STD Grand Rounds: Genital Dermatology
Question and Answer Summary
The Q and A summary for the March 9, 2000 satellite
broadcast "STD Grand
Rounds: Genital Dermatology" is posted below. This Q and
A summary is also available on
CDC's faxback system -(888) 232-3299; document #
Produced by the New York State Centers for
STD/HIV Prevention Training in collaboration with the
STD/HIV Prevention Training Center of New England.
The following responses provide general information.
They should not be interpreted as diagnostic or treatment
recommendations for specific cases.
Question 1: What can cause hairline
fissures near the hood of the clitoris or introitus? What
can be used to treat these areas?
Answer: In the presence of fissures it
would be important to rule out trauma, HSV and candida with
this clinical presentation. Treatment would obviously be
dependent upon the cause.
Question 2: Is an RPR needed for
all cases of pityriasis rosea? I was taught that if a
patient has negative adenopathy in axilla and groin and no
lesions on the palms and soles and no significant risk
factors then an RPR/VDRL is not needed.
Answer: Although syphilis cases have
reached an all time low in the United States, pityriasis
rosea remains indistinguishable from secondary syphilis. It
is important to remember, most, but not all secondary
syphilis cases will present with generalized adenopathy or a
macular papular eruption on the palms and/or soles. Other
signs of secondary syphilis include: mucous patches,
condyloma lata, constitutional symptoms and alopecia. An RPR
is an inexpensive, easy, and readily available means of
excluding early syphilis in any patient at risk.
Question 3: I recently saw a
young woman in my clinic who had a 3-year history of
recurring genital lesions, which she describes as usually
singular, non-painful but itchy lesions, which occur around
the time of her menses. She denies history of oral ulcers.
She has had two negative HSV cultures. On examination I
found a singular moist ulceration and felt certain it was
HSV, however, the culture result was once again negative. I
plan to do an HSV antibody test next. Given this history, if
the antibody test is negative, do I assume that this is an
aphthous ulcer or are there other diagnostic tests? Can this
condition have the typical HSV recurrence pattern? How
concerned should I be about a Behcet's disease diagnosis in
someone with aphthous ulcers?
Answer: This patient certainly has a
history consistent with herpetic outbreaks. It would be
important to know when the herpes cultures were performed
and how old the lesions were because the sensitivity of an
HSV culture dramatically decreases with the age of the
lesion. An antibody test would be very helpful if the result
was negative. If it is positive, it does not add much
definitive information as to the cause of the ulcers. With a
recurring genital ulcer in the same area it would also be
important to ask what medications and/or foods she is
consuming at the time of these occurrences. A fixed drug
eruption may be one diagnosis to consider with
acetaminophen, aspirin, salicylates, tetracyclines,
sulfonamides, oral contraceptives, metronidazole, NSAIDs,
penicillins, phenolphthalein and phenothiazides being
implicated most often. ---- Another important question would
be to ask the patient what, if any, cleaning methods of the
genitals this patient employs? For example, does she utilize
any soaps or topically applied products and what
types are used? Consideration should be given to a biopsy
if all results are negative. ---- Behcet's disease is
characterized by oral and genital ulcers (aphthous major),
and ocular inflammation. A history of uveitis, skin rashes,
arthritis, thrombophlebitis, gastrointestinal symptoms,
psychiatric problems and neurological symptoms would also be
important information to elicit. One distinguishing
characteristic with this patient is the absence of oral
ulcers, which occur essentially in all patients with
disease. This patient may indeed have a recurrent aphthous
ulcer in the absence of Behcet=s
disease. A Rheumatology consult may also be helpful.
Question 4: Are skin tags on the
penis shaft a common finding? How can they be differentiated
from HPV and/or Molluscum Contagiosum?
Answer: It is very difficult to
definitively differentiate HPV from a skin tag without a
biopsy. A biopsy is indicated if the diagnosis is uncertain,
the lesions do not respond to standard therapy, the patient
is immunocompromised, or warts are pigmented, indurated,
fixed and ulcerated. In the presence of a skin tag and/or
HPV you would not find the molluscum body or core, after
opening the lesion via skin curette. Direct microscopic
examination of this central semisolid core reveals these
entities easily via light microscopy.
Question 5: What would the
differential be for a blue, bruised like area found between
the vagina and anus?
and pigmented nevi would be high in the differential,
however, a more detailed history and description of the
lesion is needed. Such as, the length of time the lesion has
been present. Is the lesion, raised, flat, indurated, or
scaly? Has there been any recent trauma? Is it tender,
Question 6: Other than
antibiotics, what are the other (long-term) treatments for a
patient suffering from furunculosis of the genitalia?
Answer: Antibiotics, topical and oral,
are certainly the mainstay of treatment for recurrent
folliculitis/furuncles in the groin. In addition,
keratolylitics such as salicylic acid or benzoyl peroxide
may be helpful. But, you must be cautious concerning
irritation in the groin. In severe or recalcitrant disease,
systemic retinoids can be used in medically appropriate
patients. Obese patients may gain some benefit from weight
Question 7: Does hypopigmentation
have to be biopsied? Is there any treatment for vitiligo or
post-HSV hypopigmentation? Are there symptoms besides visual
discoloration? If you didn=t
biopsy what could you be missing that would be serious?
hypopigmentation and vitiligo account for the majority of
cases of genital hypopigmentation. The history (e.g., recent
outbreak or treatment procedure in the area) as well as
physical examination findings often establish the diagnosis
without biopsy. In the absence of epidermal surface changes
(e.g., scaling, hyperplasia, erythema) or dermal alterations
(e.g., induration, atrophy) little else enters the
differential. A variant of cutaneous T-cell lymphoma can
present as hypopigmented macules/patches and represents an
example of a serious condition that would require a biopsy
for the diagnosis. It would, however, be unusual for its
sole presentation to be in the genitals. Any time the
diagnosis is uncertain, a biopsy is the correct thing to do.
Post-inflammatory hypopigmentation usually improves with
time. Low potency topical corticosteroids (e.g.,
hydrocortisone or desonide) have been beneficial in some
patients with vitiligo (and acute post-inflammatory
hypopigmentation). Caution should be stressed as striae are
a possible adverse effect of corticosteroid application in
Question 8: What management have
you found effective for the treatment of pubic hair
Answer: Many of the
points discussed for furuncles also apply for patients with
pubic hair folliculitis. More often these are acute
outbreaks and oral antibiotics are the treatment of choice.
In addition, intralesional corticosteroids (usually
triamcinolone acetonide 2-5 mg/cc) can be helpful to speed
up the resolution of individual lesions. Patients with more
chronic or recurrent pubic hair folliculitis should use an
antibacterial soap when showering, for prophylaxis, as well
as chronically apply a topical antibiotic.
Question 9: Other than testosterone
cream, what else can be used in the treatment of lichen
steroid preparations can be used to treat lichen sclerosis.
In particular, Clobetasol Propionate 0.05 percent is the
treatment of choice. This is applied to the affected skin
once daily, usually at night, until there is an improvement,
after which the frequency can be gradually reduced. A 30
gram tube should last three months, but considerably less is
required once the disease is under control. Ointments are
more effective than creams. There seems to be less contact
dermatitis with the ointment formulation. --- Despite the
high incidence of lichen sclerosis at the time of menopause,
and the apparent improvement in pregnancy, both systemic and
topical exogenous estrogens are ineffective in the treatment
of lichen sclerosis. A soap substitute, such as an aqueous
cream, is a useful adjunct treatment. ---- The fluorinated
high-potency creams can increase vulvar atrophy over time.
Clearly, there will be some systemic absorption from steroid
creams and, therefore, I would recommend that they be used
intermittently as opposed to chronically. ----- Finally, a
word of caution, even with a biopsy coming back showing
lichen sclerosis, if you see a lesion that is raised and
discrete, it is very important to excise it. Commonly,
lichen sclerosis can be associated with underlying invasive
cancer. Sometimes this is missed on a biopsy which is only
getting the edge of the lesion. While lichen sclerosis has a
classic look of resorption of the vulvar appendages, a
cancer will appear as an exophytic mass.
Question 10: I have been noticing
an erythematous or pale rash of the vulva/perineum in many
women, who often report a history of using feminine pads or
panty liners. Contact dermatitis is high on the
differential. Is a mild corticosteroid appropriate if
symptomatic, or just avoidance of synthetic material?
Answer: There is an extensive list of
preservatives in these products including formaldehyde. In
the absence of severe symptoms it would be reasonable to
discontinue the offending agent and monitor the recovery.
There are many health food stores and pharmacies that are
now offering 100% cotton and preservative-free products as
alternatives to this increasingly common problem.
Question 11: Is there a
collection procedure available that could be shared with
health departments to assure optimal samples are collected
for Tzanck smears?
state or local Health Department could provide you with a
copy of their protocol. I have included our Standard
Operating Procedure for acquisition of Tzanck smear utilized
by the STD Center for Excellence at Montefiore Medical
Center, (I am sure they are very similar).
Tzanck smears stained by Volu-sol Giemsa (Dif-Quick) or
Wright stain demonstrating multinucleated giant cells due to
REAGENTS AND MATERIALS:
"Stat Stain" -- Distilled/De-ionized Water -- Sodium
Hypochlorite Solution -- Glass slides --Scalpel blades --
SPECIMEN PREPARATION AND
(1) Label the slides with the patient's initials (2)
Select the lesion site (3) Using gloves, cleanse the site
with gauze or swab soaked in water (4) Incise the top of a
vesicle with a sterile scalpel and lightly apply the
specimen to the middle of a glass slide (5) Lightly scrape
the base of the vesicle and apply the lesion material to the
middle of another glass slide. Smear an area about the size
of a U.S. dime, i.e., just enough to be covered by a No. 1
(22 X 22mm) cover slip
(6) Prepare two or more smears if necessary.
a) Crusted Lesions: Remove the crust and prepare
smear of the basal scrapings
b) Erosive Lesions: Lightly scrape and prepare smear
(1) Wearing gloves, carefully add sodium hypochlorite
solution (diluted 1:10) into the disinfectant vessel until
it is one-fourth full (2) Place the labeled (smeared) slides
on the disinfectant vessel (3) Air dry the slides for no
less than five minutes (4) Using the dropper bottle add 2 or
3 drops of stat stain on the smear (or just enough to cover
the smear) and let stand for exactly 20 seconds (5) DO NOT
DRAIN (6) Add an equal number of drops of distilled or
de-ionized water to the staining smears (i.e., dilute 1:1)
and let stand for an additional 10 seconds (7) Pour off
stain/water mixture into the disinfectant and (8) Quickly
wash slides (over the disinfectant) by gently squirting
distilled water (or de-ionized water) via wash "squeeze
(9) Wipe the underside of each slide with an isopropyl
alcohol pad or tissue moistened with 70% isopropyl alcohol
(10) DRAIN DRY over an absorbent surface (DO NOT BLOT).
Question 12: How often does a positive
Tzanck smear turn out to be something other than HSV?
Answer: A positive Tzanck smear almost
always indicates a diagnosis of herpes simplex virus.
However, it is important to remember that other members of
the herpes family can also result in a positive smear,
including: herpes zoster and cytomegalovirus. The clinical
manifestation should help with the diagnosis as will a
culture for confirmation of HSV.
Question 13: Should follow-up
cultures be done on negative Tzanck smear samples if
Answer: Tzanck smears
have a sensitivity of only 50%, and that is highly dependent
upon the age of the lesion, therefore, cultures would be
very helpful in this clinical setting.
Question 14: Assuming that Tzanck
smears are relatively insensitive and that your clinic has a
positivity rate of 10-15%, what could you assume your true
positivity rate to be?
would be important to compare them to your herpes culture
Question 15: How common are ulcers
(genital) with mono? (EBV)
Answer: Although Epstein-Barr virus
is the causative organism in most cases of mononucleosis and
is part of the herpes family of viruses, I could find no
reference to ulcers in the genitalia as presenting symptoms
of this illness.
Question 16: Dr. Gilbert
mentioned seeing 5-6 patients who presented with lesions on
male and female genitalia that contained M. tuberculosis.
Knowing that the common route of transmission of TB is
through the air (with manifestation of TB disease in the
reproductive organs via the bloodstream), has the panel seen
secondary spread of TB through sexual contact? Is it
conceivable that the lesions could erupt and cause localized
infection in the partner?
Primary infection of TB can result from direct inoculation
of the skin. This results in a shallow ulcer with an
irregular base and local lymph node enlargement.
Hematogenous spread from a distant site of TB can also cause
a cutaneous infection, known as lupus vulgoris. Patients
with genital lesions of TB that were seen were quite ill and
were not engaging in sexual activity but may well have
acquired the infection from direct inoculation from
genital TB lesions.
Question 17: What is the cause of
aphthous ulcers, oral or genital?
Answer: Although almost 50% of the
population have developed aphthous ulcers at some point in
their lifetime, the exact etiology remains an enigma. Some
postulated theories include, immunologic, genetic, and
psychological factors. No definitive method of transmission
is currently known.
Question 18: What is the recommended
treatment regimen for aphthous ulcers in patients who are
not HIV infected? Would the same treatment be recommended
for aphthous ulcers of the mouth and genital area?
Answer: Generally small lesions can be
left untreated. If comfort is a concern, topical lidocaine
can be applied several times per day. Topical and systemic
steroids are the treatments most often employed. When ulcers
in the mouth, especially in hard to reach areas, are
present, (i.e: posterior pharynx, uvula), an inhaled,
steroid-metered dose inhaler may be helpful. Instead of
having the patient inhale the medication, ask them to
perform a valsalva maneuver upon releasing the medication,
to concentrate the spray on areas in the back of the throat.
Other treatments with anti-inflammatory properties that have
been used are: tetracyclines, dapsone, cholcicine,
azathioprine and intralesional triamcinalone injections. In
cases where a patient is immunocompromised and the lesions
have not responded to conventional therapy, thalidomide has
Question 19: Was the woman with
Seborrheic Dermatitis of the vulva, HIV+?
Answer: This patient=s
HIV status is unknown.
Question 20: I would like to know your
technique/advice on obtaining samples from lesions for
Darkfield study, such as in condyloma lata with its white
velvety top, and other lesions which cause the lesion to
bleed and render the specimen unsatisfactory.
Answer: The technique for obtaining
samples for Darkfield interpretation requires a fresh
preparation of a lesion in order to view the organism
actively mobile. The test requires much skill and experience
and is recommended only in those places where it is
routinely performed. If the test is deemed unsatisfactory on
a particular day, serial Darkfield on several
may be useful. Below is the protocol we utilize for our
Darkfield specimen acquisition:
NECESSARY EQUIPMENT AND
Microscope with Darkfield condenser -- Frosted end
microscope slides -- Cover glass, size No. 1 (22 x 22 mm
square) -- Microscope immersion oil -- Disposable
bacteriological loop -- Disposable scalpel -- Capillary with
rubber bulb (1 ml capacity) -- Saline (physiologic) --
COLLECTION OF SPECIMENS:
The objective in collecting a specimen for Darkfield
examination is to obtain serous fluid that is rich in
Treponema pallidum and as free as possible of red blood
cells and tissue or other organisms, which may obscure the
treponemes. ----- When collecting specimens follow all the
biohazard precautions. Select the lesion for Darkfield
examination and clean it with a gauze pad or swab moistened
with physiological saline. Remove any scab or crust covering
the lesions. Abrade the lesion with a dry gauze pad to
provoke slight bleeding or use a scalpel. As oozing occurs,
wipe away the red blood cells and await the appearance of
clear serous exudate. Sometimes it is necessary to apply
pressure at the base of the lesion by gently squeezing with
the thumb and index finger to promote the appearance of
serous fluid. ----- For direct examination, apply
clear-cover glasses or slides to the oozing lesion or use
the bacteriological loop to transfer the fluid from the
lesion to glass slides. Flatten the cover glass evenly on
the slide with the blunt end of the applicator stick to
remove air bubbles. Prepare three slides to maximize the
specificity. Use the capillary tube for the collection of
the serum if Darkfield examination of the slide is delayed
>15 minutes. ------ If darkfield examination is negative
on a lesion and you suspect that local therapy is needed,
the physician can collect fluid from the palpable lymph node
using a 20-gauge needle syringe and prepare the slide as
EXAMINATION OF THE SPECIMEN FOR TREPONEMA
(1) Adjust the microscope with the Darkfield condenser
and align it by focusing 4X, 10X, 40X and 100X by centering
the round dark area (2) Place a drop of immersion oil on the
top of the condenser or the bottom of the slide (3) Place
slide on the stage and center specimen over the condenser
with mechanical stage (4) Raise slowly the substage until
there is an oil contact between the top of the condenser and
the bottom of the slide (5) Bring specimen in focus by using
10X objective lens and search the entire specimen
methodically by using high dry (40-45X) objective lens (6)
Search all the slides for the spiral organisms having
morphology and motility characteristic of Treponema pallidum
before making a negative report (7) If a suspected organism
is observed, center it in the field for subsequent
examination with the oil immersion objective (8) Rotate the
objective turret halfway so that a small drop of immersion
oil can be placed on the cover glass and rotate again until
the oil immersion objective is in place over the specimen
and in contact with the oil on the cover glass (9) Examine
the organism carefully for identification; focus with the
fine adjustment knob only (10) If organisms are found that
have the characteristic morphology and motility of T.
pallidum, make a positive report.
CHARACTERISTICS OF T. PALLIDUM:
(a) Delicate spirilliform (corkscrew-shaped) organisms
with an average of 8-14 regular, rigid, tightly wound, deep
spirals (b) Usually 6-14 microns in length, averaging
slightly larger than the diameter of a red blood cell (c)
Very thin, approximately 0.25 - 0.30 microns (d) Spiral
amplitude (distance from the top of one coil to the top of
the next coil) of 1.1 micron (e) Spiral depths (distance
from the top of one coil to the bottom of the same coil) of
0.5 - 1.0 micron (f) Slow rotation about the long axis (like
a corkscrew) and forward and backward movement (g) Coiled
appearance retained despite active motility.
INTERPRETATION OF DARKFIELD:
Presence of single treponemes with characteristic
morphology and motility in Darkfield examinations for T.
pallidums constitutes a positive diagnosis of syphilis in
the Darkfield column of logbook to be reported as
------ If all three slides were negative for T. pallidums,
report in the column of Darkfield as "negative.@
----- Presence of any other spiral, specifically Borrelia
spa. To be reported to clinicians, and the characteristics
are as follows under the Darkfield: Variable number of
loosely wound spiral (3 to 20) -- Variable length of
microns -- Thick and course appearance -- Spiral
amplitude of 2 microns and above -- Extreme flexibility and
frequent relaxation of coils during active motility -- Rapid
movement across or on the field with a twisting motion.
U.S. Department of Health, Education and Welfare:
Darkfield microscopy for the detection and identification
of Treponema pallidum PHS publ. No. 990 Washington D.C.,
U.S. Government Printing Office, 1962.
Question 21: Please provide
clarification and more information on genital warts that may
be congenital? How should these be managed? Please address
counseling and treatment implications.
Answer: Recurrent respiratory
papillomatosis (RRP) is a condition in which papillomata
(benign growths) can occur at sites in the respiratory tract
from the nasal vestibule to the lung. It is often found in
the triad of a first-born child delivered from a woman
vaginally with condyloma. This is not a common occurrence.
Risk seems to be greatest in the presence of clinical rather
than sub-clinical disease at the time of delivery. At
present there is no documented benefit of delivering a child
via C-section in a mother with HPV lesions. Management of
these cases is dependent upon the clinical manifestation of
illness, which often begins, with a history of hoarseness
and upper airway obstruction in varying degrees of severity.
Laryngoscope is often needed. The disease may never recur
once a lesion is removed, may recur at varying intervals,
may distribute to previously non-diseased sites, may undergo
malignant transformation, and rarely, may undergo
spontaneous regression. If your question is asking if
congenital HPV lesions can occur on the skin, anus, genitals
of infants born to women with HPV the answer is yes, and
treatment would be dependent upon the age and area of
Question 22: Please elaborate on
fusospirochetal co-infection of HSV lesions (vulvar, anal),
which was discussed, but I would like to hear it again, plus
more. Answer: HSV infection of the oral
cavity (herpetic gingivostomatitis) was observed in children
who had severe overgrowth with Fusobacterium and Borrelia.
This is reported in an article by Craig Tendler, M.D. and
Edward J. Bottone, Ph.D., entitled "Fusospirochetal
ulcerative gingivitis in children" in The Jl of Pediatrics,
Sept 1987, pp., 400-403. We observed patients with genital
and HSV infections which did not respond to antiviral
therapy for HSV. The patients had co-infection with
fusospirochetes seen on gram stain. Treatment with
penicillin cleared these organisms and rapidly improved the