|Year : 2013 | Volume
| Issue : 1 | Page : 38-40
Pseudoepitheliomatous keratotic and micaceous balanitis with malignant transformation
Vidyadhar R Sardesai, Trupti D Agarwal, Avinash B Dalal, Madhulika A Mhatre
Department of Dermatology, Venereology and Leprosy, Bharati Vidyapeeth University Medical College and Hospital, Pune, India
|Date of Web Publication||4-Jun-2013|
Vidyadhar R Sardesai
102 Alliance Nakshatra, 48 Tulshibagwale Colony, Sahakar Nagar No. 2, Pune - 411009
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Pseudoepitheliomatous, keratotic and micaceous balanitis (PKMB) is a non-venereal and extremely rare pre-malignant condition characterized by silvery white plaque with micaceous scaling on glans seen in elderly uncircumcised men. Symptoms include phimosis, pain, and interference with sexual activity.Herein we present a young, 40-year-old male with PKMB of 5 years duration with deviation of urinary stream and histology showing acanthosis, hyperkeratosis with features of cellular atypia and abnormal mitosis suggestive of malignant transformation.
Keywords: Keratotic and micaceous balanitis, malignant transformation, meatal involvement, Pseudoepitheliomatous
|How to cite this article:|
Sardesai VR, Agarwal TD, Dalal AB, Mhatre MA. Pseudoepitheliomatous keratotic and micaceous balanitis with malignant transformation. Indian J Sex Transm Dis 2013;34:38-40
|How to cite this URL:|
Sardesai VR, Agarwal TD, Dalal AB, Mhatre MA. Pseudoepitheliomatous keratotic and micaceous balanitis with malignant transformation. Indian J Sex Transm Dis [serial online] 2013 [cited 2022 Nov 29];34:38-40. Available from: https://www.ijstd.org/text.asp?2013/34/1/38/112871
| Introduction|| |
Pseudoepitheliomatous, keratotic and micaceous balanitis (PKMB) is a non-venereal and extremely rare penile disease characterized by slow growing, thick, well demarcated plaques with micaceous scaling on the glans. This condition is mostly seen in uncircumcised elderly male more than 60 years of age. The most common presenting symptoms are phimosis, pain and sexual inactivity. This condition is considered pseudo malignant, premalignant or as low-grade squamous malignancy. This case is rare and unique, often diagnosed as a wart and treated accordingly. Less than 20 cases have been reported until date, very few of them from India.
| Case Report|| |
A 40-year-old male presented with thick, hard lesions over the penis of 5 years duration, which were progressive in nature and associated with deviation of urinary stream. In some areas, yellowish white scales were seen with free edges. The scales were easily removable after rubbing, however, the scales recurred. He later developed phimosis for which he underwent circumcision. There was no history of sexually transmitted infection and diabetes mellitus. The patient gave history of use of anti-bacterial and keratolytic creams with no improvement.
Examination revealed thick, non-tender, hard, keratotic yellowish plaques localized on the glans and partially obstructing the external urinary meatus, measuring about 2 cm × 1.5 cm in size with micaceous scaling and fissures at places [Figure 1]. The penile shaft and scrotum were normal. There was no inguinal or femoral lymphadenopathy. General and systemic examination revealed no abnormality.
|Figure 1: Keratotic, micaceous scaly lesion over the glans with meatal involvement|
Click here to view
Blood counts and blood sugar levels were within normal limits. Tests for HIV antibodies, hepatitis B surface antigen were negative and Venereal Disease Research Laboratory test was non-reactive. Wedge biopsy from the glans revealed features of acanthosis, hyperkeratosis, parakeratosis with cellular atypia and abnormal mitosis suggestive of malignant transformation [Figure 2].
|Figure 2: Features of acanthosis, hyperkeratosis, parakeratosis with cellular atypia and abnormal mitosis (H and E, × 40)|
Click here to view
A diagnosis of PKMB of Civatte with carcinoma in situ was made and the patient underwent a partial penectomy [Figure 3]. He has been asked to follow-up every month to check for any new growths and lymphadenopathy.
| Discussion|| |
PKMB was first named and described by Lortat-Jacob and Civatte in 1961.  The exact etiology is unknown. Later on cases were described in the English literature and until date there are less than 20 cases reported.  Only a few cases have been reported since then in India.
It is mainly seen in elderly over 60 years of age,  unlike our patient who presented at the age of 40. Though, originally considered to be a benign entity, it has been shown to be capable of invasive growth by Bart and Kopf who considered the lesion to be in intermediate stage between benign hyperplasia and squamous cell carcinoma.  It has been regarded as a form of pyodermatitis or pseudoepitheliomatous response to infection. 
The pathogenesis of PKMB occurs in four stages
Clinically, it presents as a coronal balanitis, which gradually takes on a silvery white appearance, and mica-like and keratotic horny masses formed on the glans. Sometimes ulcerations, cracking and fissuring crusts on the surface of the glans are present. The keratotic scaling is usually micaceous and resembles psoriasis. 
- Initial plaque stage
- Late tumor stage
- Verrucous carcinoma, and
- Transformation to squamous cell carcinoma and metastasis. 
Classically, histological examination of these lesions reveals acanthosis, hyperkeratosis, and pseudoepitheliomatous hyperplasia with no cytological atypia.  However, in our case there was cellular atypia and abnormal mitosis in addition to the above features.
The treatment of PKMB should be conservative when there is no histological evidence of malignancy.  Whenever, there is cellular atypia, local surgical excision produces excellent cosmetic and functional results.  When frank malignancy is seen excision with wide margin is the rule. 
The case is being reported as a rare non-venereal penile disorder with malignant transformation and having meatal involvement.
| References|| |
|1.||Lortat-Jacob E, Civatte J. Balanite pseudoepitheliomateuse, kertosique micacee. Bull Soc Fr Dermatol Syphilol 1961;68:164-7. |
|2.||Pai VV, Hanumanthayya K, Naveen KN, Rao R, Dinesh U. Pseudoepitheliomatous, keratotic, and micaceous balanitis presenting as cutaneous horn in an adult male. Indian J Dermatol Venereol Leprol 2010;76:547-9. |
|3.||Bart RS, Kopf AW. On a dilemma of penile horns: Pseudoepitheliomatous, hyperkeratotic and micaceous balanitis? J Dermatol Surg Oncol 1977;3:580-2. |
|4.||Perry D, Lynch PJ, Fazel N. Pseudoepitheliomatous, keratotic, and micaceous balanitis: Case report and review of the literature. Dermatol Nurs 2008;20:117-20. |
|5.||Rook A, Wilkinson DS, Ebling FJ, Champin RH, Burton JL. The Umbilical, Perianal and Genital Regions. Textbook of Dermatology. 5 th ed. Oxford: Blackwell Scientific Publications; 1986. p. 2811. |
|6.||Krunic AL, Djerdj K, Starcevic-Bozovic A, Kozomara MM, Martinovic NM, Vesic SA, et al. Pseudoepitheliomatous, keratotic and micaceous balanitis. Case report and review of the literature. Urol Int 1996;56:125-8. |
|7.||Subudhi CL, Singh PC. Pseudoepitheliomatous, keratotic and micaceous balanitis producing nail-like lesion on the glans penis. Indian J Dermatol Venereol Leprol 1999;65:75-7. |
|8.||Read SI, Abell E. Pseudoepitheliomatous, keratotic, and micaceous balanitis. Arch Dermatol 1981;117:435-7. |
|9.||Child FJ, Kim BK, Ganesan R, Southern SA, Herrington CS, Calonje E. Verrucous carcinoma arising in pseudoepitheliomatous keratotic and micaceous balanitis, without evidence of human papillomavirus. Br J Dermatol 2000;143:183-7. |
[Figure 1], [Figure 2], [Figure 3]
|This article has been cited by|
||Pseudoepitheliomatous keratotic and micaceous balanitis: a series of eight cases
| ||A. Spencer, R.E. Watchorn, G. Kravvas, I. Ben-Salha, A. Haider, N. Francis, A. Freeman, H.M. Alnajjar, A. Muneer, C.B. Bunker |
| ||Journal of the European Academy of Dermatology and Venereology. 2022; |
|[Pubmed] | [DOI]|
||Pseudoepitheliomatous keratotic and micaceous balanitis: A literature review
| ||Antoine Salloum, Nagham Bazzi, Wajih Saad, Julien Bachour, Hala Mégarbané |
| ||Australasian Journal of Dermatology. 2021; 62(3): 421 |
|[Pubmed] | [DOI]|
||Urologic dermatology: a comprehensive foray into the noninfectious etiologies of balanitis
| ||Daniel R. Nemirovsky, Rohan Singh, Aria Jalalian, Rena D. Malik |
| ||International Journal of Dermatology. 2021; |
|[Pubmed] | [DOI]|