Common Skin Disorders Of The Penis

Review of penile skin disorders

1. Common skin disorders of
the penis
Main reference:
BJU International
2002
S.A. BUECHNER
Department of Dermatology, University of
Basel, Switzerland
Urology Conference
Presented by:
Ahmad Kharrouby PGY3

2. Outline

3. Outline
A-Viral infections
1.Genital warts
2.Genital herpes
B-Bacterial ulcerative
lesions
1.Chancre (Syphilis)
2.Chancroid (H. ducreyi)
C-Infestations
1.Scabies
2.Pediculosis pubis
D-Cutaneous diseases
1.Psoriasis
2.Lichen planus
3.Penile lichen sclerosus
4.Contact dermatitis
5.Fixed-drug eruptions
E-Balanitis and
balanoposthitis
1.Plasma cell balanitis
2.Balanitis circinata
F-Premalignant and
malignant genital tumours
1.Giant condyloma
2.Bowen’s disease
3.Bowenoid papulosis
4.Erythroplasia of Queyrat
5.Penile SCC

4. A-Viral infections
1-Genital warts
2-Genital herpes

5. 1-Genital warts

6. A-Viral infections
1-Genital warts
The most common sexually transmitted disease
Caused by HPV
1 percent of all sexually active adults have genital
warts
10% can be documented to have active HPV by
PCR
Elevated genital warts, condyloma acuminata, are
due to low-risk HPV types (usually 6 and 11)
Occur mostly under the prepuce, and on the penile
shaft

7. A-Viral infections
1-Genital warts
There are three major types of
anogenital warts:
1.Condyloma acuminata are pedunculated,
cauliflower-like, skin-coloured to reddish
verrucous papules
2.Dome-shaped, usually flesh coloured
papules
3.Flat warts are flat-topped papules which
may vary in colour from pink-red to reddish-
brown

8. Multiple papular pigmented condylomata acuminata on the
penile shaft

9. Numerous whitish condylomata acuminata on the tip of the
penis

10. A-Viral infections
1-Genital warts
Current treatments can eradicate only
the warts and not the virus, recurrence
is very common (>25%)
There are 2 basic forms of therapy:
–Patient applied
–Health-care worker applied

11. A-Viral infections
1-Genital warts
Patient-applied treatment:
–Podophyllotoxin is applied twice daily for 3
days per week for 6–10 weeks
–Imiquimod is an immune modulator that
results in the local production of interferon, It
is applied once daily for three times per week

12. A-Viral infections
1-Genital warts
Physician-applied treatments include:
–Liquid nitrogen cryotherapy
–Electrocautery
–Laser therapy
–Intralesional or systemic immunotherapies

13. 2-Genital herpes

14. A-Viral infections
2-Genital herpes
The most common cause of genital ulcersThe most common cause of genital ulcers
Is an incurable and recurrent viral infection
Sexually transmitted
Is predominantly caused by HSV type 2
HSV-1 is responsible for 5–30% of cases of first-
episode
After infection, the viral genome remains in a
latent state in the nuclei of sensory neurons for
the life of the host
Genital HSV-1 infections are usually less severe
and less prone to recur than those caused by
HSV- 2

15. A-Viral infections
2-Genital herpes
Appears as macules and papules, followed
by vesicles, pustules and ulcers
Systemic complaints including fever,
myalgias and lethargy may be present, but
are rare
Patients will often have accompanying
tender lymphadenitis

16. Genital herpes; grouped vesicles and erosions are located on
the penis shaft and scrotum

17. A-Viral infections
2-Genital herpes
Recurrent episodes are less severe and
undergo rapid involution within 5– 10 days
Recurrence rate reach 90% in HSV 2
Diagnosis can be confirmed by virus
isolation in cell culture or by PCR

18. A-Viral infections
2-Genital herpes

19. B-Bacterial ulcerative lesions
1-Chancre (Syphilis)
2-Chancroid (H. ducreyi)

20. 1-Chancre (Syphilis)

21. B-Bacterial ulcerative lesions
1-Chancre (Syphilis)
Caused by the spirochete Caused by the spirochete Treponema pallidumTreponema pallidum
Occurs during the first stage of syphilis i.e.Primary Occurs during the first stage of syphilis i.e.Primary
syphilissyphilis
Is an ulcerative lesion at the site of spirochete entry Is an ulcerative lesion at the site of spirochete entry
Appears about 3-4 weeks after infectionAppears about 3-4 weeks after infection
The chancre is usually hard and painlessThe chancre is usually hard and painless
The lesions typically clear after about a month without The lesions typically clear after about a month without
scarringscarring
Serologic tests are often negative when the chancre first Serologic tests are often negative when the chancre first
appears but become reactive in the following 1-4 weeks appears but become reactive in the following 1-4 weeks

22. Syphilitic chancres may appear on or around the genitals

23. B-Bacterial ulcerative lesions
1-Chancre (Syphilis)
Definitive diagnosis involves Definitive diagnosis involves
demonstration of demonstration of Treponema pallidumTreponema pallidum by by
darkfield microscopy in lesionsdarkfield microscopy in lesions
Treatment of primary syphilis is Treatment of primary syphilis is
Benzathine penicillin G, 2.4 million units
IM as a single dose

24. 2-Chancroid (H. ducreyi)

25. B-Bacterial ulcerative lesions
2-Chancroid (H. ducreyi)
Chancroid is an acute ulcerative disease,
often associated with inguinal adenopathy
(“bubo”)
H. ducreyi, a gram-negative facultative
bacillus, is the cause
Definitive diagnosis of chancroid requires
identification H. ducreyi, on specialized
culture media that are not widely available

26. B-Bacterial ulcerative lesions
2-Chancroid (H. ducreyi)
In practice, a probable diagnosis of
chancroid may be based on the following:
–the patient has a painful genital ulcer
–there is no evidence of T. pallidum by
darkfield examination
–an HSV test is negative
–the clinical appearance is typical

28. B-Bacterial ulcerative lesions
2-Chancroid (H. ducreyi)
Treatment of chancroid is Azithromycin, 1
g as a single oral dose
or ceftriaxone, 250 mg as a single IM dose
or ciprofloxacin, 500 mg orally twice a day
for 3 days

29. C-Infestations
1-Scabies
2-Pediculosis pubis

30. 1-Scabies

31. C-Infestations
1-Scabies
Caused by human mite Sarcoptes scabiei
Causes a severely pruritic, widespread
eruption
Very itchy papules or nodules with a
central crust on the penile shaft or glans
and on the scrotum
In adults, scabies is a sexually transmitted
disease

32. Scabies; multiple erythematous papules

33. C-Infestations
1-Scabies
Treatment consists of overnight application
of 5% permethrin cream to the whole body
from the neck down
To be repeated in 1 week
All sexual partners should be treated
simultaneously
All clothing, bedding, and towels should be
washed and heat dried

34. 2-Pediculosis pubis

35. C-Infestations
2-Pediculosis pubis
Pediculosis pubis may be sexually or
nonsexually transmitted
Itching may be intense
The nits are found on the hair shafts in the
pubic area and the eyelids

37. The nits are found on the hair shafts in the pubic area and the eyelids

38. C-Infestations
2-Pediculosis pubis
Treatment consists of application of permethrin
1% crème rinse applied for 10 minutes then
washed off
To be repeated in 1 week
All hairy areas contiguous with the genital area
should be treated
The sexual partner(s) should be treated also
All clothing, bedding, and towels should be
washed and heat dried

39. D-Cutaneous diseases
1-Psoriasis
2-Lichen planus
3-Penile lichen sclerosus
4-Contact dermatitis
5-Fixed-drug eruptions

40. 1-Psoriasis

41. D-Cutaneous diseases
1-Psoriasis
A solitary plaque may present on the glans
penis, leading to confusion with high-
grade dysplasia (erythroplasia of Queyrat)
Itching may be intense or nonexistent
The diagnosis usually can be made by
inspection and by noting other areas of
involvement such as the scalp, elbows,
knees, and nails

42. Psoriasis; red scaly patches on the glans penis

44. D-Cutaneous diseases
1-Psoriasis
Hydrocortisone cream, 1%
plus an imidazole cream (clotrimazole,
1%) is usually efficacious
Washing the glans after intercourse is
critical in controlling penile psoriasis

45. 2-Lichen planus

46. D-Cutaneous diseases
2-Lichen planus
Lichen planus may affect the glans penis
The genitalia may be the only site of
involvement
The lesions are polygonal, violet-hued,
flat-topped papules, with shiny surfaces
Lesions may be asymptomatic, pruritic, or
painful if eroded
A biopsy may be required

47. Lichen planus; numerous annular violaceous papules on the
glans penis

48. D-Cutaneous diseases
2-Lichen planus
Topical corticosteroids and topical
tacrolimus 0.1% ointment
The disease may disappear after months
to years

49. 3-Lichen Sclerosis

50. D-Cutaneous diseases
3-Lichen Sclerosis
LS almost inevitably involves the
anogenital regions, where severe pruritus
or painful erosions may develop
LS of the glans penis may lead to
phimosis and urethral stenosis

51. Lichen sclerosus; a typical white sclerotic ring at the tip of
foreskin

52. D-Cutaneous diseases
3-Lichen Sclerosis
Topical steroids are the treatment of
choice
An initial trial should be 6 weeks of
treatment
Once the patient is in remission, milder
steroids or bland emollients may be used
for maintenance

53. 4-Contact dermatitis

54. Cutaneous diseases
4-Contact dermatitis
True allergic contact dermatitis is pruritic,
erythematous, edematous, and weepy
Possible causes are hygiene products,
condoms, and plants

55. D-Cutaneous diseases
4-Contact dermatitis
Twice-daily cool water compresses
Followed immediately by the application of
a mild topical steroid (1% hydrocortisone
ointment)

56. 5-Fixed-drug eruptions

57. D-Cutaneous diseases
5-Fixed-drug eruptions
Fixed drug eruption, due usually to
laxatives sulfonamides, or NSAIDs,
commonly presents on the genitalia
Two percent of all genital ulcers are fixed
drug eruptions
Lesions often begin within a day of drug
exposure and present as bright red to
violaceous macules that quickly blister and
erode

58. Fixed drug eruption caused by ingestion of trimethoprim-sulphamethoxazole,
showing the dusky erythematous solitary lesion

59. D-Cutaneous diseases
5-Fixed-drug eruptions
The erosion is superficial and broad
(usually >1 cm)
Fixed drug eruption occurs in the same
site with each exposure to the same drug
Treatment is to stop the offending
medication

60. E-Balanitis and
balanoposthitis
1-Plasma cell balanitis
2-Balanitis circinata

61. 1-Plasma cell balanitis

62. E-Balanitis and balanoposthitis
1-Plasma cell balanitis
Is a benign chronic balanitis of unknown
origin
The condition usually manifests in middle-
aged or elderly uncircumcised men
Plasma cell balanitis is characterized by a
solitary red-orange plaque of the glans
and prepuce
The plaque surface is shiny and smooth,
slightly moist

63. Plasma cell balanitis; a well circumscribed, shiny red plaque

64. E-Balanitis and balanoposthitis
1-Plasma cell balanitis
The disease tends to be chronic and may
persist for months to years
It is important to verify the diagnosis by
biopsy
The histopathology is characteristic
showing a band-like infiltrate of plasma
cells

65. E-Balanitis and balanoposthitis
1-Plasma cell balanitis
The treatment of choice for is circumcision
Temporary relief is usually achieved by a
topical steroid

66. 2-Balanitis circinata

67. E-Balanitis and balanoposthitis
2-Balanitis circinata
Balanitis circinata is a mucocutaneous
manifestation of Reiter’s syndrome
A multisystem disease, that is clinically
characterized by the triad of
nongonococcal urethritis, arthritis and
conjunctivitis
Manifests as a well-demarcated, moist,
erythematous plaque with a ragged or
scalloped white border on the glans penis

68. Balanitis circinata; well-demarcated, erythematous plaque
with a ragged border on the glans penis

69. F-Premalignant and malignant
genital tumours
1-Giant condyloma
2-Bowen’s disease
3-Bowenoid papulosis
4-Erythroplasia of Queyrat
5-Penile SCC

70. 1-Giant condyloma

71. F-Premalignant and malignant genital tumours
1-Giant condyloma
Giant condylomata acuminata are cauliflower-
like lesions arising from the prepuce or glans
Most cases are caused by infection with low risk
HPV 6 and 11
These lesions may be difficult to distinguish from
well-differentiated squamous cell carcinoma
Most represent a subtype of low-grade SCC
Deep biopsies are needed

72. Giant condylomata acuminata are cauliflower-like lesions
arising from the prepuce or glans

73. 2-Bowen’s disease

74. F-Premalignant and malignant genital tumours
2-Bowen’s disease
Bowen’s disease is a squamous cell
carcinoma in situ typically involving the
penile shaft
The lesion appears as a red plaque with
encrustations
Surgical excision is the best treatment
option for small lesions, preferably by
cryosurgery or CO2 laser

75. 3-Bowenoid papulosis

76. F-Premalignant and malignant genital tumours
3-Bowenoid papulosis
Similar to Bowen’s but multiple papules instead
of plaques
Bowenoid papulosis is a high grade
intraepithelial lesion
Bowenoid papulosis is characterized by flat, skin-
coloured, pink or often hyperpigmented papules
Is strongly associated with HPV 16
Occurs mainly in young sexually active adults,
with lesions on the glans and prepuce

77. Bowenoid papulosis; multiple flat pigmented papules

78. F-Premalignant and malignant genital tumours
3-Bowenoid papulosis
The most effective treatment is excision of
the papules
However, cryosurgery with liquid nitrogen
and carbon dioxide laser are the most
frequently used method

79. 4-Erythroplasia of Queyrat

80. F-Premalignant and malignant genital tumours
4-Erythroplasia of Queyrat
Is a velvety, red lesion with ulcerations
that usually involve the glans
Microscopic examination shows typical,
hyperplastic cells in a disordered array
with vacuolated cytoplasm and mitotic
figures
Surgical excision is the treatment of
choice, but topical 5-fluorouracil and the
CO2 laser may also be used

81. Erythroplasia of Queyrat is a velvety, red lesion with ulcerations

82. 5-Penile SCC

83. F-Premalignant and malignant genital tumours
5-Penile SCC
Of all cancers affecting the penis 95% are SCC
The disease is rare
The age at the onset of penile SCC has a wide
range (20– 90 years) with a peak around the fifth
decade
Risk factors are
–Phimosis
–Lack of circumcision
–Chronic inflammatory conditions
–Multiple sexual partners
–HPV infection

84. F-Premalignant and malignant genital tumours
5-Penile SCC
The clinical appearance of penile SCC varies
from
–erythematous plaque
–induration
–verrucous lesions
–exophytic lesions
–irregularly shaped mass
As it increases in size, superficial ulceration,
necrosis and bleeding may become evident

85. Penile SCC presenting as an erythematous, nodular, erosive
lesion on the glans penis

86. Squamous cell carcinoma exophytic erosive lesion with evident keratanization

87. F-Premalignant and malignant genital tumours
5-Penile SCC
The treatment of penile SCC depends on
tumour staging and includes surgery,
radiotherapy, laser surgery and
chemotherapy

88. ReferencesReferences
BJU International (2002), Common skin
disorders of the penis, S.A.
BUECHNER, Department of Dermatology,
University of Basel, Switzerland
Smith’s General Urology, Seventeenth
Edition, Skin Diseases of the External
Genitalia, Timothy G. Berger, MD

89. Thank YouThank You