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Year : 1999  |  Volume : 65  |  Issue : 2  |  Page : 75-77

Pseudoepitheliomatous, keratotic and micaceous balanitis producing nail-like lesion on the glans penis

Correspondence Address:
C L Subudhi

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A rare case of pseudoepitheliomatous, keratotic and micaceous balanitis (PEKMB) is described.

Keywords: Balanitis, Micaceous

How to cite this article:
Subudhi C L, Singh P C. Pseudoepitheliomatous, keratotic and micaceous balanitis producing nail-like lesion on the glans penis. Indian J Dermatol Venereol Leprol 1999;65:75-7

How to cite this URL:
Subudhi C L, Singh P C. Pseudoepitheliomatous, keratotic and micaceous balanitis producing nail-like lesion on the glans penis. Indian J Dermatol Venereol Leprol [serial online] 1999 [cited 2020 Feb 25];65:75-7. Available from: http://www.ijdvl.com/text.asp?1999/65/2/75/4765

  Introduction Top

Penile tumours invariably cause alarm and always warrant early biopsy to establish the correct diagnosis so that an appropriate treatment can be carried out and unnecessary mutilating surgery avoided. Certain rare tumours initially show benign histology or later show either a low grade or delayed malignant growth potential. Three clinical entities fall into this category. Those are penile horn, giant condyloma (Buschke-Lowenstein tumour) and an extremely rare penile growth pseudoepitheliomatous, keratotic and micaceous balanitis (PEKMB).[1] This report describes a very rare case of PEKMB producing a nail-like lesion over the glans penis and showing benign histology.

  Case Report Top

A 50-year-old man came in August 1994 with the complaint of a slow growing painless swelling over the penis of two years duration. He was not diabetic. He had no urinary irritative or obstructive symptoms. He had no urethral discharge. Examination of the penis revealed tight primary phimosis. A firm and non- tender flat plaque of 1 cm diameter was felt on the glans penis through the prepuce. There was no inguinal lymphadenopathy, and the rest of the physical examination was unremarkable. His fasting blood sugar was 94 mg/ dl and VDRL test was non- reactive; and urinalysis revealed 2-4 pus cells/h.p.f. He underwent formal circumcision. There was a whitish yellow nail-like lesion on the dorsum of the glans extending distally from the corona, which could be easily peeled off. A biopsy of the glans at that site revealed hyperkeratosis, acanthosis and pseudoepitheliomatous hyperplasia and infiltration with a few chronic inflammatory cells but there was no cytological atypia or malignancy. The patient was discharged with an advice to have frequent check up. He came after 8 months and reported that every 3-5 weeks a crust slowly formed at the original site on the glans which could be easily peeled off. He brought a few of such crusts [Figure - 1]. One of such crusts was kept in 10% potassium hydroxide solution in a test tube overnight and was found to have dissolved totally showing that it was nothing but keratin. A repeat biopsy from the glans was taken and it also did not reveal any malignancy. A diagnosis of pseudoepitheliomatous, keratotic and micaceous balanitis was made. He was asked not to remove the crust for 3-4 months and report. [Figure - 2] shows a typical nail-like lesion over the glans at the end of 4 months which could be easily peeled off. Then the patient was lost to follow up.

Unfortunately, he died in September 1997 due to acute myeloid leukaemia.

  Discussion Top

Pseudoepitheliomatous, keratotic and micaceous balanitis was originally named and described by Lortat-Jacob and Civatte.[2] This is a curious condition in which a coronal balanitis gradually takes on a silvery white appearance, and mica-like crusts and keratotic horny masses formed on the glans. Sometimes ulcerations, cracking and fissuring on the surface of the glans are present. The keratotic scaling is usually micaceous and resembles psoriasis. Nail-like lesion an the glans due to this condition as seen in our case has not been reported in the literature. Similar to our patient, the original patient had preexisting phimosis.[2] It has 'been regarded as a form of pyodermatitis or pseudoepitheliomatous response to infection, possibly a variant of Reiter's syndrome.[3] Originally this lesion was considered entirely to be benign[2] but Bart and Kopf[4] first thought it to be capable of invasive growth. Read and Abell[1] suggested that this lesion may have locally invasive or aggressive tendencies and that it should be considered to have low grade or limited malignant potential.

Classically histological examination of these lesions revealed acanthosis, hyperkeratosis and pseudoepitheliomatous hyperplasia with no cytological atypia.[5] Our case did not reveal any feature of malignancy even in repeat biopsy. Jenkins and Jakubovic[6] opine that it is a distinctive clinical entity that represents a histologic spectrum ranging from hypertrophic-hyperplastic penile dystrophy to verrucous carcinoma.

This rare penile condition was considered in the beginning to be benign and subsequently to be pseudomalignant, premalignant or as a low grade squamous malignancy. The treatment of PEKMB should be conservative[1] when there is no histological evidence of malignancy. Such patients should have close follow up. Some lesions have been successfully treated with topical 5- fluorouracil cream[5] and in some there was only partial response. Whenever there is cellular atypia, complete surgical excision produced excellent cosmetic and functional results,[1] and when frank malignancy is seen excision with wide margin is the rule.

  References Top

1.Reed S I, Abell E, Pseudoepitheliomatous, keratotic and micaceous balanitis. Arch Dermatol 1981;117:435-437.  Back to cited text no. 1    
2.Lortat-Jacob E. Civatte J .Balanite pseudoepitheliomateuse, keratosique et micacee. Bull Soc Fr Dermatol syphilol 1966;73:631-935.  Back to cited text no. 2    
3.Rook A, Wilkinson DS, Ebling FJU, Champin RH, Burton J L.: Textbook of Dermatology,4th Edn., Balckwell Scientific Publication 1986;2188.  Back to cited text no. 3    
4.Bart S, Kopf A W. On a dilemma of penile horns: pseudoepitheliomatous, hyperkeratotic and micaceous balanitis?. J Dermatol Surg Oncol 1977;3:580-582.  Back to cited text no. 4    
5.Krunic A L, Djerdj K, et al. Pseudoepitheliomatous, keratotic and micaceous balanitis. Case report and review of the literature. Urologica Internationalis 1996;56:125-128.  Back to cited text no. 5    
6.Jenkins D Jr, Jakubovic-H R. Pseudoepitheliomatous, keratotic, micaceous balanitis. A clinical lesion with two histologic subsets: hyperplastic dystrophy and verrucous carcinoma. J Am Acad Dermatol 1988;18:419-422.  Back to cited text no. 6    


[Figure - 1], [Figure - 2]


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