Inflammatory dermatoses

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Template:BalanitisV Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S[2]

Overview

Inflammatory dermatoses of penis represents a group of inflammatory conditions which effect the penis causing balanitis. Pathogenesis, risk factors, clinical features, laboratory findings and treatment vary from condition to condition.

Distinguishing clinical features, diagnosis, and management inflammatory dermatoses of penis

Distinguishing clinical features, diagnosis, and management of balanitis due to inflammatory dermatoses, include:[1][2][3][4][5][6][7][8][9]

Distinguishing clincal features, diagnosis, and management of balanitis due to inflammatory dermatosis
Distinguishing clinical features shown on the penis Diagnosis Management
Recommended regimen Alternative regimens Follow-up
Lichen sclerosus Biopsy of lesion
  • Ultrapotent topical steroids(e.g. clobetasol proprionate) applied once daily until remission, then gradually reduced. Intermittent use (e.g. once weekly) may be required to maintain remission.
  • Secondary infection should be treated.
  • Persistent requirement for topical treatment is an indication of circumcision.
  • Patients should be advised to contact the health care provider if they notice any change in appearances of the lesion.
Lichen planus
  • Purplish lesions on the penis
  • Presence of lichen planus lesions elsewhere in body
Biopsy of lesion

Epidermis

Irregular saw-toothed acanthosis, increased granular layer and basal cell liquefaction

Dermis: Band-like dermal infiltrate (mainly lymphocytic)

Moderate to ultrapotent topical steroids depending on severity
  • Topical and oral ciclosporin have been used for erosive disease.
  • Circumcision: May be the treatment of choice for some cases of erosive lichen planus
  • Persistent requirement for topical treatment is an indication of circumcision.
  • Patients should be advised to contact the health care provider if they notice any change in appearances of the lesion.
Zoon’s (plasma cell) balanitis
  • Well-circumscribed orange-red glazed areas on the glans and foreskin.
  • Multiple symmetrical pinpoint redder spots – ‘cayenne pepper spots.’
Biopsy of lesion
  • Circumcision
  • Topical steroid preparations(Trimovate cream, applied once or twice daily)
  • Hygiene measures
  • CO2 laser
  • Topical tacrolimus can also be useful.
  • In atypical cases or cases which do not resolve with treatment, penile biopsy should be performed.
Psoriasis Circumcised male

Red scaly plaques

Uncircumcised

  • Patches appear red and glazed
  • Scaling is lost
Biopsy of lesion

Parakeratosis and acanthosis with elongation of rete ridges and collections of neutrophils in the epidermis may be present

  • Topical Vitamin D preparations (calcipotriol or calcitriol applied twice daily)
  • Topical bethamethasone dipropionate/calcipotriol ointment may be well tolerated in treatment of anogenital psoriasis, but potent steroids may not be indicated
  • Topical tacrolimus has been used in small studies but should not be used as first-line therapy
  • Topical pimecrolimus can also be useful
Circinate balanitis
  • Greyish white areas on the glans
  • These areas may coalesce to form ‘geographical’ areas with a white margin
  • Usually associated with Reiter's syndrome
Biopsy of lesion

Epidermis: Spongiform pustules in the upper epidermis

STD's should be appropriately treated as per protocol
  • Topical steroids like hydrocortisone/ triamcinolone, or combination of keratolytic agents likes 10% salicylic acid ointment with hydrocortisone 2.5% cream, and oral aspirin are effective
  • Topical calcineurin inhibitors can also be useful
Follow up may be needed in persistent symptomatic lesions
Eczema Eczema may present has mild non-specific erythema to wide spread edema of penis.
Biopsy of lesion

Eczematous with spongiosis and non-specific inflammation

  • Patients should be advice to avoid precipitants(Soap) and apply emollients
  • Hydrocortisone 1% applied once or twice daily until resolution of symptoms
  • Follow up is usually not required.
Seborrhoeic dermatitis Mild itch or redness Anti-fungal cream with mild to moderate topical steroids.
Fixed drug eruption Biopsy of lesion
  • Hydropic degeneration of the basal layer
  • Epidermal detachment and necrosis with pigmentary incontinence
  • Condition will settle without treatment
  • Topical steroids – e.g. mild to moderate strength twice daily until resolution
  • Rarely systemic steroids may be required if the lesions are severe
Non-specific balanoposthitis Chronic symptomatic presentation with relapses and remissions or persistent Circumcision is curative

References

  1. Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
  2. Kishimoto M, Lee MJ, Mor A, Abeles AM, Solomon G, Pillinger MH (2006). "Syphilis mimicking Reiter's syndrome in an HIV-positive patient". Am J Med Sci. 332 (2): 90–2. PMID 16909057.
  3. Neill SM, Lewis FM, Tatnall FM, Cox NH, British Association of Dermatologists (2010). "British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010". Br J Dermatol. 163 (4): 672–82. doi:10.1111/j.1365-2133.2010.09997.x. PMID 20854400.
  4. Chi CC, Kirtschig G, Baldo M, Brackenbury F, Lewis F, Wojnarowska F (2011). "Topical interventions for genital lichen sclerosus". Cochrane Database Syst Rev (12): CD008240. doi:10.1002/14651858.CD008240.pub2. PMID 22161424.
  5. Porter WM, Francis N, Hawkins D, Dinneen M, Bunker CB (2002). "Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases". Br J Dermatol. 147 (6): 1159–65. PMID 12452865.
  6. Weyers W, Ende Y, Schalla W, Diaz-Cascajo C (2002). "Balanitis of Zoon: a clinicopathologic study of 45 cases". Am J Dermatopathol. 24 (6): 459–67. PMID 12454596.
  7. Kumar B, Sharma R, Rajagopalan M, Radotra BD (1995). "Plasma cell balanitis: clinical and histopathological features--response to circumcision". Genitourin Med. 71 (1): 32–4. PMC 1195366. PMID 7750950.
  8. Nast A, Kopp I, Augustin M, Banditt KB, Boehncke WH, Follmann M; et al. (2007). "German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version)". Arch Dermatol Res. 299 (3): 111–38. doi:10.1007/s00403-007-0744-y. PMC 1910890. PMID 17497162.
  9. Zawar V, Kirloskar M, Chuh A (2004). "Fixed drug eruption - a sexually inducible reaction?". Int J STD AIDS. 15 (8): 560–3. doi:10.1258/0956462041558285. PMID 15307969.

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