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Chapter 10: Nonulcerative Genital Lesions

Cutaneous genital lesions can, in general, be classified as ulcerative or nonulcerative. Nonulcerative genital lesions are often caused by sexually transmitted infections such as scabies, human papillomavirus (HPV), and molluscum contagiosum. Candida albicans and other fungi, such as dermatophytes, also cause genital skin lesions. However, many nonvenereal dermatologic conditions can also involve the genitalia. In order to effectively treat the patient and control transmission of infections, the clinician must accurately distinguish one type of lesion from another.

Characteristics of the most common nonulcerative genital skin lesions are presented in Table 10-1. A careful medical history should include questions about systemic disease, family history, and use of systemic or local drugs.

Among the most important features to consider in distinguishing various nonulcerative skin lesions of the genitalia are:

  1. the appearance and distribution of the lesions,
  2. whether lesions are seen in nongenital areas,
  3. whether the lesion is pruritic or nonpruritic, and
  4. the duration of the lesions.

Diagnostic tests, where available, should be done as indicated in Table 10-1. Response to therapy sometimes must be used as a means of establishing the diagnosis.

ANOGENITAL WARTS (CONDYLOMATA ACUMINATA)

Image 10-1. Rectal Condyloma acuminata
Image 1.
Rectal condyloma acuminatum (HPV infection)
Image 10-2. Condylomata accuminata (warts) Image 2.
Condyloma acuminatum (warts)

Diagnosis

The typical "cauliflower" lesions of genital warts usually involve the external genitals, perineum, or perianal area. "Flat" condylomata of the cervix are documented by colposcopy or cervical cytology. Images 1 and 2 depict typical images for rectal and penile warts.

Treatment

The goal of therapy for genital warts is to reduce the amount of HPV and improve the cosmetic appearance. In general, topical therapies (liquid nitrogen, podophyllin, podophyllotoxin, imiquimod and trichloroacetic acid) are associated with 60 to 80% response rates and approximately 30% will have a recurrence due to persistent HPV. Patients need to be counseled about realistic expectations for treatment efficacy. Laser therapy and surgical excision can be considered for extensive warts.

Table 10-1
Common Nonulcerative Genital Skin Lesions – Venereal
DISEASE APPEARANCE GENITAL DISTRIBUTION ITCHING TIME COURSE DIAGNOSTIC TEST TREATMENT OTHER
Scabies Red, linear, excoriated areas, often with papules, pustules, and burrows External genitalia, often on finger webs, thighs, lower abdomen, buttocks Marked, often worse at night or in a warm room Days Demonstration of mite in burrow on skin scraping permethrin 5% cream or ivermectin orally Launder sheets and clothes; treat other sex partners or household contacts simultaneously
Pediculosis Pubis Lice or nits on pubic hair; irritated reddish skin underneath Pubic hair Marked Days Demonstration of lice or nits permethrin 1% cream, pyrethrins with piperonl butoxide As for scabies
Genital Warts (HPV) Ranges from flat- topped to verrucous, to frond-like, elevated, well- demarcated lesions Around glans, distal penis; intraurethral in men; introitus and vagina in women; perirectal Mild or none Weeks to months Clinical, can be confirmed by biopsy Podophyllin, imiquimod, TCA/BCA, liquid nitrogen, resection, May recur if not treated adequately
Candida Flat, reddish- brown, well demarcated, slightly scaly lesions; often satellite lesions Glans and under foreskin in men; vulva in women; occasional perirectal lesions Moderate to marked Days KOH prep shows budding yeasts and pseudohyphae Clotrimazole or miconazole, fluconazole Partner should be treated if symptomatic
Molluscum Contagiosum Pearly-white papular, smooth- surfaced umbilicated papules Anywhere on genitalia Minimal Weeks None; may be able to express a discharge from the central core Curettage, liquid nitrogen, electrodessication, keratolytic paints Often become superinfected, particularly if manipulated; often multiple lesions in genital and nongenital areas. STD exam of contacts
Secondary Syphilis* Condyloma lata (moist, red, raised wheal-like lesions) or mucous patches (reddish ulcers with a violaceous border) Vagina, vulva, penis, scrotum, perirectal area Minimal Weeks Positive VDRL or RPR with confirmatory MHA or FTA and darkfield See Appendix A Evaluation and treatment of sexual partners critical

* Obtain RPR for all patients with atypical warts or undiagnosed rash.


Table 10-1
Common Nonulcerative Genital Skin Lesions – Non-venereal
DISEASE APPEARANCE GENITAL DISTRIBUTION ITCHING TIME COURSE DIAGNOSTIC TEST TREATMENT OTHER
Lichen Planus Annular, polygonal, flat- topped, violaceous lesion; mild scaling Single or multiple, usually on penile shaft or glans Mild to moderate Days Biopsy Symptomatic topical steroids may be beneficial History of previous similar lesions; lesion on non-genital area
Psoriasis Well-demarcated papulosquamous plaques with silver scale; usually bleeds if scale removed Penile shaft, scrotum, perirectal Moderate Days to weeks, may wax and wane None Dependent upon severity of disease; refer to dermatologist Usually has psoriatic lesions elsewhere (elbows, knees, lower back); history of episodic lesions; may have pitted nails
Fixed Drug Eruption Erythematous, well-demarcated "burn-like" area, may evolve from erythema to vesicles or blebs Any part of genitalia, but glans and penile shaft most common in men; labia in women Moderate Days, sudden onset None None or topical steroids in severe cases. Avoid drug usage. Often hx of previous similar reaction in same location; may have nongenital lesions; hx of new drug within 10 d of onset; usually recurrences occur with taking the drug; most common with sulfa, barbiturates, tetracycline
Superficial Mycoses Brawny red; well-marginated, often scaling Medial thighs, scrotum, in gluteal folds, usually symmetrical Moderate to marked Weeks KOH prep, culture Topical tinactin, miconazole, or oral azole Often foot lesions also; worse in hot, humid weather or under occlusive clothing
Deep Mycoses Sharply marginated, indurated, often raised, irregular, verrucous lesions; may ulcerate Scrotum and penile shaft in men; external genital lesions rare in women Minimal Weeks, months KOH test, culture, biopsy Dependent upon type of fungus May have nongenital skin lesions or visceral lesions also
Carcinoma Sharply demarcated, variegated, firm, raised, irregular Any part of external genitalia Minimal Weeks to months Biopsy Dependent upon type of carcinoma, usually surgical May have firm, hard, regional lymph nodes; may have systemic signs of weight loss, weakness, etc.
Reactive Arthritis (Reiter's Syndrome) Multiple inflamed, tender, elevated, moist papules Lesions characteristically around the glans penis; circinate balanitis Moderate Days None Same as psoriasis May be associated with arthritis, conjunctivitis, and pustular or hyperkeratotic skin lesions on the soles of the feet
Trauma Superficial abrasion Areas of friction or trauma Mild Days None None Prevent bacterial superinfection

Liquid nitrogen

  • Freeze each lesion twice for 10 to 15 seconds. Vary the length of freezing in future treatments based on the individual's therapeutic response.
  • Allow time for thawing between each application.
  • Usually requires at least 3 to 4 weekly or biweekly treatments.

External genital warts

Recommended Treatments

For a more detailed discussion of these regimens and other treatment considerations, please refer to the CDC STD Treatment Guidelines at http://www.cdc.gov/std/treatment/

Patient-applied

Any of the following:

  • Podofilox 0.5% solution or gel: Patients may apply podofilox solution with a cotton swab, or podofilox gel with a finger, to visible genital warts twice as day for 3 days, followed by 4 days of no therapy. This cycle may be repeated as necessary for a total of four cycles. The total wart area treated should not exceed 10 cm2, and a total volume of podofilox should not exceed 0.5 mL per day. If possible, the health-care provider should apply the initial treatment to demonstrate the proper application technique and identify which warts should be treated. The safety of podofilox during pregnancy has not been established.
  • Imiquimod 5% cream: Patients should apply imiquimod cream with a finger at bedtime, three times a week for as long as 16 weeks. The treatment area should be washed with mild soap and water 6-10 hours after the application. Some experts recommend the use of daily applications in men with warts on dry areas of skin. The safety of imiquimod during pregnancy has not been established.
  • Sinecatechin ointment.  Patients should apply sinecatechin ointment, a green-tea extract, three times daily (0.5-cm strand of ointment to each wart) using a finger to ensure coverage with a thin layer of ointment until complete clearance of warts.  It should not be used for longer than 16 weeks.  Sexual activity (i.e. genital, anal or oral) ought to be avoided while the ointment is being used.  Moreover, for enhanced efficacy, it should not be washed off following application.   The most common side effects of sinecatechins 15% are erythema, pruritis/burning, pain, ulceration, edema, induration, and vesicular rash.  Providers should counsel patients that this ointment may weaken condoms and diaphragms. No clinical data are available regarding the efficacy or safety of sinecatechins compared with other available wart treatments The medication is not recommended for HIV-infected persons, immunocompromised persons, or persons with clinical genital herpes because the safety and efficacy of therapy in these settings has not been established. The safety of sinecatechins during pregnancy also is unknown.
Provider-administered

Any of the following:

  • Cryotherapy with liquid nitrogen or cryoprobe: Repeat applications every 1 to 2 weeks.
  • Podophyllin resin 10-25% in compound tincture of benzoin. A small amount should be applied to each wart and allowed to air dry. To avoid the possibility of complications associated with systemic absorption and toxicity, the application should be limited to 0.5 mL of podophyllin or   <10 cm2 of warts per session. The preparation should be thoroughly washed off 1-4 hours after application to reduce local irritation. Repeat weekly if necessary. The safety of podophyllin during pregnancy has not been established.
  • Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90%: Apply a small amount only to warts and allow to dry, at which time a white “frosting” develops; powder with talc, sodium bicarbonate (i.e., baking soda), liquid soap preparations to remove unreacted acid if an excess amount is applied. Repeat weekly if necessary.
  • Surgical removal: either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.
Alternative Treatments

Either of the following:

  • Intralesional Interferon
  • Laser Surgery

Vaginal or cervical warts

Women with vaginal or cervical warts should have a Pap smear and should be examined by an experienced colposcopist. Treatment of vaginal or cervical warts is complicated and should be carried out in consultation with an expert.

Current therapies include:

  • Cryotherapy with liquid nitrogen. The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation.
  • TCA or BCA 80-90% applied only to warts. Apply a small amount only to warts and allow to dry, at which time a white "frosting" develops; powder with talc or sodium bicarbonate (i.e., baking soda) to remove unreacted acid if an excess amount is applied. Repeat weekly if necessary.

Urethral meatal warts

Small warts (4 mm) which can be visualized in their entirety (i.e., mucosal attachment clearly visible). Current therapies include:

  • Cryotherapy with liquid nitrogen
  • Podophyllin 10-25% in compound tincture of benzoin. The treatment area must be dry before contact with podophyllin. Repeat weekly if necessary. The safety of podophyllin during pregnancy has not been established.

Anal warts

Any of the following:

  • Cryotherapy with liquid nitrogen
  • TCA or BCA 80-90% applied to warts. Apply a small amount only to warts and allow to dry, at which time a white "frosting" develops; powder with talc or sodium bicarbonate (i.e., baking soda) to remove unreacted acid if an excess amount is applied. Repeat weekly if necessary.
  • Surgical removal.
  • Note: Management of warts on rectal mucosa should be referred to an expert.

Oral warts

Either of the following:

  • Cryotherapy with liquid nitrogen.
  • Surgical removal.

Follow-up

Retreat once or twice weekly until visible warts resolved.

  • Vulvar or perianal warts: Internal reexamination (vaginal speculum or anoscope) should be done at all follow-up treatments.
  • Extensive warts, "flat" cervical condylomata (including wart diagnosis by Pap test), and warts not responding to the above measures over 3 to 4 weeks: Refer to an appropriate specialist (gynecologist, dermatologist, proctologist, or urologist) for possible surgical excision, CO2 laser therapy, or other treatment.

Management of Contacts

  • Routine STD examination for all contacts, including cervical cytology for female partners.
  • Condom use is advisable; however, some patients in stable monogamous relationships choose not to use condoms.

Sequelae

Multiple HPV types, including 16 and 18, as well as types 31, 33, and 35 have been associated with cervical and anal dysplasia and carcinomas.

MOLLUSCUM CONTAGIOSUM

Diagnosis

Typical firm, small (1-5 mm), pink fleshy papules, often umbilicated; firm white "pearl" expressed on compression, usually followed by brisk bleeding. Image 3 depicts typical appearance of molluscum contagiosum.

Image 10-3. Lesions of molluscum contagiosum
Image 3.
Lesions of molluscum contagiosum

Treatment

For a more detailed discussion of these regimens and other treatment considerations, please refer to the CDC Guidelines at http://www.cdc.gov/ncidod/dvrd/molluscum/clinical_overview.htm

  • Unroof lesions with a needle.
  • Express the central material.
  • Liquid nitrogen therapy may be effective for small lesions.

Follow-up

  • PRN for recurrences

Management of Contacts

  • Routine STD examination

PEDICULOSIS PUBIS

Diagnosis

Typical Phthirus pubis organisms or their nits are found usually in pubic hair; they may be seen on hairs of the thighs, trunk, eyelashes, eyebrows, and scalp occasionally.

Treatment

For a more detailed discussion of these regimens and other treatment considerations, please refer to the CDC STD Treatment Guidelines at http://www.cdc.gov/std/treatment/

Any of the following:

  • Permethrin 1% creme rinse applied to affected areas and washed off after 10 minutes.
  • Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes.

Follow-up

PRN for recurrences

Management of Contacts

  • Routine STD examination
  • Treat all regular sexual partners and other household members.
  • Contaminated clothing and bedding should be machine washed and dried or removed from body contact for at least 72 hours.

SCABIES

Diagnosis

Clinical

Intensely pruritic papular or excoriated erythematous skin lesions which are occasionally serpiginous are seen clinically. The predominant sites classically include finger webs, wrists, elbows, axillary folds, the trunk (especially at the belt line), gluteal folds, and inguinal areas, but any site may be involved, including the penis, scrotum, and labia majora. Atypical lesions and locations occur frequently.

Image 10-4. Rash due to scabies infestation
Image 4.
Rash due to scabies infestation
Image 10-5. Sarcoptes scabiei and Phthiris pubis, each in an oil prep slide
Image 5.
Sarcoptes scabiei and Phthiris pubis, each in an oil prep slide

Laboratory

  • Obtain scrapings of a "fresh" papule by excoriating the lesions with a scalpel blade, attempting to avoid causing the papule to bleed.
  • Transfer the scraping to a slide.
  • Apply a drop of oil and a coverslip.
  • Examine microscopically.

Demonstration of the scabies mite or typical fecal pellets confirms the diagnosis.

Treatment

For a more detailed discussion of these regimens and other treatment considerations, please refer to the CDC STD Treatment Guidelines at http://www.cdc.gov/std/treatment/

Recommended regimen

  • Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8-14 hours.
  • Ivermectin in 2 doses of 200µg/kg orally separated by 2 weeks

Alternative regimens

  • Lindane (1%) 1 oz. of lotion or 30 g of cream applied thinly to all areas of the body from the neck down and thoroughly washed off after 8 hours.

Re-treatment is recommended if symptoms still present after 1-2 weeks and live mites are present. Launder clothes, bed sheets, etc.

Follow-up

PRN for recurrences

Management of Contacts

  • Routine STD examination
  • Treat all regular sexual partners and other household members.

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