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Letter

Pseudoepitheliomatous, Keratotic, and Micaceous Balanitis

Author Affiliation(s)

Introduction

Pseudoepitheliomatous, keratotic, and micaceous balanitis (PEKMB) is a genital disease of uncertain malignant potential that warrants close clinical observation, as it can rarely evolve into squamous cell carcinoma or verrucous carcinoma.

Case Presentation

A 46-year-old man presented with complaints of scaling and erosion over the glans for the preceding 5 years. He had undergone circumcision 12 years earlier, when he noticed depigmentation over the glans; a few years later, thick, scaly crust developed over the glans. He had no history of high-risk sexual behavior. The patient had previously been treated with topical steroids, emollients, and calcineurin inhibitors without much improvement. On examination, there was hypopigmentation and sclerosis of the glans with localized, thick, yellowish, nail-like keratotic scaling along with underlying induration and superficial erythematous erosions ( Figure 1 ). There was no associated lymphadenopathy, and systemic examination was within normal limits. A skin biopsy from scaly indurated plaque showed hyperkeratosis, parakeratosis, and acanthosis with dysplastic changes limited to lower layers of epidermis along with a few mitotic figures and an essentially normal dermis ( Figure 2 ). A diagnosis of PEKMB was made. The patient was treated with topical 5-fluorouracil, once daily application over scaly and indurated areas, and he was followed up monthly. However, after 4 months of treatment there was a residual area of persistent induration, a biopsy of which showed moderately differentiated squamous cell carcinoma with areas of necrosis. There was no lymphovascular invasion or distant metastases. A final diagnosis of PEKMB evolving to squamous cell carcinoma was made and the lesion was excised with wide margins.

Figure 1 .

Clinical photograph showing scaling and erosion on the glans.

Figure 2 .

Histopathology (H&E, ×4) showing hyperkeratosis, parakeratosis, and acanthosis with dysplastic changes limited to lower layers of epidermis along with a few mitotic figures and an essentially normal dermis.

Conclusions

PEKMB is a rare, nonvenereal, premalignant genital dermatosis. It was first described by Lortat-Jacob and Civatte in 1961, and until now approximately 20 cases have been reported in the literature. It occurs in older men, most of whom were circumcised late in life. It presents as a keratotic plaque with thick, white, mica-like silvery scales and keratotic horny masses on the glans. Ulcerations and fissuring may develop. The etiology of PEKMB is unknown and it progresses through 4 different stages: plaque, tumor, verrucous carcinoma, and later squamous cell carcinoma [ 1 ] .

Although PEKMB has uncertain malignant potential, it can sometimes progress to verrucous carcinoma and squamous cell carcinoma and therefore an early biopsy and close follow-up are warranted [ 2 ] . Histological examination of these lesions reveals acanthosis, hyperkeratosis, and pseudoepitheliomatous hyperplasia with no cytological atypia.

Treatment depends on severity and may range from topical treatment with 5-flurouracil cream, cryotherapy, shaving biopsy plus electrocoagulation, or triamcinolone acetonide cream (0.1%) to excision with wide margins. However, treatment is not always satisfactory and relapses are frequent.

References

  1. Pseudoepitheliomatous, keratotic and micaceous balanitis: case report and review of the literature Krunic AL, Djerdj K, Starcevic-Bozovic A, et al. Urol Int.1996;56(2):125-128.
  2. Pseudoepitheliomatous, keratotic, and micaceous balanitis: case report and review of the literature Perry D, Lynch PJ, Fazel N. Dermatol Nurs.2008;20(2):117-120.

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