Blue-gray plaque of the penis

Abstract

We report the case of a 66-year-old white man with a 6-month history of a blue-gray plaque of the glans. The patient was heterosexual, with 2 sexual partners in the last 6 months, and denied condom use. There was no personal or family history of melanoma. Physical examination of the uncircumcised penis found a round, well-demarcated, smooth, blue-gray plaque measuring 8 × 10 mm, arising within an erythematous background plaque of the glans (Fig 1). The remaining physical examination was unremarkable, including the oral cavity. Within the plaque we observed regularly arranged gray dots surrounded by a white halo over a blue-white structureless background (Fig 2). We observed a cordlike pattern with refractile round cellular structures in the stratum corneum, suggesting parakeratosis.1Gonzalez S. [Clinical applications of reflectance confocal microscopy in the management of cutaneous tumors].Actas Dermosifiliogr. 2008; 99: 528-531PubMed Google Scholar We also observed a typical honeycomb pattern (Fig 3). A shave biopsy found the presence of parakeratosis, acanthosis, and papillomatosis of the epidermis. We also observed within the keratinocytes, abundant cytoplasm and irregularly hyperchromatic nuclei (koilocytosis) (Fig 4). Polymerase chain reaction of the biopsy was positive for human papillomavirus type 6.Key messageGenital warts are the most common sexually transmitted disease, and they are caused by the human papillomavirus.2Partridge J.M. Koutsky L.A. Genital human papillomavirus infection in men.Lancet Infect Dis. 2006; 6: 21-31Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar This case highlights the difficulties encountered in the differential diagnosis of darkly pigmented planar lesions of the penis. Dermoscopic patterns in genital warts have been described by several investigators (fingerlike, knoblike, mosaiclike, and pattern combinations).3Dong H. Shu D. Campbell T.M. Fruhauf J. Soyer H.P. Hofmann-Wellenhof R. Dermatoscopy of genital warts.J Am Acad Dermatol. 2011; 64: 859-864Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 4Ozdemir F. Kilinc-Karaarslan I. Akalin T. A pigmented, hemorrhagic genital wart: clinical, dermoscopic, and histopathologic features.Arch Dermatol. 2008; 144: 1072-1073Crossref PubMed Scopus (6) Google Scholar, 5Ozkur E. Falay T. Turgut Erdemir A.V. Gurel M.S. Leblebici C. Vestibular papillomatosis: an important differential diagnosis of vulvar papillomas.Dermatol Online J. 2016; 22PubMed Google Scholar, 6Pastar Z. Lipozencic J. Significance of dermatoscopy in genital dermatoses.Clin Dermatol. 2014; 32: 315-318Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 7Veasey J.V. Framil V.M. Nadal S.R. Marta A.C. Lellis R.F. Genital warts: comparing clinical findings to dermatoscopic aspects, in vivo reflectance confocal features and histopathologic exam.An Bras Dermatol. 2014; 89: 137-140Crossref PubMed Scopus (25) Google Scholar, 8Zalaudek I. Giacomel J. Cabo H. et al.Entodermoscopy: a new tool for diagnosing skin infections and infestations.Dermatology. 2008; 216: 14-23Crossref PubMed Scopus (146) Google Scholar We present a case of genital wart that falls into none of the aforementioned patterns. The honeycomb pattern observed on confocal microscopy is normally observed in seborrheic keratoses. This case illustrates the complementarity of dermoscopy and confocal microscopy in the diagnosis of clinically atypical lesions of the genital mucosa. Genital warts are the most common sexually transmitted disease, and they are caused by the human papillomavirus.2Partridge J.M. Koutsky L.A. Genital human papillomavirus infection in men.Lancet Infect Dis. 2006; 6: 21-31Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar This case highlights the difficulties encountered in the differential diagnosis of darkly pigmented planar lesions of the penis. Dermoscopic patterns in genital warts have been described by several investigators (fingerlike, knoblike, mosaiclike, and pattern combinations).3Dong H. Shu D. Campbell T.M. Fruhauf J. Soyer H.P. Hofmann-Wellenhof R. Dermatoscopy of genital warts.J Am Acad Dermatol. 2011; 64: 859-864Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 4Ozdemir F. Kilinc-Karaarslan I. Akalin T. A pigmented, hemorrhagic genital wart: clinical, dermoscopic, and histopathologic features.Arch Dermatol. 2008; 144: 1072-1073Crossref PubMed Scopus (6) Google Scholar, 5Ozkur E. Falay T. Turgut Erdemir A.V. Gurel M.S. Leblebici C. Vestibular papillomatosis: an important differential diagnosis of vulvar papillomas.Dermatol Online J. 2016; 22PubMed Google Scholar, 6Pastar Z. Lipozencic J. Significance of dermatoscopy in genital dermatoses.Clin Dermatol. 2014; 32: 315-318Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 7Veasey J.V. Framil V.M. Nadal S.R. Marta A.C. Lellis R.F. Genital warts: comparing clinical findings to dermatoscopic aspects, in vivo reflectance confocal features and histopathologic exam.An Bras Dermatol. 2014; 89: 137-140Crossref PubMed Scopus (25) Google Scholar, 8Zalaudek I. Giacomel J. Cabo H. et al.Entodermoscopy: a new tool for diagnosing skin infections and infestations.Dermatology. 2008; 216: 14-23Crossref PubMed Scopus (146) Google Scholar We present a case of genital wart that falls into none of the aforementioned patterns. The honeycomb pattern observed on confocal microscopy is normally observed in seborrheic keratoses. This case illustrates the complementarity of dermoscopy and confocal microscopy in the diagnosis of clinically atypical lesions of the genital mucosa.