Inflammatory dermatoses

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Overview

Inflammatory dermatoses effecting penis

Balanitis xerotica obliterans

Lichen planus

Zoon’s balanitis

Psoriasis

Circinate balanitis

Eczema

Seborrhoeic dermatitis

Fixed drug eruption

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 dermatosis 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 clincal features, diagnosis, and management inflammatory dermatosis of penis

Distinguishing clincal features, diagnosis, management of balanitis due to inflammatory dermatosis, 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
  • White patches on glans, which may often involve prepuce.
  • Haemorrhagic vesicles, purpura with rarely blisters and ulceration may be present .
Biopsy
  • Epidermis: Thickened epidermis which then becomes atrophic with follicular hyperkeratosis.
  • Dermis: Dermal hyalinisation with loss of elastin fibers and underlying perivascular lymphocytic infiltrate
  • 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.
  • Although topical calcineurin inhibitors have been claimed to be efficacious (pimecrolimus applied twice daily, there is concern about the risk of malignancy.
  • Surgery is indicated when lesion are associated with phimosis and meatal stenosis. Surgical procedures include circumcision, meatotomy ot urethroplasty.
  • Circumcision is indicated for failed topical medical treatment.
  • 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
  • Purlish lesions on the
  • Presence of lichen planus lesions elsewhere in body
Biopsy

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
  • Epidermis: Epidermis thickening which is followed by epidermal atrophy, at times with erosions.
  • Dermis: Plasma cell infiltrate with haemosiderin and extravasated red blood cells.
  • Circumcision
  • Topical steroid preparations - Trimovate cream, applied once or twice daily.
  • Hygiene measures.
  • CO2 laser
  • Topical tacrolimus
  • In atypical cases or cases which do not resolve with with treatment penile biopsy should be performed.
Psoriasis Circumcised male

Red scaly plaques

Uncircumcised

  • Patches appear red and glazed
  • Scaling is lost
Biopsy

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

  • Moderate potency topical steroids( antibiotic and antifungal).
  • Emollients
  • 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 Reiters syndrome
Biopsy

Epidermis: Spongiform pustules in the upper epidermis.

  • Screening for STIs. Syphilis can also give rise to similar features.
  • Consider testing for HLAB27.
  • A positive test can confirm a diagnosis and provide important information about the risk of associated disease, such as urethritis, gastrointestinal disease and arthritis
  • STD's: Sexual partners should be tested for STD's.
Follow up may be needed in persistent symptomatic lesions.
Eczema Eczema may present has mild non-specific erythema to wide spread edema on penis . Biopsy

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
  • Potent topical steroids combine with antifungal and antibiotics may be needed in florid cases
  • Hydrocortisone 1% can be applied until resolution of symptoms
  • Follow up is usually not required.
Seborrhoeic dermatitis Mild itch or redness Antifungal cream with a mild to moderate steroid.
  • Oral azole itraconazole
  • Oral tetracycline
  • Oral terbinafine may be effective43
Fixed drug eruption
  • Well demarcated and erythematous lesions.
  • Lesion may be bullous and may undergo subsequent ulceration
Biopsy
  • 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 persistence.
  • Failure to respond to maximal topical steroid and antifungal treatments.
  • Non-specific histology on biopsy.
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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