3119
CASE REPORT Giant Seborrheic Keratoses on Penis Martina Part, MD,* Danka Švecová, MD, PhD,* Daniela Brezová, MD,† and Ján Breza, MD, DrSc.‡ *Faculty of Medicine, Department of Dermatology and Venerology, Comenius University in Bratislava, Bratislava, Slovakia; †Department of Dermatology and Venerology, University Hospital, Bratislava, Slovakia; ‡Faculty of Medicine, Department of Urology, Comenius University in Bratislava, Bratislava, Slovakia DOI: 10.1111/jsm.12676
ABSTRACT
Introduction. Seborrheic keratoses are very common benign epidermal tumors. Despite the high frequency, the pathogenesis is still unknown. They are extremely rare in the genital area. The participation of human papilloma viruses (HPVs) in pathogenesis of seborrheic keratoses is being discussed. Aims. The aims of this case report are to inform about extremely rare lesion in genital area in a young man and evaluate the association of HPVs in the development of seborrheic keratoses. Methods. We used histopathological examination to establish the correct diagnosis, which revealed signs of seborrheic keratosis. The real-time polymerase chain reaction method confirmed low-risk HPV 6 from the lesions. Main Outcome Measures. HPVs may play a role in pathogenesis of seborrheic keratoses. Results. The patient was successfully treated with shave excision under spinal anesthesia. Six-month follow-up was without any recurrence. We suggest that HPVs can be considered as etiologic factor in creation of seborrheic keratosis. Conclusions. Seborrheic keratoses are very common on sun-exposed skin, but they are rare in the genital area, such as on the shaft of penis. This localization may lead to misdiagnosis. Seborrheic keratoses in genital area might negatively influence the sexual life of the patient. Containing HPV 6 low-risk virus, they never lead to malignant transformation. Part M, Švecová D, Brezová D, and Breza J. Giant seborrheic keratoses on penis. J Sex Med 2014;11:3119–3122. Key Words. Seborrheic Keratoses; Penis; Low-Risk HPV 6; RT-PCR Method; Dermatologic Lesions of the Penis
Introduction
S
eborrheic keratoses are very common benign epidermal tumors. They usually occur in patients over 50 years of age [1]. Despite the high frequency, the pathogenesis is still unknown. Sun exposure, skin phototype I and II, and family predisposition are considered as risk factors. Seborrheic keratoses are more prevalent in individuals with skin phototype I and II. The participation of human papilloma viruses (HPVs) in pathogenesis of seborrheic keratoses is being discussed [2]. Sunexposed skin of face and trunk are common site for seborrheic keratoses; however, in genital area, especially on penis, they are extremely rare [3]. Due to the localization in the genital region, the specialists might misdiagnose the lesion as condy© 2014 International Society for Sexual Medicine
loma acuminatum. A careful histopathological examination is essential to establish the correct diagnosis [4]. Aims
The aims of this case report are to inform about extremely rare lesion in genital area in a young man and evaluate the association HPVs in the development of seborrheic keratoses. Methods
A 33-year-old man presented to department with giant masses on the base of the penis shaft (Figure 1). The disease started 8 years ago with a J Sex Med 2014;11:3119–3122
3120
Part et al. pathologically using hematoxylin-eosin staining. Microscopically, the lesions appeared as basal cell papilloma with typical papillary structure and keratin pearls composed of small slightly elongated epithelial cells with accumulation of the brown pigment melanin accumulation in cytoplasm (Figure 2). Low-risk HPV 6 was identified from excised sample using RT-PCR method. Wounds after excision healed per secundam without skin flaps. No recurrence was observed during 6-month follow-up.
Conclusions Figure 1 Seborrheic keratoses on the base and shaft of penis
small brown papule on the base of penis. The papule gradually increased in size and number resembling mainly condylomata acuminata and to a lesser extent seborrheic keratoses. The patient was healthy and did not suffer from any immunosuppresive conditions. The lesions were painless and dry without any fetor. Regarding the epidemiological history, both of couple said to live in straight monogamy without any sexual promiscuity in both of married couple. Examination on human immunodeficiency virus, syphilis, hepatitis B, and hepatitis C proved negative. Physical examination revealed one large lesion on the base of penis and numerous small lesions on the penis shaft. The lesions were 10 × 8 cm and 1–4 cm in size. All lesions were of brown color and well demarcated with papillomatous and verrucous surface. The patient was deeply frustrated because of the absence of sexual intercourse with his wife for several years after manifestation of the lesions. His wife was free of symptoms confirmed by gynecologic examination. We used histopathological examination to establish the correct diagnosis and real-time polymerase chain reaction (RT-PCR) method to evaluate the presence of HPV in the lesion.
Seborrheic keratoses are very common epidermal tumors of benign origin. They can occur on various cutaneous location, mainly on the sunexposed skin of trunk and face. The palms and soles are never affected, the genital region only very rarely. Seborrheic keratoses mostly affect people over 50 years of age, whereas young individuals are affected very rarely [1,3,4]. Despite the high number of cases of seborrheic keratoses, the pathogenesis is still not completely understood [2]. Some authors believe in genetic predisposition and somatic mutations of particular genes, which lead to the formation of seborrheic keratoses after sun exposure. It is not exactly known which molecular or functional mechanism is responsible for pathological changes leading to seborrheic keratoses [2]. It has been suggested that HPVs could play role in the pathogenesis of seborrheic keratosis. The causal relationship is controversial. Tardío et al. [5] studied the relationship
Main Outcome Measures
Low-risk HPV 6 was identified from excised sample using RT-PCR method. Results
The patient underwent shave excision under spinal anesthesia. The diagnosis was confirmed histoJ Sex Med 2014;11:3119–3122
Figure 2 Histopathologic picture: basal cell papilloma (hematoxylin and eosin staining)
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Seborrheic Keratoses on Penis with Low-Risk HPV 6 between genital and nongenital seborrheic keratoses and HPVs. They confirmed HPVs in 70% of seborrheic keratoses in genital area, whereas in nongenital area, it was only in 5% of cases [5]. The HPV infection can be acquired during sexual intercourse and can lead to development of seborrheic keratoses, especially in young individuals [5]. On one hand, it can be only the accessory contamination of the surface. Association of seborrheic keratoses and skin neoplasm (basalioma, malignant melanoma, etc) was documented in several studies [2]. On the other hand, seborrheic keratoses can be associated with malignancy of internal organs. Most frequently, eruptive seborrheic keratoses are associated with adenocarcinoma [2,6]. The diagnosis of seborrheic keratoses can be sometimes challenging, especially in young individuals with lesions in the genital region, particularly on the penis shaft, and it may be misdiagnosed as condyloma acuminatum. The histopathological examination is used to confirm the diagnosis. The typical histopathological findings include acanthosis, papillomatosis, hyperkeratosis, horn cysts, and pseudocysts. There are several histopathological subtypes which can overlap including acanthotic, hyperkeratotic, adenoid, clonal, Bowenoid, and irritated subtype and melanoacanthoma [7]. The treatment of seborrheic keratoses is not mandatory, given the benign origin of the disorder. The most common treatment modality is cryotherapy with nitrogen liquid, curettage, laser or surgical shave, and other ablative methods. Some studies show good efficacy of topical administration of vitamin D and tazarotene which result in the induction of keratinocytes apoptosis [8,9]. Patients with multiple lesions have to be examined to exclude malignancy of internal organs, especially in eruptive type of seborrheic keratoses. Seborrheic keratoses are very common especially in elderly patients on sun-exposed skin, and they are rare in the genital area, such as on the shaft of penis. This localization may lead to misdiagnosis. Sexually transmitted infections and a wide range of noninfectious diseases affecting genital area, such as pearly penile papules, Status Fordyce, psoriasis, etc, should be considered in the differential diagnostic process [10,11]. In general, all patients suffering from dermatologic problems in genitals are at risk of developing psychiatric disorders, depression, anxiety, and sexual dysfunction [11,12]. Seborrheic keratoses in genital area might also negatively influence the sexual life of the patient.
Containing HPV 6 low-risk virus, they never lead to malignant transformation. Corresponding Author: Martina Part, MD, Faculty of Medicine, Department of Dermatovenerology, Comenius University in Bratislava, Mickiewiczova 13, Bratislava, Slovakia. Tel: 00421 2 5729 0407; Fax: 00421 2 5729 0534; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest.
Statement of Authorship
Category 1 (a) Conception and Design Martina Part (b) Acquisition of Data Martina Part; Daniela Brezová; Ján Breza (c) Analysis and Interpretation of Data Martina Part
Category 2 (a) Drafting the Article Martina Part (b) Revising It for Intellectual Content Danka Švecová
Category 3 (a) Final Approval of the Completed Article Martina Part; Danka Švecová; Daniela Brezová; Ján Breza
References 1 Livaoglu M, Karacal N, Gücer H, Arvas L. Giant genital seborrheic keratosis. Dermatol Surg 2007;33:1357–8. 2 Hafner C, Vogt T. Seborrheic keratosis. J Dtsch Dermatol Ges 2008;8:664–77. 3 Thakur JS, Thakur A, Chauhan CGS, Diwana AK, Chauhan DC. Giant pedunculated seborrheic keratosis of penis. Indian J Dermatol 2008;53:37–8. 4 El Amrani F, Meknassi I, Bouaddi M, Raffas W, Kettani F, Senouci K, Hassam B. Giant keratosis in an unusual site. Ann Dermatol Venereol 2012;139:723–6. 5 Tardío JC, Bancalari E, Moreno A, Martín-Fragueiro LM. Genital seborrheic keratoses are human papillomavirus-related lesions. A linear array genotyping test study. APMIS 2012;120:477–83. 6 Noiles K, Vender R. Are all seborrheic keratoses benign? Review of the typical lesion and its variants. J Cutan Med Surg 2008;12:203–10. 7 Amyia KN, Rashmi K, Gajesh G, Devinder MT, Debdatta B. Giant seborrheic keratosis of the genitalia. Indian J Dermatol 2012;57:310–2. 8 Mitsuhashi Y, Kawaguchi M, Hozumi Y, Kondo S. Topical vitamin D3 is effective in treating senile warts possibly by inducing apoptosis. J Dermatol 2005;32:420–3.
J Sex Med 2014;11:3119–3122
3122 9 Herron MD, Bowen AR, Krueger GG. Seborrheic keratoses: A study comparing the standard cryosurgery with topical calcipotriene, topical tazarotene and topical imiquimod. Int J Dermatol 2004;43:300–2. 10 Rodrigo-Nicolás B, Armengot-Carbó M, Gimeno Carpio E. Papules on genitals: Always an infectious disease? J Sex Med 2013;10:616–7.
J Sex Med 2014;11:3119–3122
Part et al. 11 Chen YJ, Chen CC, Lin MW, Chen TJ, Li CY, Hwang CY, Chu SY, Lee DD, Chang YT, Wang WJ, Liu HN. Increased risk of sexual dysfunction in male patients with psoriasis: A nationwide population-based follow-up study. J Sex Med 2013;10:1212–8. 12 Kucukunal A, Altunay IK, Mercan S. Sexual dysfunction in men suffering from genital warts. J Sex Med 2013;10:1585–91.
CASE REPORT Giant Seborrheic Keratoses on Penis Martina Part, MD,* Danka Švecová, MD, PhD,* Daniela Brezová, MD,† and Ján Breza, MD, DrSc.‡ *Faculty of Medicine, Department of Dermatology and Venerology, Comenius University in Bratislava, Bratislava, Slovakia; †Department of Dermatology and Venerology, University Hospital, Bratislava, Slovakia; ‡Faculty of Medicine, Department of Urology, Comenius University in Bratislava, Bratislava, Slovakia DOI: 10.1111/jsm.12676
ABSTRACT
Introduction. Seborrheic keratoses are very common benign epidermal tumors. Despite the high frequency, the pathogenesis is still unknown. They are extremely rare in the genital area. The participation of human papilloma viruses (HPVs) in pathogenesis of seborrheic keratoses is being discussed. Aims. The aims of this case report are to inform about extremely rare lesion in genital area in a young man and evaluate the association of HPVs in the development of seborrheic keratoses. Methods. We used histopathological examination to establish the correct diagnosis, which revealed signs of seborrheic keratosis. The real-time polymerase chain reaction method confirmed low-risk HPV 6 from the lesions. Main Outcome Measures. HPVs may play a role in pathogenesis of seborrheic keratoses. Results. The patient was successfully treated with shave excision under spinal anesthesia. Six-month follow-up was without any recurrence. We suggest that HPVs can be considered as etiologic factor in creation of seborrheic keratosis. Conclusions. Seborrheic keratoses are very common on sun-exposed skin, but they are rare in the genital area, such as on the shaft of penis. This localization may lead to misdiagnosis. Seborrheic keratoses in genital area might negatively influence the sexual life of the patient. Containing HPV 6 low-risk virus, they never lead to malignant transformation. Part M, Švecová D, Brezová D, and Breza J. Giant seborrheic keratoses on penis. J Sex Med 2014;11:3119–3122. Key Words. Seborrheic Keratoses; Penis; Low-Risk HPV 6; RT-PCR Method; Dermatologic Lesions of the Penis
Introduction
S
eborrheic keratoses are very common benign epidermal tumors. They usually occur in patients over 50 years of age [1]. Despite the high frequency, the pathogenesis is still unknown. Sun exposure, skin phototype I and II, and family predisposition are considered as risk factors. Seborrheic keratoses are more prevalent in individuals with skin phototype I and II. The participation of human papilloma viruses (HPVs) in pathogenesis of seborrheic keratoses is being discussed [2]. Sunexposed skin of face and trunk are common site for seborrheic keratoses; however, in genital area, especially on penis, they are extremely rare [3]. Due to the localization in the genital region, the specialists might misdiagnose the lesion as condy© 2014 International Society for Sexual Medicine
loma acuminatum. A careful histopathological examination is essential to establish the correct diagnosis [4]. Aims
The aims of this case report are to inform about extremely rare lesion in genital area in a young man and evaluate the association HPVs in the development of seborrheic keratoses. Methods
A 33-year-old man presented to department with giant masses on the base of the penis shaft (Figure 1). The disease started 8 years ago with a J Sex Med 2014;11:3119–3122
3120
Part et al. pathologically using hematoxylin-eosin staining. Microscopically, the lesions appeared as basal cell papilloma with typical papillary structure and keratin pearls composed of small slightly elongated epithelial cells with accumulation of the brown pigment melanin accumulation in cytoplasm (Figure 2). Low-risk HPV 6 was identified from excised sample using RT-PCR method. Wounds after excision healed per secundam without skin flaps. No recurrence was observed during 6-month follow-up.
Conclusions Figure 1 Seborrheic keratoses on the base and shaft of penis
small brown papule on the base of penis. The papule gradually increased in size and number resembling mainly condylomata acuminata and to a lesser extent seborrheic keratoses. The patient was healthy and did not suffer from any immunosuppresive conditions. The lesions were painless and dry without any fetor. Regarding the epidemiological history, both of couple said to live in straight monogamy without any sexual promiscuity in both of married couple. Examination on human immunodeficiency virus, syphilis, hepatitis B, and hepatitis C proved negative. Physical examination revealed one large lesion on the base of penis and numerous small lesions on the penis shaft. The lesions were 10 × 8 cm and 1–4 cm in size. All lesions were of brown color and well demarcated with papillomatous and verrucous surface. The patient was deeply frustrated because of the absence of sexual intercourse with his wife for several years after manifestation of the lesions. His wife was free of symptoms confirmed by gynecologic examination. We used histopathological examination to establish the correct diagnosis and real-time polymerase chain reaction (RT-PCR) method to evaluate the presence of HPV in the lesion.
Seborrheic keratoses are very common epidermal tumors of benign origin. They can occur on various cutaneous location, mainly on the sunexposed skin of trunk and face. The palms and soles are never affected, the genital region only very rarely. Seborrheic keratoses mostly affect people over 50 years of age, whereas young individuals are affected very rarely [1,3,4]. Despite the high number of cases of seborrheic keratoses, the pathogenesis is still not completely understood [2]. Some authors believe in genetic predisposition and somatic mutations of particular genes, which lead to the formation of seborrheic keratoses after sun exposure. It is not exactly known which molecular or functional mechanism is responsible for pathological changes leading to seborrheic keratoses [2]. It has been suggested that HPVs could play role in the pathogenesis of seborrheic keratosis. The causal relationship is controversial. Tardío et al. [5] studied the relationship
Main Outcome Measures
Low-risk HPV 6 was identified from excised sample using RT-PCR method. Results
The patient underwent shave excision under spinal anesthesia. The diagnosis was confirmed histoJ Sex Med 2014;11:3119–3122
Figure 2 Histopathologic picture: basal cell papilloma (hematoxylin and eosin staining)
3121
Seborrheic Keratoses on Penis with Low-Risk HPV 6 between genital and nongenital seborrheic keratoses and HPVs. They confirmed HPVs in 70% of seborrheic keratoses in genital area, whereas in nongenital area, it was only in 5% of cases [5]. The HPV infection can be acquired during sexual intercourse and can lead to development of seborrheic keratoses, especially in young individuals [5]. On one hand, it can be only the accessory contamination of the surface. Association of seborrheic keratoses and skin neoplasm (basalioma, malignant melanoma, etc) was documented in several studies [2]. On the other hand, seborrheic keratoses can be associated with malignancy of internal organs. Most frequently, eruptive seborrheic keratoses are associated with adenocarcinoma [2,6]. The diagnosis of seborrheic keratoses can be sometimes challenging, especially in young individuals with lesions in the genital region, particularly on the penis shaft, and it may be misdiagnosed as condyloma acuminatum. The histopathological examination is used to confirm the diagnosis. The typical histopathological findings include acanthosis, papillomatosis, hyperkeratosis, horn cysts, and pseudocysts. There are several histopathological subtypes which can overlap including acanthotic, hyperkeratotic, adenoid, clonal, Bowenoid, and irritated subtype and melanoacanthoma [7]. The treatment of seborrheic keratoses is not mandatory, given the benign origin of the disorder. The most common treatment modality is cryotherapy with nitrogen liquid, curettage, laser or surgical shave, and other ablative methods. Some studies show good efficacy of topical administration of vitamin D and tazarotene which result in the induction of keratinocytes apoptosis [8,9]. Patients with multiple lesions have to be examined to exclude malignancy of internal organs, especially in eruptive type of seborrheic keratoses. Seborrheic keratoses are very common especially in elderly patients on sun-exposed skin, and they are rare in the genital area, such as on the shaft of penis. This localization may lead to misdiagnosis. Sexually transmitted infections and a wide range of noninfectious diseases affecting genital area, such as pearly penile papules, Status Fordyce, psoriasis, etc, should be considered in the differential diagnostic process [10,11]. In general, all patients suffering from dermatologic problems in genitals are at risk of developing psychiatric disorders, depression, anxiety, and sexual dysfunction [11,12]. Seborrheic keratoses in genital area might also negatively influence the sexual life of the patient.
Containing HPV 6 low-risk virus, they never lead to malignant transformation. Corresponding Author: Martina Part, MD, Faculty of Medicine, Department of Dermatovenerology, Comenius University in Bratislava, Mickiewiczova 13, Bratislava, Slovakia. Tel: 00421 2 5729 0407; Fax: 00421 2 5729 0534; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest.
Statement of Authorship
Category 1 (a) Conception and Design Martina Part (b) Acquisition of Data Martina Part; Daniela Brezová; Ján Breza (c) Analysis and Interpretation of Data Martina Part
Category 2 (a) Drafting the Article Martina Part (b) Revising It for Intellectual Content Danka Švecová
Category 3 (a) Final Approval of the Completed Article Martina Part; Danka Švecová; Daniela Brezová; Ján Breza
References 1 Livaoglu M, Karacal N, Gücer H, Arvas L. Giant genital seborrheic keratosis. Dermatol Surg 2007;33:1357–8. 2 Hafner C, Vogt T. Seborrheic keratosis. J Dtsch Dermatol Ges 2008;8:664–77. 3 Thakur JS, Thakur A, Chauhan CGS, Diwana AK, Chauhan DC. Giant pedunculated seborrheic keratosis of penis. Indian J Dermatol 2008;53:37–8. 4 El Amrani F, Meknassi I, Bouaddi M, Raffas W, Kettani F, Senouci K, Hassam B. Giant keratosis in an unusual site. Ann Dermatol Venereol 2012;139:723–6. 5 Tardío JC, Bancalari E, Moreno A, Martín-Fragueiro LM. Genital seborrheic keratoses are human papillomavirus-related lesions. A linear array genotyping test study. APMIS 2012;120:477–83. 6 Noiles K, Vender R. Are all seborrheic keratoses benign? Review of the typical lesion and its variants. J Cutan Med Surg 2008;12:203–10. 7 Amyia KN, Rashmi K, Gajesh G, Devinder MT, Debdatta B. Giant seborrheic keratosis of the genitalia. Indian J Dermatol 2012;57:310–2. 8 Mitsuhashi Y, Kawaguchi M, Hozumi Y, Kondo S. Topical vitamin D3 is effective in treating senile warts possibly by inducing apoptosis. J Dermatol 2005;32:420–3.
J Sex Med 2014;11:3119–3122
3122 9 Herron MD, Bowen AR, Krueger GG. Seborrheic keratoses: A study comparing the standard cryosurgery with topical calcipotriene, topical tazarotene and topical imiquimod. Int J Dermatol 2004;43:300–2. 10 Rodrigo-Nicolás B, Armengot-Carbó M, Gimeno Carpio E. Papules on genitals: Always an infectious disease? J Sex Med 2013;10:616–7.
J Sex Med 2014;11:3119–3122
Part et al. 11 Chen YJ, Chen CC, Lin MW, Chen TJ, Li CY, Hwang CY, Chu SY, Lee DD, Chang YT, Wang WJ, Liu HN. Increased risk of sexual dysfunction in male patients with psoriasis: A nationwide population-based follow-up study. J Sex Med 2013;10:1212–8. 12 Kucukunal A, Altunay IK, Mercan S. Sexual dysfunction in men suffering from genital warts. J Sex Med 2013;10:1585–91.
