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LETTER TO EDITOR |
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| Year : 2023 | Volume
: 44
| Issue : 1 | Page : 94-95 |
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Pseudoepitheliomatous keratotic and micaceous balanitis: A distinct entity
Rita Vipul Vora, Jalpa Kailasbhai Patel, Devna Subramonia Pillai
Senior Professor and Head, Department of Dermatology, Shree Krishna Hospital and Pramukhswami Medical College, Karamsad, Gujarat, India
| Date of Submission | 15-Sep-2022 |
| Date of Decision | 19-Sep-2022 |
| Date of Acceptance | 13-Oct-2022 |
| Date of Web Publication | 09-Dec-2022 |
Correspondence Address:
Dr. Rita Vipul Vora
Senior Professor and Head, Department of Dermatology, Shree Krishna Hospital and Pramukhswami Medical College, Karamsad- 388 325, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijstd.ijstd_92_22
How to cite this article:
Vora RV, Patel JK, Pillai DS. Pseudoepitheliomatous keratotic and micaceous balanitis: A distinct entity. Indian J Sex Transm Dis 2023;44:94-5 |
How to cite this URL:
Vora RV, Patel JK, Pillai DS. Pseudoepitheliomatous keratotic and micaceous balanitis: A distinct entity. Indian J Sex Transm Dis [serial online] 2023 [cited 2023 Sep 30];44:94-5. Available from: https://ijstd.org/text.asp?2023/44/1/94/363122 |
Sir,
Through this letter, we wish to draw an attention to a rare case report of pseudoepitheliomatous, keratotic, and micaceous balanitis (PKMB) in a 28-year-old young adult. PKMB is an extremely rare condition occurring over the glans, more commonly seen in the elderly, and characterized by silvery white plaque with mica-like crust.[1] In 1961, Lortat-Jacoband Civatte first reported a thick diffuse form of hyperkeratosis on the glans penis, along with mica-like scaly layers.[2] The most common presenting symptoms are phimosis, pain, and sexual inactivity. The condition is usually asymptomatic, but ulceration, fissuring, maceration, and irritation may be associated. In some cases, it may progress to verrucous carcinoma or invasive squamous cell carcinoma (SCC).
We present a 28-year-old male, with a complaint of thick, pruritic, whitish growth, and whitish urethral discharge from glans penis foe 20 days. He had undergone circumcision in childhood. There was no history of any unprotected sexual intercourse, spontaneous bleeding, trauma, or burning micturition. Clinical examination showed a well-defined hyperkeratotic plaque with thick mica-like scales, measuring 3 cm × 4 cm over the glans penis [Figure 1]a. Bilateral local, nontender inguinal lymphadenopathy was noted. Biopsy was performed with clinical differential diagnoses of balanitis xerotica obliterans, Zoon's balanitis, SCC, and PKMB. Wedge biopsy from the glans revealed hyperkeratosis, parakeratosis with elongated rete ridges mixed with neutrophils.[Figure 2]a and [Figure 2]b. Acanthosis with nonspecific dermal inflammatory infiltrate predominantly composed of eosinophils and lymphocytes [Figure 2]c and [Figure 2]d. Positron emission tomography scan was normal. Based on these clinical and histopathological findings, a diagnosis of PKMB was made. The patient applied some home remedies, after which the lesion resolved [Figure 1]b. | Figure 1: (a) Single, well-defined, hyperkeratotic plaque with thick mica-like scales, measuring 3 cm × 4 cm over the glans penis (pretreatment). (b) Single, well-defined, hypopigmented patch, measuring 3 cm × 4 cm over the glans penis (posttreatment)
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 | Figure 2: (a and b) Hyperkeratosis, parakeratosis with elongated rete ridges mixed with neutrophils. (H and E, ×4, ×40). (c and d) Acanthosis with nonspecific dermal inflammatory infiltrate predominantly composed of eosinophils and lymphocytes. (H and E, ×4, ×40)
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PKMB has a very characteristic appearance that includes mica-like crusts and keratotic horny mass on the glans penis, and it is necessary to distinguish it from hypertrophic lichen sclerosis, Buschke–Lowenstein tumor, verrucous carcinoma, and SCC. Krunic et al.[3] stated that PKMB evolves into four stages: (i) the initial plaque stage, (ii) late tumor stage, (iii) verrucous tumor on the plaque, and (iv) transformation to SCC and invasion. Thickness of the plaque can be sometimes quite huge that the lesion appears as a penile horn. Hyperkeratotic plaques involving perimeatal skin can cause multiple urinary streams on micturition giving an appearance of a “watering-can penis.” Histopathological examination demonstrates hyperkeratosis, parakeratosis, acanthosis, elongated rete ridges, and mild lower epidermal dysplasia with a nonspecific dermal inflammatory infiltrate composed of eosinophils and lymphocytes.[1] Differential diagnoses include penile horn, penile psoriasis (early plaque stage), giant condyloma, verrucous carcinoma, erythroplasia of Queyrat, SCC, and keratoacanthoma. Chaux et al.[4] studied 74 penile intraepithelial lesions using a triple immunohistochemical panel (p16/p53/Ki-67) and found a distinctive immunohistochemical profile for associated and precursor penile epithelial lesions. All patients with squamous hyperplasia were p16 and p53 negative, and patients with high-grade penile intraepithelial neoplasia (basaloid and warty patterns) were consistently p16 and p53positive and variably Ki-67 positive. Treatment options include topical measures such as 5-fluorouracil, podophyllin resin, and steroids and physical measures such as cryotherapy, radiotherapy, and wide local excision.[5]
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 initials 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 | |  |
| 1. | Adya KA, Palit A, Inamadar AC. Pseudoepitheliomatous keratotic and micaceous balanitis. Indian J Sex Transm Dis AIDS 2013;34:123-5.  |
| 2. | Beljaards RC, van Dijk E, Hausman R. Is pseudoepitheliomatous, micaceous and keratotic balanitis synonymous with verrucous carcinoma? Br J Dermatol 1987;117:641-6. |
| 3. | 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. |
| 4. | Chaux A, Pfannl R, Rodríguez IM, Barreto JE, Velazquez EF, Lezcano C, et al. Distinctive immunohistochemical profile of penile intraepithelial lesions: A study of 74 cases. Am J Surg Pathol 2011;35:553-62. |
| 5. | Zhu H, Jiang Y, Watts M, Kong F. Treatment of pseudoepitheliomatous, keratotic, and micaceous balanitis with topical photodynamic therapy. Int J Dermatol 2015;54:245-7. |
[Figure 1], [Figure 2]
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