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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 78-84

A study on clinical patterns of nonvenereal male genital dermatoses at a rural-based tertiary care center


Department of Dermatology and Venereology, Pramukhswami Medical College, Karamsad, Gujarat, India

Date of Submission08-Mar-2020
Date of Decision15-Apr-2020
Date of Acceptance10-May-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Pragya Ashok Nair
Department of Dermatology and Venereology, Pramukhswami Medical College, Karamsad - 388 325, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_60_20

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  Abstract 


Background: All dermatoses affecting genitalia are not sexually transmitted. Wrongly labeling a patient as a case of venereal disease can have great psychosocial implications, apart from the resultant wrong treatment. It is necessary to have detailed knowledge and broader view while approaching genital lesions as it can be a nonvenereal disease. Objectives: The aim was to study the clinical patterns of nonvenereal male genital dermatoses. Materials and Methods: It was a cross-sectional observational study of male patients having nonvenereal genital dermatoses attending the Department of Dermatology for a period of 1 year from June 2016 to May 2017. Male patients with genital lesions were included in the study after taking their written consent in vernacular language. A detailed history and examination was carried out according to a prestructured pro forma. Investigations were done as and when required. Patients diagnosed with sexually transmitted disease were excluded from the study. Results: The study included 200 male patients having forty different nonvenereal genital dermatoses. Most patients belong to the age group of 19–40 years (46%), with a mean age of 36.47 years. Most of them were students (32%), were graduate (38.5%), and belonged to middle socioeconomic class (60.5%). Sixty percent of the patients were married. Common dermatoses encountered were scabies (27 [13.5%]), dermatophytoses (19 [9.5%]), scrotal dermatitis (16 [8%]), lichen planus (15 [7.5%]), vitiligo (12 [6%]), and psoriasis and pearly penile papules each with 10 (5%) cases. Other rare dermatoses were median raphe cyst, genital lentigenosis, granuloma annulare, nevus, cutaneous tuberculosis, and lichen sclerosus. Conclusions: Scabies was the most common nonvenereal genital dermatosis found in this study.

Keywords: Genital dermatoses, nonvenereal diseases, scabies, zoon's balanitis


How to cite this article:
Singhal RR, Nair PA. A study on clinical patterns of nonvenereal male genital dermatoses at a rural-based tertiary care center. Clin Dermatol Rev 2021;5:78-84

How to cite this URL:
Singhal RR, Nair PA. A study on clinical patterns of nonvenereal male genital dermatoses at a rural-based tertiary care center. Clin Dermatol Rev [serial online] 2021 [cited 2021 Feb 28];5:78-84. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/78/309773




  Introduction Top


Male genitalia, being a sexual organ, harbor many sexually transmitted infections (STIs). The external genitalia is a site for various inflammatory diseases which are completely unrelated to sexual transmission, such as psoriasis,[1] and zoon's balanitis which is completely or predominantly confined to this area and yet not sexually transmitted. These all genital dermatoses which are not transmitted sexually are called as nonvenereal genital dermatoses.

Most of the disorders affecting the genitalia are dermatological, modified by anatomical, hormonal, and microbiological influences and have multifactorial etiology than dermatoses of other body sites. There is a peculiar challenge in the management of these disorders as the specialists predominantly treating them are gynecologists, urologists, and genitourinary physicians, who would have little or no training in dermatology.

The present study attempts to know the clinical pattern of nonvenereal genital dermatoses at a rural-based tertiary care center.


  Materials and Methods Top


A cross-sectional observational study was carried out from June 2016 to May 2017 in the department of dermatology, venerology, and leprosy after approval from the ethical committee. All male patients of any age group attending the skin outpatient department with dermatoses involving the genital area with or without involvement of other body sites were consecutively selected. All included patients had given their written consent in vernacular language. Patients with STI were excluded from the study.

A detailed history was taken, and a thorough general, physical, local, and systemic examination was carried out according to a prestructured pro forma. Investigations including potassium hydroxide (KOH) smear, Gram stain, ZN stain, Giemsa stain, Wood's lamp examination, blood tests, Venereal Disease Research Laboratory, HIV, routine urine examination, stool examination, radiographs, and biopsy were done, as and when required. Photographs' were taken after taking patient's consent ensuring that their identity will not be revealed anytime and confidentiality will be maintained at all levels.

Statistical analysis

The descriptive statistics was used to describe the quantitative data. Qualitative data were presented using frequency. All findings were analyzed using STATA (version 14.2, Stata Corporation, Texas, USA).


  Results Top


A total of 200 male patients with nonvenereal dermatoses were included in the study. Demographic details are mentioned in [Table 1]. The age of the patients ranged from less than 1 year to 88 years, with a mean age of 36.47 years. Most patients belonged to the age group of 19–40 years (46%). Maximum patients were graduate 77 (38.5%). Occupation wise, students were the commonly affected group with 64 (32%) cases. According to the Modified Kuppuswami classification,[2] 121 (60.5%) patients belonged to middle socioeconomic class.
Table 1: Demographic profile

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Onset of the disease condition was gradual in 81% of cases, progressive in 23% of cases, while a history of recurrence was seen in 12% of cases. All the patients had lesion over the genitalia with complain of itching in 104 (52%) cases. Maximum patients (52 [26%]) presented with a duration of 10–30 days. Diabetes mellitus (17 [8.5%]) was among the most common precipitating factor [Table 2].
Table 2: Complaints, duration, and precipitating factors

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Penis (88 [44%]) was more commonly involved than scrotum (58 [29%]), with shaft of the penis as the most common site. Site-wise distribution of various common dermatoses is mentioned in [Table 3].
Table 3: Frequency of common dermatoses over different sites of genitalia

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Other body part involvement was present in 79 (39.5%) cases. Nails were involved in 11 (5.5%) patients, scalp in 6 (3%), oral cavity in 9 (4.5%), and lymphadenopathy in 5 (2.5%) cases.

A total of forty different nonvenereal dermatoses were noted in this study. Dermatoses were classified into six groups.[3] The most common group encountered was dermatological disorders affecting the genitalia such as dermatitis and papulosquamous disorders with 78 (39.9%) [Figure 1] followed by non-STIs (70 [35%]) [Figure 2], physiological and developmental variants (29 [14.5%]), lesions peculiar to genitalia (15 [7.5%]) [Figure 3], premalignant and malignant conditions (6 [3.5%]) [Figure 4], and traumatic conditions (2 [1%]). The most common dermatosis was scabies present in 27 (13.5%) cases followed by dermatophytoses in 19 (9.5%) and scrotal dermatitis in 16 (8%) cases [Table 4].
Figure 1: (a and b) Generalized psoriasis involving genitalia

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Figure 2: (a) Epidermodysplasia verruciformis with warts over the ventral aspect of the penis. (b) Vacuolated cells in the upper stratum malphigii and granular layer suggestive of epidermodysplasia verruciformis (H and E, ×40). (c) Papillomatosis with vacuolated cells suggestive of warts (H and E, ×10)

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Figure 3: Zoon's balanitis

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Figure 4: (a) Squamous cell carcinoma over the penis. (b) The section shows pleomorphic, round-to-oval tumor cells with hyperchromatic-to-vesicular nuclei with prominent nucleoli and abundant eosinophilic cytoplasm. Extensive keratin pearl formations and individual cell keratinization are seen (H and E, ×10)

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Table 4: Frequency of different dermatoses

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  Discussion Top


In current clinical practice, there is a tendency to attribute sexually transmitted origin to any pathologic condition involving the genitalia. Wrongly labeling a patient as having a venereal disease can have great psychosocial implications, apart from the resultant wrong treatment.[4] There should be a broader view while approaching genital lesions. One should consider nonvenereal genital dermatoses as important differential.

Nonvenereal genital dermatoses range from infectious etiology to inflammatory and neoplastic conditions. Sometimes, they even pose diagnostic challenge to various specialists by their unusual modified presentation. This study included only male patients, but in few studies of nonvenereal dermatoses which involved both sexes, males outnumbered females.[5],[6],[7] Forty-six percent belonged to the age group of 19–40 years, i.e., middle age group with a mean age of 36.47 years, which was similar to other studies.[5],[6],[7],[8],[9],[10],[11]

Most of the patients (38.5%) were graduate and occupation wise, students were the commonly affected group with 32% followed by servicemen (26%). Laborers (74%) were the most common affected group according to the study done by Karthikeyan et al.[11] In our study, patients were coming from both from rural and urban area, while in other studies, patients especially belonged to urban background.[8],[9],[10] This can be considered as coincidental finding because of common age groups which were affected were not teenagers. (60%) except in Hogade et al.,[8] in which unmarried patients (52%) were slightly more than that of married patients. According to the Modified Kuppuswami classification, 60.5% of patients belonged to middle socioeconomic class, while 39.5% were from lower class and none was from upper class. Talamala et al. also noticed similar status in which half of the patients were from lower class, half from middle, and none was from upper class.[10] This finding may be biased because of the type of setup where poor people are more commonly seen as compared to rich people.

In our study, all patients presented with lesions over the genitalia with the complaint of itching in 52% of cases. Other studies also found itchy genitalia as the most common presenting feature.[5],[6],[7],[8],[9],[10],[11] Similar to our study, Puri et al. and Talamala et al. found penis as the most common site of involvement than scrotum[6],[10] while Hogade et al.,[8] Karthikeyan et al.,[11] and Saraswat et al.[9] showed scrotum as the common site of involvement.

Common dermatoses found in various studies are mentioned in [Table 5]. Scabies was the most common genital dermatosis found in our study with 13.5% of cases. Babu et al. had also labeled scabies as the most common disorder in their study.[5] The age group ranged from 2 to 42 years. Eleven percent of the patients had other body part involvement over finger web spaces, axilla, umbilicus, and thigh area. Based on history, negative spouse history, and other body part involvement, they were considered nonsexually transmitted. Eight percent had a positive family history of scabies. Both scrotum and penis were affected in 6.5% of patients.
Table 5: Comparison of various parameters in different studies

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In this era of resistant dermatophytoses, the trend of genital dermatoses is changing and dermatophytic infection is becoming common nowadays. We reported it as the second most common dermatoses (9.5%), while Shinde et al. found it in 16% of patients. To confirm the diagnosis, we performed potassium hydroxide wet mount in all the cases. Cases involving groin area without genital involvement were found to be more common than that with genital involvement and were excluded from the study. Lichen planus with different morphologies such as annular and erosive lichen planus over the mucosal surface and violaceous papular lesions over the skin surface of genitalia were seen in 7.5% of patients. Pruritus was the prominent feature. Involvement of the oral cavity was seen in 2.5% of cases in contrast to Saraswat et al.[9] who reported oral involvement in 4% of cases. Candidal balanoposthitis secondary to diabetes mellitus was seen in 7% of cases who presented with erythematous plaques with satellite lesions, erosions, fissuring, whitish thrush, and maceration of prepucial skin. One percent of patients had phimosis secondary to candidiasis.

In our study, 6% of patients had vitiligo, out of which 4% had exclusive genital involvement, in 1.5% disease was progressive, and in 0.5% cases, family history was positive. In Saraswat et al., 10% had generalized vitiligo and 8% had exclusive genital involvement.[9] Vitiligo was found as the most common dermatosis in various studies.[8],[9],[10],[11] In our study, vitiligo was present in all the age groups ranging from 13 to 88 years, whereas Karthikeyan et al. found vitiligo patients in older age group.[11]

In our study, 5% of patients had psoriasis involving genital area, of which 4.5% of patients had generalized psoriasis with nail and scalp involvement in 1% of case. Shinde et al. who included both males and females in their study found genital psoriasis in 17% cases, of which only 5% of cases had purely genital lesions.[7] In our study, the age group ranged from 26 to 70 years, while Shinde et al. found age group between 13 and 65 years.[7] Approximately 3%–7% of psoriasis patients present with inverse psoriasis. In inverse psoriasis, genital area is usually involved in up to 79% of the patients.[12] Half of the patients had a history of winter aggravation. One seropositive patient developed erythroderma secondary to psoriasis.

Genital lesion secondary to drug reaction was found in 3.5% of cases. Saraswat et al. found fixed-drug eruptions in 12% of cases as the third most common cause.[9] One patient (0.5%) had developed Stevens Johnson syndrome/toxic epidermal necrolysis (SJS-TEN) due to phenytoin, while Shinde et al. reported 7% of males with SJS due to ingestion of co-trimaxozole, anti-tuberculosis drugs, i.e., ethambutol and pyrizinamide and brufen. Other drug reaction that was found in our study was fixed drug reaction (3%) due to diclofenac, metronidazole, ciprofloxacin, and co-trimoxazole. Karthikeyan et al. and Babu et al. reported similar reaction in three and one patients, respectively, all developed due to cotrimoxazole.[5],[11]

Zoon's balanitis was seen in 3% of patients, all being in the sixth decade and uncircumscribed. Lesions were asymptomatic in nature. Talamala et al.[10] and Saraswat et al.[9] found Zoon's balanitis in 2% of cases each, while Hogade et al.[8] found it in 0.5% of cases. Phimosis was present in 1.5% of patients, with 0.5% being congenital and other 1% case being secondary to diabetes mellitus. Talamala et al.[10] found phimosis in 6% of cases. Paraphimosis was present in 1.5% of patients secondary to first-time sexual intercourse causing friction-induced preputial edema. Talamala et al.[10] found paraphimosis in 2% of cases. One percent patient had traumatic lesions over genitalia.

Penile tumors can be subdivided into benign and malignant lesions. The most important tumor by epidemiology and prognosis is penile cancer. In contrast, malignant melanoma, sarcomas, and lymphomas are rare.[13] Squamous cell carcinoma was present in 0.5% of cases in our study, which was confirmed by histopathology. Pseudoepitheliomatous micaceous-keratotic balanitis was present in 1.5% of cases, and all denied for penectomy and therefore, were not confirmed by histopathological examination. Lichen sclerosus et atrophicus and epidermodysplasia verruciformis each with 0.5% of cases were confirmed by histopathological examination. Other rare dermatoses have been mentioned in Table 5. One of the limitations of the study was that the sample size was not restricted to particular age group of male patients and all male patients with no history of STI were included.


  Conclusion Top


The study is useful in understanding the various clinical patterns and presentation of nonvenereal dermatoses and also helps in knowing the current changing trends with dermatophytic infection evolving as a common nonvenereal genital dermatosis nowadays.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Andreassi L, Bilenchi R. Non-infectious inflammatory genital lesions. Clin Dermatol 2014;32:307-14.  Back to cited text no. 1
    
2.
Shaikh Z, Pathak R. Revised Kuppuswamy and B G Prasad socio-economic scales for 2016. Int J Community Med Public Health 2017;4:997-9.  Back to cited text no. 2
    
3.
Mohanty P, Mohanty L, Nayak S. Nonvenereal male genital lesions: An update. In: Ghosh S, Sarma N, De D, editors. Recent Advances in Dermatology. Vol. 3. New Delhi: Jaypee Brothers Medical Publishers Ltd.; 2014. p. 242-60.  Back to cited text no. 3
    
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Sehgal VN, Pandhi D, Khurana A. Nonspecific genital ulcers. Clin Dermatol 2014;32:259-74.  Back to cited text no. 4
    
5.
Babu AN, Mathan R, Ramasamy PP. A clinical study of non-venereal genital dermatoses. J. Evolution Med Dent Sci 2016;5:6694-7.  Back to cited text no. 5
    
6.
Puri N, Puri A. A study on non venereal genital dermatoses in north India. Our Dermatol Online 2013;4:304-7.  Back to cited text no. 6
    
7.
Shinde G, Popere S. A clinical study of non venereal genital dermatoses of adult in a tertiary care center. Int J Biomed Adv Res 2017;8:168-73.  Back to cited text no. 7
    
8.
Hogade AS, Mishra S. A study of pattern of nonvenereal genital dermatoses of male attending skin OPD of tertiary centre in Kalaburagi. Int J Res Dermatol 2017;3:407-10.  Back to cited text no. 8
    
9.
Saraswat PK, Garg A, Mishra D, Garg S. A study of pattern of nonvenereal genital dermatoses of male attending skin OPD at a tertiary care center. Indian J Sex Transm Dis AIDS 2014;35:129-34.  Back to cited text no. 9
    
10.
Talamala SP, Gummadi P, Vatti GP. A clinical study of patterns of non venereal genital dermatoses of adult males in a tertiary care center. IOSR J Dent Med Sci 2016;15:47-50.  Back to cited text no. 10
    
11.
Karthikeyan KE, Jaishankar TJ, Thappa DM. Non-venereal dermatoses of male genital region-prevalence and pattern in a referral centre in South India. Indian J Dermatol 2001;46:18-22.  Back to cited text no. 11
  [Full text]  
12.
Wang G, Li C, Gao T, Liu Y. Clinical analysis of 48 cases of inverse psoriasis: A hospital-based study. Eur J Dermatol 2005;15:176-8.  Back to cited text no. 12
    
13.
Wollina U, Steinbach F, Verma S, Tchernev G. Penile tumours: A review. J Eur Acad Dermatol Venereol 2014;28:1267-76.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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