can be associated with
Crohn’s disease. Patients with
Crohn’s-associated genital oedema
will often show a granulomatous
histology on biopsy. Active exclusion of Crohn’s disease may be
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Psychological and sexual
dysfunction may accompany the
presentation
Consider STIs in at-risk groups
Rule out malignancy in the older age
group
Further reading
Figure 15: Scrotal calcinosis arising
from epidermoid cysts.
warranted in persistent cases even
in the absence of GI symptoms.
Prophylactic antibiotics, such as
erythromycin and trimethoprim,
are commonly used to prevent secondary infection that can worsen
underlying lymphatic obstruction
and scarring. Short courses of systemic steroids can be helpful to
reduce swelling in severe cases. Circumcision may be necessary in
refractory cases.
Genital dysaesthesia
There is a strong link
between genital
dysaesthesia and
psychosexual
dysfunction.
Genital dysaesthesia covers a diverse
range of symptoms that include
burning, itching and pain, with some
individuals also complaining of redness. Some of the diagnostic labels
include penodynia and scrotodynia
for painful penis and scrotum,
respectively.
The complaints are typically persistent with repeated presentations
to the same doctor or opinions
sought from multiple practitioners.
Because of the absence of outward
signs, management is less straightforward and can contribute to a
sense of frustration and despondency
in both patient and practitioner. Not
surprisingly, there is a strong link
between genital dysaesthesia and
psychosexual dysfunction.
A discordance between societal
expectation of accepted sexual
behaviour vs the individual’s
actual sexual behaviour can result
in feelings of shame, guilt and low
self-esteem. Examples include matters of sexual orientation, sexual
acts such as oral and anal sex and
non-monogamous sexual activity.
For less liberal sociocultural
groups where strict moral and
social codes govern sexual behaviour and practice, there can be
considerable psychological and
emotional distress when personal
sexual behaviour departs from the
expected norm. Even in liberal
societies unhampered by strict
sexual mores, there is still a considerable stigma associated with
STIs.
It is difficult to estimate what
proportion of genital dysaesthesia
can be directly linked to underlying feelings of guilt or shame. For
example, the occasional married
patient anxiously repeatedly
attending with genital itch or other
forms of dysaesthesia without eviwww.australiandoctor.com.au
dence of skin disease may be distressed by recent extramarital
sexual contact. These patients are
typically harbouring a sense of
guilt and are also concerned they
may have contracted an STI, or
transmitted it to their spouse.
Tactful yet unambiguous enquiry
(eg, “Have you had sexual relations with anyone else?”) directed
at the source of the psychological
discomfort is often met with a
sense of relief. For this group of
patients, there can be significant
symptom resolution as their covert
fears and concerns are being
openly addressed.
Symptomatic treatment of this
group may be required and medications such as doxepin or
amitriptyline, 25-50mg at night
for a period of 3-6 months may
be required to alleviate symptoms.
Neurogenic pain or neuropathy
may be the cause of some of the
complaints, but this is essentially
a diagnosis of exclusion. The list
of genital dermatoses as differential diagnoses should be actively
considered and excluded. Postherpetic neuralgia and intercurrent HSV can account for a subset
of neuropathic pain as can
referred pain from the lumbosacral region.
• Wolff K, et al. Fitzpatrick’s
Dermatology in General
Medicine. 7th edn. McGraw-Hill,
New York, 2007.
• Bolognia JL, et al. Dermatology.
2nd Edn. Elsevier Ltd, Edinburgh,
2008.
Online resources
• DermNet NZ — facts about the
skin from the New Zealand
Dermatological Society Inc:
www.dermnetnz.org.
Pruritus ani
An itchy anus and related genital
itch can range in severity from
mild to severe or intractable. Most
cases are idiopathic with no
detectable cause. The challenge for
the practitioner is to exclude and
manage secondary causes including eczema, psoriasis, contact dermatitis, lichen sclerosus, candida,
warts, pinworms, haemorrhoids
and poor hygiene.
Management involves treating
the underlying cause and keeping
in mind that overzealous cleaning
will make the problem worse.
With genital itch, common groin
and genital rashes such as candida,
tinea and dermatitis may occasionally be the cause.
Scabies and pubic lice must be
excluded. As discussed previously,
scabies usually presents with diagnostic itchy, inflammatory penile or
scrotal nodules while pubic lice (after
careful search) can be clinically
detected at the base of pubic hairs.
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HOW TO TREAT Male genital dermatoses
Authors’ case studies
Case study 1
A 60-YEAR-old man presents with
intermittent genital rash that is currently flaring (figure 5, page 26).
This has been a recurring problem
over the past decade with a fluctuating course. He has been using
Dettol antiseptic washes daily. Clinically, there is significant erythema
of the genital region with areas of
scaling. There is associated scaling
of the eyebrows and scalp dandruff.
The likely primary diagnosis is
seborrhoeic dermatitis also involving the scalp, eyebrows and genitalia. Seborrhoeic dermatitis results
from commensal yeast overgrowth
and typically follows a fluctuating
course. The condition can be
asymptomatic, although mild itching and irritation is not uncommon. The differential diagnoses
include psoriasis and eczema.
Management begins with general
measures to reduce irritation. The
use of Dettol antiseptic has exacerbated the problem by producing an
irritant dermatitis on top of the
seborrhoeic dermatitis. Swap the
Dettol for a gentle soap-free
cleanser such as QV cream or
The use of antiseptic
has exacerbated the
problem by
producing an irritant
dermatitis on top of
the seborrhoeic
dermatitis.
Cetaphil. Application of 1%
hydrocortisone with 1% clotrimazole cream will settle the rash in a
few days. The facial seborrhoeic
dermatitis (eyebrows, nasolabial
folds) can be similarly treated.
Treatment of the scalp with antidandruff shampoos containing tar,
ketoconazole or zinc pyrithione is
recommended.
Although the rash should
respond well to treatment, the
patient should be advised that
recurrence, rather than cure, is the
rule.
Case study 2
A 45-year-old man presents with
a six-month history of penile itch,
pain and dyspareunia. Clinically,
the penis shows ivory-white
atrophic changes to the skin of the
How to Treat Quiz
2. With respect to examination and
investigation of the male genital skin which
TWO statements are correct?
a) Examination of non-genital skin is irrelevant
b) Visual aids such as a magnifying lens can
greatly assist in visualising pubic lice, while a
dermatoscope is helpful for pigmented lesions
c) Scrapings for microscopy can confirm fungal
infections
d) Skin biopsy by a GP is mandatory if there is a
lesion of concern
3. With respect to normal anatomical variants
of the male genital skin which TWO
statements are correct?
a) Prominent hair follicles on the penile skin are
abnormal as this is hairless skin
b) Prominent sebaceous glands in the penile
skin are pre-malignant and require biopsy
c) Pearly penile papules are anatomical variants
found on the coronal sulcus and are
frequently mistaken for warts
d) Sebaceous prominences on the glans penis
are referred to as Tyson’s glands
INSTRUCTIONS
Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes
by post or fax.
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer.
Male genital dermatoses
— 25 May 2012
1. With respect to male genital dermatoses
which TWO statements are correct?
a) Foreskin-related problems (eg, phimosis)
occur only in the paediatric age group
b) STIs are more common in men in early
adulthood
c) Older males are more prone to skin cancer
d) A history of eczema or psoriasis is not
relevant in the assessment of genital skin
glans penis extending along the
shaft with focal areas of superficial
erosion (figure 13B, page 27).
The ivory-white skin changes
and genital location are characteristic of genital lichen sclerosus.
The diagnosis can be confirmed
on biopsy or by a dermatologist.
Check for lichen sclerosus in
other sites as the condition can
present on the torso, perineum
and perianal regions.
Look for possible autoimmune
associations such as vitiligo. A
blood test for thyroid autoantibodies and intrinsic factor antibodies (pernicious anaemia) can
sometimes uncover occult associations.
Start with potent topical
steroids such as betamethasone.
Review the patient after 4-6
weeks to assess treatment
response. Review every 1-2
months until the condition stabilises and remits during which
the frequency of application can
be reduced to twice a week.
Relapses should be managed by
reversion to full potency topical
steroids until control is re-established. Advise the patient to avoid
harsh soaps and over-cleaning,
which can exacerbate the symptoms.
Inadequate treatment can lead
to stricture of the urethral meatus,
phimosis and irreversible sclerotic
changes. There is also a rare, but
recognised risk of SCC transformation with genital lichen sclerosus, and thus long-term follow-up
is necessary.
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4. With respect to sexually acquired disease
which TWO statements are correct?
a) Sexually acquired subtypes of infections
such as herpes simplex virus (HSV 2) often
show phenotypic and genetic adaptation to
the genital region
b) HSV 2 only occurs on genital skin
c) Pubic lice have a more slender structure,
better adapted to pubic hair, than do head
lice
d) Screening for sexually acquired blood-borne
diseases, such as HIV and viral hepatitis,
may be necessary, especially in the context
of unprotected sex
5. With respect to non-genital-specific skin
diseases which TWO statements are
correct?
a) Common skin diseases such as eczema
infrequently affect the genitals
b) Scaly rashes such as psoriasis may appear
less scaly on the male genital skin,
especially over the glans in the
uncircumcised penis
c) If it occurs, eczema tends to be milder on
genital skin and more responsive to
treatment than other body sites
d) Genital psoriasis usually requires treatment
with phototherapy
6. With respect to seborrhoeic dermatitis of
the male genital skin which THREE
statements are correct?
a) Seborrhoeic dermatitis usually occurs in
conjunction with an overgrowth of
commensal skin yeast
b) Seborrhoeic dermatitis can involve the groin
and genital region
c) Management involves keeping the area
moist
d) 1% hydrocortisone with 1% clotrimazole
topical preparations (eg, Hydrozole) is
effective in the management of seborrhoeic
dermatitis of the male genital skin
7. With respect to vitiligo which THREE
statements are correct?
a) Depigmenting conditions such as vitiligo
have a predilection for the genitals
b) The cosmetic impact of vitiligo is greater in
lighter-skinned individuals
c) Vitiligo can be treated with potent topical
steroids for 2-3 months at a time, which is
usually the minimum time for pigment
restoration
d) Patients with vitiligo may need to have
screening blood test for associated
autoantibody conditions such as thyroid
disease, diabetes or pernicious anaemia
8. With respect to skin cancers of the male
genital skin which TWO statements are
correct?
a) The most common genital skin cancer is
squamous cell carcinoma
b) With some cases of in-situ SCC nonsurgical alternatives such as topical 5fluorouracil cream, imiquimod cream or
photodynamic therapy may be viable
options
c) Bowenoid papulosis is not premalignant
d) Bowenoid papuloses never regress
spontaneously and always require excision
9. With respect to lichen sclerosus of the
penis which TWO statements are
correct?
a) Lichen sclerosus has a predilection for the
genital region
b) While lichen sclerosus is more common
in men, it also occurs in women and
children
c) There is a high risk of SCC transformation
with genital lichen sclerosus
d) Lichen sclerosus is a leading cause of
phimosis/stricture of the foreskin
10. With respect to dyaesthesia of the male
genital skin which THREE statements
are correct?
a) Genital dysaesthesia covers a diverse
range of symptoms including burning,
itching, and pain, with some individuals
also complaining of redness
b) These patients are commonly concerned
they may have contracted an STI
c) Often personal hygiene is at fault and
symptoms resolve with more rigorous
cleaning
d) Tactful enquiry (eg, “Have you had sexual
relations with anyone else?”) is often met
with a sense of relief
CPD QUIZ UPDATE
The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2011-13 triennium. You can
complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post or
fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
HOW TO TREAT Editor: Dr Martine Walker
Co-ordinator: Agilene De Villa
Quiz: Dr Martine Walker
NEXT WEEK For decades, warfarin has consistently been shown to be the most effective oral anticoagulant therapy. New oral anticoagulants such as dabigatran have been pushed into clinical
development. Next week’s How to Treat discusses issues in the general use of newer agents as first-line therapy for patients with atrial fibrillation. The authors are Dr Stefan Buchholz, consultant
cardiologist, cardiac services, Mackay Base Hospital, Mackay, Queensland; and Dr Vijay Solanki, head of cardiology, Hornsby Ku-ring-gai Hospital, NSW; VMO, echocardiography department, St Vincent’s
Hospital, NSW.
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| Australian Doctor | 25 May 2012
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