Pearly Penile Papules

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Background

Pearly penile papules are small dome-shaped to filiform skin-colored papules that typically are located on the sulcus or corona of the glans penis. Commonly, pearly penile papules are arranged circumferentially in one or several rows and often are assumed wrongly to be transmitted sexually. Pearly penile papules are considered to be a normal variant and are unrelated to sexual activity. Often, lesions cause great anxiety to patients until their benign nature is clarified.

See the images below.



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Pearly penile papules. Courtesy of Wiki Commons



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Pearly penile papules; close-up view. Courtesy of Wiki Commons.

Also see the two related Medscape articles, Dermatologic Diseases of the Male Genitalia: Malignant and Dermatologic Diseases of the Male Genitalia: Nonmalignant.

Pathophysiology

Pearly penile papules are considered a normal variant and harbor no malignant potential. They are not contracted or spread through sexual activity.

Pearly penile papules are observed more frequently in uncircumcised males; however, the mechanisms underlying their development remain unknown. Interestingly, in uncircumcised males with pearly penile papules who undergo circumcision later in life, regression of the papules is commonly observed.[1]

Etiology

Some evidence suggests that pearly penile papules may be observed more frequently in uncircumcised men (22%) than in circumcised men (12%). In the past, pearly penile papules were believed to contribute to the accumulation of smegma in uncircumcised men; currently however, this is known to be not true.

Epidemiology

Frequency

United States

The incidence of pearly penile papules reportedly ranges from 8-48%.[2] Several reports suggest an increased incidence of pearly penile papules in uncircumcised versus circumcised men (22% vs 12%, respectively). One study found an increase in frequency in black versus white men, in those circumcised (21% vs 7%, respectively) and uncircumcised (44% vs 33%, respectively).

International

No geographic variation in prevalence has been noted for pearly penile papules.

Race

No racial predilection has been confirmed for pearly penile papules. Reports suggesting an increased incidence in African American males may reflect an increase in uncircumcised men in that population.

Rehbein[3] studied 840 men aged 10-66 years and found an overall incidence of pearly penile papules of 30.1% in this group. Black men in the study demonstrated a rate of pearly penile papules of 32.7% (44% in uncircumcised, 20.8% in circumcised black males). White men in the study demonstrated a rate of 13.9% (33.3% in uncircumcised, 7.1% in circumcised white males).

Sex

Because of their anatomic distribution, pearly penile papules are noted only in men.

Age

Pearly penile papules are noted most commonly in males in their second or third decades of life, with a gradual decrease in frequency with aging.[1, 4]

Prognosis

Pearly penile papules typically are asymptomatic and persist throughout life, although lesions gradually may become less noticeable with advancing age.

Patient Education

Educate patients about the benign nature of pearly penile papules. Inform patients that lesions are not transmitted through sexual activity. Consider counseling for the patient's sexual partner, which often helps alleviate anxiety.

History

Most patients with pearly penile papules seek dermatologic consultation because they are concerned about a sexually transmitted disease. Pearly penile papules most commonly are confused with condyloma acuminatum (genital warts) or less often, with molluscum contagiosum.[5]

Physical Examination

Upon physical examination, pearly penile papules appear as one or several rows of small, flesh-colored, smooth, dome-topped to filiform papules situated circumferentially around the corona or sulcus of the glans penis.[6] Uncommonly, lesions may extend onto the glans penis. In order to visualize the corona and sulcus of the penis in an uncircumcised male, it is often necessary to manually retract the foreskin. Generally, pearly penile papules are readily visible in circumcised men in the same anatomical sites.

Pearly penile papules typically are asymptomatic and persist throughout life; however, they gradually may become less noticeable with increased age.[1]

See the images below.



View Image

Pearly penile papules are seen clinically as multiple, glistening, flesh-colored, dome-topped papules arranged circumferentially in 2 rows along the c....



View Image

Pearly penile papules. Courtesy of Wiki Commons



View Image

Pearly penile papules; close-up view. Courtesy of Wiki Commons.

Complications

Pearly penile papules are not known to be associated with any complications.

Laboratory Studies

Laboratory studies are not indicated for pearly penile papules.

Imaging Studies

Imaging studies are not indicated for pearly penile papules.

Other Tests

No other tests are indicated, although dermoscopic findings have been documented,[7, 8, 9]

Procedures

Confirmation of a diagnosis of pearly penile papules may be obtained by obtaining a biopsy specimen of a lesion for histopathologic analysis.

Histologic Findings

Histopathologic analysis of lesions demonstrates a variable number of thin-walled ectatic vessels in the dermis in association with a fibroblastic proliferation. Lesional fibroblasts may appear stellate or multinucleated. Concentric fibrosis surrounding adnexal structures is an additional characteristic.

These features are seen in angiofibromas and are not specific for pearly penile papules. Angiofibromas associated with tuberous sclerosis (adenoma sebaceum) and fibrous papules may show identical histologic findings. Clinical history or recognition of genital skin (in adequate biopsy sample) may provide a specific diagnosis.

Staging

No staging system exists or is necessary, given the benign and innocuous nature of pearly penile papules.

Medical Care

Pearly penile papules typically are asymptomatic and require no therapy.

Surgical Care

Some patients with pearly penile papules may request therapy to alleviate anxiety.

Ablation using carbon dioxide laser,[10, 11, 12] electrodesiccation with curettage, and excisional surgery reportedly have successfully eliminated pearly penile papules. Recent technological advancements in lasers have resulted in promising outcomes using newer fractional ablative approaches,[13, 14] including fractionated carbon dioxide lasers.[15] Successful treatment with pulsed dye laser has been reported,[16] as has treatment with erbium:yttrium-aluminium-garnet (Er:YAG) laser.[17]

Mixed results have been noted with cryotherapy.[18]

Topical application of podophyllin largely has been ineffective for pearly penile papules.

Consultations

Consultation with a dermatologist may prove useful when the diagnosis is not obvious.

Diet

Diet is not known to be a factor influencing the development or course of pearly penile papules.

Activity

Pearly penile papules are not associated with personal hygiene or sexual activity.

Prevention

Circumcision at birth may decrease the incidence of pearly penile papules, since the frequency of lesions is fewer in circumcised males (12%) versus uncircumcised males (22%).

Long-Term Monitoring

Most patients accept that treatment is not necessary for pearly penile papules once the benign nature of the lesions is explained. Patients who insist on treatment may elect to undergo ablative therapy with conventional surgical excision or carbon dioxide laser resurfacing.

Medication Summary

No effective topical or oral medical therapies are known for the treatment of pearly penile papules.

What are pearly penile papules (PPP)?What are the risk factors for development of pearly penile papules (PPP)?What causes pearly penile papules (PPP)?What is the prevalence of pearly penile papules (PPP) in the US?How does the prevalence of pearly penile papules (PPP) vary geographically?How does the prevalence of pearly penile papules (PPP) vary by race?How does the prevalence of pearly penile papules (PPP) vary by age?What is the prognosis of pearly penile papules (PPP)?What education about pearly penile papules (PPP) should patients receive?Which history findings suggest pearly penile papules (PPP)?Which physical findings suggest pearly penile papules (PPP)?What are possible complications of pearly penile papules (PPP)?Which conditions should be included in the differential diagnoses of pearly penile papules (PPP)?What are the differential diagnoses for Pearly Penile Papules?What is the role of lab tests in the workup of pearly penile papules (PPP)?What is the role of imaging studies in the workup of pearly penile papules (PPP)?What is the role of dermoscopy in the diagnosis of pearly penile papules (PPP)?What is the role of biopsy in the diagnosis of pearly penile papules (PPP)?Which histologic findings suggest pearly penile papules (PPP)?What staging system exists for pearly penile papules (PPP)?What are the treatment options for pearly penile papules (PPP)?When is surgical intervention indicated for pearly penile papules (PPP)?Which specialist consultations may be useful in the diagnosis of pearly penile papules (PPP)?How may diet affect the development or course of pearly penile papules (PPP)?What is the role of hygiene and sexual activity in the etiology of pearly penile papules (PPP)?How can pearly penile papules (PPP) be prevented?What monitoring is needed following diagnosis of pearly penile papules (PPP)?What medical therapies are used for the treatment of pearly penile papules (PPP)?

Author

Clarence William Brown, Jr, MD, FAAD, Chief Executive Officer, University Dermatology

Disclosure: Nothing to disclose.

Specialty Editors

Michael J Wells, MD, FAAD, Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Disclosure: Nothing to disclose.

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.

References

  1. Agha K, Alderson S, Samraj S, Cottam A, Merry C, Lee V, et al. Pearly penile papules regress in older patients and with circumcision. Int J STD AIDS. 2009 Nov. 20(11):768-70. [View Abstract]
  2. Sonnex C, Dockerty WG. Pearly penile papules: a common cause of concern. Int J STD AIDS. 1999 Nov. 10(11):726-7. [View Abstract]
  3. Rehbein HM. Pearly penile papules: incidence. Cutis. 1977 Jan. 19(1):54-7. [View Abstract]
  4. Agha K, Alderson S, Samraj S, et al. Pearly penile papules regress in older patients and with circumcision. Int J STD AIDS. 2009 Nov. 20(11):768-70. [View Abstract]
  5. Monroe JR. Does this man have genital warts? Pearly penile papules. JAAPA. 2009 Feb. 22(2):16. [View Abstract]
  6. Rane V, Read T. Penile appearance, lumps and bumps. Aust Fam Physician. 2013 May. 42 (5):270-4. [View Abstract]
  7. Watanabe T, Yoshida Y, Yamamoto O. Differential diagnosis of pearly penile papules and penile condyloma acuminatum by dermoscopy. Eur J Dermatol. 2010 Feb 22. [View Abstract]
  8. Ozeki M, Saito R, Tanaka M. Dermoscopic features of pearly penile papules. Dermatology. 2008. 217(1):21-2. [View Abstract]
  9. Micali G, Lacarrubba F. Augmented diagnostic capability using videodermatoscopy on selected infectious and non-infectious penile growths. Int J Dermatol. 2011 Dec. 50(12):1501-5. [View Abstract]
  10. Lane JE, Peterson CM, Ratz JL. Treatment of pearly penile papules with CO2 laser. Dermatol Surg. 2002 Jul. 28(7):617-8. [View Abstract]
  11. Magid M, Garden JM. Pearly penile papules: treatment with the carbon dioxide laser. J Dermatol Surg Oncol. 1989 May. 15(5):552-4. [View Abstract]
  12. Krakowski AC, Feldstein S, Shumaker PR. Successful Treatment of Pearly Penile Papules with Carbon Dioxide Laser Resurfacing After Local Anesthesia in an Adolescent Patient. Pediatr Dermatol. 2014 Dec 29. [View Abstract]
  13. Beylot C. [What's new in aesthetic dermatology: filler and laser treatments]. Ann Dermatol Venereol. 2009 May. 136 Suppl 4:S152-9. [View Abstract]
  14. Rokhsar CK, Ilyas H. Fractional resurfacing for the treatment of pearly penile papules. Dermatol Surg. 2008 Oct. 34(10):1420-2; discussion 1422. [View Abstract]
  15. Gan SD, Graber EM. Treatment of Pearly Penile Papules with Fractionated CO2 Laser. J Clin Aesthet Dermatol. 2015 May. 8 (5):50-2. [View Abstract]
  16. Sapra P, Sapra S, Singh A. Pearly penile papules: effective therapy with pulsed dye laser. JAMA Dermatol. 2013 Jun. 149(6):748-50. [View Abstract]
  17. Baumgartner J. Erbium: yttrium-aluminium-garnet (Er:YAG) laser treatment of penile pearly papules. J Cosmet Laser Ther. 2012 Jun. 14(3):155-8. [View Abstract]
  18. Ocampo-Candiani J, Cueva-Rodriguez JA. Cryosurgical treatment of pearly penile papules. J Am Acad Dermatol. 1996 Sep. 35(3 Pt 1):486-7. [View Abstract]

Pearly penile papules. Courtesy of Wiki Commons

Pearly penile papules; close-up view. Courtesy of Wiki Commons.

Pearly penile papules are seen clinically as multiple, glistening, flesh-colored, dome-topped papules arranged circumferentially in 2 rows along the corona of the glans penis.

Pearly penile papules. Courtesy of Wiki Commons

Pearly penile papules; close-up view. Courtesy of Wiki Commons.

Pearly penile papules are seen clinically as multiple, glistening, flesh-colored, dome-topped papules arranged circumferentially in 2 rows along the corona of the glans penis.

Pearly penile papules. Courtesy of Wiki Commons

Pearly penile papules; close-up view. Courtesy of Wiki Commons.