CASE
A 26-year-old man self-referred himself to the dermatology clinic for evaluation of “genital warts” that had not responded to OTC wart medication. The lesions had been present for several years unchanged, caused no symptoms, and had never appeared in any other locations. The patient had been heterosexually monogamous during this entire time and claimed to be otherwise healthy, with no recent behavior that elevated his risk for HIV. His female sexual partner had seen these lesions and was concerned that they represented warts; she had had twice yearly Pap smears and pelvic examinations, which had shown no signs of human papillomavirus-caused lesions.
Inspection of the penis showed a band of uniformly pigmented, 1- to 2-mm, notably soft, fleshy papules confined to the coronal sulcus, distributed circumferentially (see Figure 1). The lesion surface was smooth and shiny. No lesions were seen elsewhere on the penis, scrotum, or suprapubic or crural areas.
THE MOST LIKELY DIAGNOSIS IS
• Pilosebaceous units
• Atypical warts
• Pearly penile papules
• Molluscum contagiosum
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DISCUSSION
This patient has pearly penile papules, discussed below. Pilosebaceous units are the superficial white, cystlike tiny papules uniformly distributed over the surface of every penis and scrotum, as well as on the labial surfaces of females. As the name suggests, they represent the combination of a hair follicle and associated sebaceous gland normally invisible in thicker skin.
Warts can be atypical in appearance, but they are unlikely to be confined to this exact area, would be less uniform in size and shape, and would probably display a rough, “warty” surface. Molluscum contagiosum can develop on penises and can have a somewhat similar shiny appearance, but the lesions would be far more firm to the touch and at least some would demonstrate an umbilication at the lesion's tip.
No treatment needed The genital area is subject to much concern and resulting inspection by patients and their partners, who often consult medical providers for answers to questions of concern. Condyloma is so common now that it is often suspected as the explanation for almost any visible lesion, but pearly penile papules are entirely normal, common, have no pathologic implications, and require no treatment.
Histopathologically, pearly penile papules are angiofibromas, but they have no connection to the angiofibro¬mas seen with tuberous sclerosis. Pearly penile papules do appear to be more common in the uncircumcised, which may be why they are more common in black men, who undergo that procedure far less commonly than do white men.
First appearing in late adolescence, pearly penile papules persist unchanged until the sixth or seventh decade of life, when they usually begin to fade. Their origin is unknown, but they are almost always confined to the coronal sulcus and surrounding area. These lesions are occasionally seen on the distal shaft. No such lesion is reported on female genitalia.
As mentioned earlier, no treatment for pearly penile papules is indicated, nor has any been found to be effective. What is usually called for in these cases is exhaustive reassurance regarding the certainty of their benign nature. Rarely, biopsy is necessary to provide that reassurance. JAAPA