Male genital dermatoses: Timely intervention has benefits for quality and quantity of life

Key Points

San Francisco - Accurate diagnosis and effective treatment of male genital dermatologic conditions is important because these dermatoses can be a source of significant morbidity and even mortality, says Christopher B. Bunker, M.D., consultant dermatologist, Chelsea & Westminster and Royal Marsden Hospitals and professor of dermatology, Imperial College, London, at the 67th Annual Meeting of the American Academy of Dermatology.

"Although dyspareunia has often been considered a problem for women only, men with a genital dermatosis can suffer discomfort and even pain during intercourse, and men whose skin condition is asymptomatic may be avoiding sexual relations because they are embarrassed by the appearance of their rash.

"Appropriate diagnosis and treatment are critical for restoring quality of life for these individuals and their partners," Dr. Bunker says.

Dr. Bunker says about half of penis squamous cell carcinoma is attributable to human papilloma virus infection and the rest to lichen sclerosus.

"Penile cancer accounts for only 1 percent of all cancer fatalities, but that still represents quite a large number of preventable deaths," Dr. Bunker tells Dermatology Times.

Challenges

As for other dermatologic conditions, the work-up begins with careful history and clinical examination, supplemented in some cases by skin biopsy. However, there are particular challenges to accomplishing these tasks in men with a genital dermatosis.

"Patients are reticent to reveal they are experiencing discomfort with intercourse, and they may feel equally uncomfortable about undergoing physical examination of their genitalia, and so the dermatologist may need to work hard," Dr. Bunker says.

Skin biopsy may sometimes be necessary, and it should always be done if cancer or precancer is suspected. However, it needs to be undertaken intelligently, and there should be good communication between the dermatologist and dermatopathologist.

"The penis is not a homogenous sheet of tissue. Careful attention must be paid to choosing the biopsy site in order to improve the diagnostic yield of the histopathologic review and to minimize the risk of causing significant organ injury," Dr. Bunker says.

The spectrum of male genital dermatologic diseases includes sexually transmitted infections, along with various inflammatory conditions and neoplastic disorders.

Excluding sexually transmitted infections, the most common diagnoses to consider are lichen sclerosus, lichen planus, psoriasis, seborrheic dermatitis, Zoon's balanitis, nonspecific balanoposthitis, the different clinical presentations of penile intraepithelial neoplasia (Bowenoid papulosis, Bowen's disease of the penis and erythroplasia of Queyrat) and frank squamous cell carcinoma.

Clues

In a patient who complains only about the appearance of the eruption without any dyspareunia, psoriasis and Zoon's balanitis are two diagnoses that should come first to mind. Discomfort during sex suggests lichen sclerosus, lichen planus and penile cancer.

Physical signs can be subtle or florid and vary according to the diagnosis. However, persistent plaques, erosions, ulcers, or nodules are particularly important, as they raise suspicion of cancer.

Dr. Bunker says that inflammatory and neoplastic male genital dermatologic conditions are, by and large, problems for the uncircumcised population. Depending on the diagnosis, medical treatment may be curative.

However, circumcision has a central role to play in managing lichen sclerosus and the precancerous dermatoses. For example, he says that his data show that approximately 50 percent of men with lichen sclerosus will be cured by medical treatment (usually potent topical steroids), and the remainder will require circumcision. Of these, about 90 percent will be cured by the surgery.