Anogenital (non-venerial) disease Flashcards
What is the histology of Zoon Balanitis (plasmacytosis mucosae)/vulvitis
Lichenoid interface dermatitis with ↑↑plasma cells
- Flattened keratinocytes, band-like plasma cell infiltrate, and RBC extravasation
What is the clinical apperence of Zoon Balanitis/Vulvitis?
Bright red, speckled, well-defined, smooth patches on glans penis (may have “kissing” lesions – e.g., glans of penis and inner foreskin) ≫ vulva
What is the treatment of Zoon Balanitis/Vulvitis?
Circumcision is curative in men, can try potent topical steroids
What is the etiology of Zoon Balanitis/Vuvitis?
Unknown, but thoguht to be poor hygiene or chronic irritation from warmth/rubbing
Can circumscribed men get Zoon balanitis/vulvitis?
No
What should be on the ddx with Zoon Balanitis/Vulvitis?
LP (less plasma cells, more apoptotic keratinocytes), plasmaytoma. Also this dx is questionable in women, consider also erosive LP, mucous membrane pemphigoid, or lupus
What is the etiology of the majority of vulvar dermatitis?
Usualy an endogenous etiology (hx of atopic or seborrheic dermatitis
What ares are most commonly affected by lichenification in the anogenital area?
Scrotum and labia majora
Clincal manifestations of anogenital dermaitis?
Usually poorly demarcated erythema, look for lichenification
- Fissuring is common in the perianal area
Most common locations for anogenital dermaitis?
Labia majora, mons pubis, crura, scrotum and perianal area
What are the treatments for anogenital dermatitis?
Potent topical steroids +/- topical antifungals, antibacterial agents and/or immunomodulators for acutely inflamed lesions
Avoid irritants, Exacerbating factors such as stress, heat, excessive washing and candidiasis should be identified
Sedative antihistamines or doxepin may be helpful
Taper steroid after a few weeks to moderately potent steroids
If you see scarring with vulvar pruitis what should be on the ddx?
Lichen sclerosus, lichen planus, mucous membrane pemphigoid
What diagnoses should be considered with anogenital pruritus?
Lichen sclerosus (look for hypopigmentation, atrophy, purpura, extragenital lesions)
Dermatitis/contact etc (look for hx of AD or seb derm, scale/crust, dermatitis elsewhere)
Psoriasis (look for well-demarcated palques, favor hair bearing skin, nail/other areas)
Enterobiasis (kids, worsens at night, adhesive tape test can pick up eggs
Drug-induced: (no specific leisons, scratching, drug hx)
What things can cause type I immediate hypersensitivty in the anogenital area?
Seminal fluid and latex are common
What are common allergic contact allergens in the anogenital area?
Hemorrhoid creams, medicated toilet paper, rubber chemicals, spermicides, fragrances, preservatives, topical anesthetics
Common sites for psoriasis in the genital region?
Women: labia majora and mons pubis
Men: Glans penis and shaft
can also get painful fissuring in the perianal area and interguteal cleft
Treatment for psoriasis in the genital region?
Moderately potent topical steroid/antibiotic/antifungal combinations
Topical tacrolimus or pimecrolimus may be helpful
coal tar, anthrain, vit D anologs or retinoids likely too irritating
What is bowenoid papulosis?
Multiple brown papules/smooth plaques on genitals/perineum/perianal that are high-grade squamous intraepithelial lesions (HSIL) or SCCIS
What is the risk of progression to SCC in bowenoid papulosis?
Progression to invasive SCC is very rare; a/w high-risk HPV types
What HPV subtypes are a/w bowenoid papulosis?
High risk ones: 16,18,31, 33, etc
What is Erythroplasia of Queyrat?
Juicy red, erosive plaques on glans penis
Risk of progression to SCC in Erythroplasia of Queyrat?
More often progresses to SCC than bowenoid papulosis
What HPV subtypes are a/w Erythroplasia of Queyrat?
Also associated with high risk subtypes
What two conditions account for the majority of SCC in the anogenital region?
HPV and lichen sclerosus
What is the clinical appearance of SCC in the anogenital area?
- Ulcers or plaques on glans, coronal sulcus or prepuce
- Ulcers often have heaped up edge
- Phimosis may mask tumor in uncircumcised men
- Non-healing ulcers, fissures, nodules or plaques on labia
- Anal may arise from anal margin or w/I lower anal canal
How common is anogenital melanoma?
Rare, (0.3% of all melanomas in women)
sun doesn’t play a role
What are the most common areas for anogenital melanoma?
Women: labia majora and clitoris, can alos be seen on the vulva, cervix and vagina
Men: most common presentaton is a nodule on the glans penis
What is the most common subtype of melanoma to occur on the anogenital region?
Mucosal lentiginous –> looks similar histologicaly to acral lentiginous melanoms
What is the clinical appreance of extramammary Paget’s disease?
Red and white macerated/eroded plaques (“strawberries and cream”) located around anal verge and below dentate line
What are the most common locations for extramammary Paget’s disease?
Most common sites are vulva (women) and perianal regions (men)
What are the two main subtypes of extramammary Paget’s disease and how common are they relative to one another?
Primary = >75%
Secondary= 20%
What is primary Extramammary Paget’s Disease?
Primary cutaneous adenocarcinoma (intraepithelial)
Likely derived from Toker cells or cutaneous adnexal glandular epithelium (sweat glands)
What is the etiology of primary Extramammary Paget’s Disease?
Derived from Toker cells or cutaneous adnexal glandular epithelium (sweat glands)
What is the immunophenotype of primary extramammary paget’s disease?
CK7+, CK20- ,CEA+, BerEP4+
What is secondary extrammammary paget’s disease?
May be the result of direct extension or epidermotropic metastases of underlying GI/GU (> prostate, ovarian, and endometrial) +− adenocarcinoma
What cancers are most commonly associated with secondary extrammammary paget’s disease?
Prostate, ovarian, and endometrial +− adenocarcinoma
What is the immunophenotype of secondary extrammammary paget’s disease?
CK7 +/- , GCFDP-15- , and CK20 +
Treatments for extramammary paget’s disease?
High rate of recurrence, even w/ mohs
- Can try C02 laser, radiotherapy, imiquimod, or 5-FU
What type of extramammary paget’s disease is highest risk for internal malingancy?
Perianla (5 fold increased risk vs vulvar or penoscrotal)
What is the histology of extrammamary Paget’s disease histology?
Intraepidermal nests of pale bluish cells
Compressed basal keratinocytes
Nests of Paget cells compress the healthy basal layer of keratinocytes
Diffuse pagetoid scatter (“buckshot” pattern)
Transepidermal elimination of tumor cells
Mucin in cytoplasm
+/− ducts
What is an algorithm for staining for pagetoid cells in epidermis?
- S100/MART-1/MITF/HMB45 –> if + think melanoma if negative go to 2
- CAM5.2, CK7, pankeratin marker (AE1/AE3, and or CEA) –> if pankeratin markers are positive but CEA/Ck7 is - then think SCC in situ/Bowens, if pankeratin is negative and CEA/CK7 is + then we think pagets go to 3
- If on breast –> Paget disease of the breast, if not on breast –> check CK20 and GCFDP-15–> if CK20 - (GCFDP-15 +), this favors cutaneous origin (primary) if the CK20+ and GCFDP-15 - –> secondary
What should be considered in a pt w/ disabling pain in the genital region without rash?
Regional pain sydromes (post-stimulatory unmyelinated c-fiber remodeling)
What is localized vulvodynia?
Superficial dyspareunia and point tenderness w/i the vestibule
MC in premenopausal sexually active women
Insertion of tampons may be impossible
Pain when the vestibular area is pressed by cotton-tipped applicator
What is the treatment for localized vulvodynia?
Treat with bland emollients, avoidance of irritants, desensitization, topical anesthetics prior to intercourse, TCAs, topical steroids/antifungals, gabapentin can be tried
What is generalized vulvodynia/scrotodynia?
Persistent burning pain over vulva, scrotum or penis, may extend down thighs
Association with fibromyalgia and irritable bowel syndrome
Precipitating events include sexual activity, exercise, friction, heat
What is the clinical apperence of epidermioid cysts in the genital region?
Can be multiple, usually vary in size and can become inflamed. Have a yellow apperence
What are the most common areas of epidermioid cysts in the genital region?
Labia majora and scrotum
What is vestibular papillomatosis?
W/i the vestibule
~45% of premenopausal women and 10% of postmenopausal women
Pink, asx, fine projections
normal finding
