Videodermatoscopy enhances diagnostic capability in psoriatic balanitis

Abstract

To the Editor: Balanitis is an inflammatory condition of the glans penis that may be caused by a wide range of dermatologic conditions, including psoriasis. Psoriatic balanitis is clinically characterized by erythematous, nonscaling plaques most commonly located proximally on the glans and under the prepuce.1Bull R.H. Bates D.O. Mortimer P.S. Intravital video-capillaroscopy for the study of the microcirculation in psoriasis.Br J Dermatol. 1992; 91: 343-345Google Scholar Most often, genital psoriasis is part of a more generalized disease process, but in the case of exclusively penile involvement, the correct diagnosis may be difficult to make, and several investigations, including a skin biopsy, are often necessary.2De Angelis R. Bugatti L. Del Medico P. Nicolini M. Filosa G. Videocapillaroscopic findings in the microcirculation of the psoriatic plaque.Dermatology. 2002; 204: 236-239Crossref PubMed Scopus (65) Google Scholar Previous studies have demonstrated that the evaluation of the vascular pattern may facilitate the clinical diagnosis of psoriasis1Bull R.H. Bates D.O. Mortimer P.S. Intravital video-capillaroscopy for the study of the microcirculation in psoriasis.Br J Dermatol. 1992; 91: 343-345Google Scholar, 2De Angelis R. Bugatti L. Del Medico P. Nicolini M. Filosa G. Videocapillaroscopic findings in the microcirculation of the psoriatic plaque.Dermatology. 2002; 204: 236-239Crossref PubMed Scopus (65) Google Scholar, 3Rosina P. Zamperetti M.R. Giovannini A. Girolomoni G. Videocapillaroscopy in the differential diagnosis between psoriasis and seborrheic dermatitis of the scalp.Dermatology. 2007; 214: 21-24Crossref PubMed Scopus (35) Google Scholar, 4Micali G. Nardone B. Scuderi A. Lacarrubba F. Videodermatoscopy enhances the diagnostic capability of palmar and/or plantar psoriasis.Am J Clin Dermatol. 2008; 9: 119-122Crossref PubMed Scopus (27) Google Scholar; in particular, the capillaries in psoriatic plaques are much larger than those in normal skin, appearing as “bushy” structures, related to an overexpression of vascular endothelial growth factor leading to the elongation of capillary loops through the proliferation of endothelial cells in the venous limb.5Detmar M. Brown L.F. Claffey K.P. Yeo K.T. Kocher O. Jackman R.W. et al.Overexpression of vascular permeability factor/vascular endothelial growth factor and its receptors in psoriasis.J Exp Med. 1994; 180: 1141-1146Crossref PubMed Scopus (641) Google Scholar The aim of our preliminary investigation was to determine if videodermatoscopy (VD), a noninvasive technique, may provide additional information useful to address the diagnosis by evaluating the superficial vascular pattern. A series of patients affected by psoriatic balanitis was studied. Six subjects (mean age, 49.1 years; range, 41-70 years) were enrolled in an open study. Inclusion criteria were the presence of biopsy-proven psoriatic balanitis and no other skin involvement. Exclusion criteria were the presence of comorbid disorders and the use of systemic and/or topical drugs during the last 4 and 2 weeks, respectively. VD was performed using a Video Microscope System Hi-Scope KH-2200 (Hirox Co Ltd, Tokyo, Japan). In order to evaluate the vascular pattern, VD examination was performed using two different magnifications (×100 and ×200). To eliminate light reflection and achieve optimal visualization of vascular structures, as a rule, each field was covered with immersion oil and a disposable glass slide; this simple procedure also prevents the spread of infectious disease. Six cases of histologically or microbiologically proven nonpsoriatic balanitis (2 lichen planus, 1 lichen sclerosus, 1 Zoon balanitis, and 2 candidiasis) were also evaluated by VD. At the end of the study, VD showed in all psoriatic balanitis subjects a uniform pattern, consisting of dilated and tortuous capillaries, with a typical “bushy,” homogenous aspect in all examined fields (Fig 1). This pattern histologically corresponded to dilated, elongated, and tortuous capillary loops in the papillary dermis. In the six cases of nonpsoriatic balanitis, no “bushy” pattern was observed; in contrast, a nonspecific pattern, with dilated, linear, irregularly distributed capillaries without any peculiar aspect, was evident (Fig 2).Fig 2Zoon balanitis. A, Clinical appearance. B, Presence of dilated, linear, irregularly distributed capillaries without any definitive structure. (Videodermatoscopic magnification: ×200.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Although further studies in larger series are necessary to confirm our findings, VD seems to represent a promising tool that may improve the clinical diagnosis of psoriatic balanitis through the evaluation of superficial vascular structures, thereby avoiding skin biopsy. This is particularly important in those cases in which psoriatic lesions located in typical body areas or elsewhere on the body are absent. It should be noted that VD examination must be performed by gently applying a glass slide to the skin in order to obtain good visualization of vascular structures. Moreover, a fully trained operator is necessary to avoid blanching of the vessels while performing VD. Our results are comparable with those obtained in a previous study that evaluated the vascular pattern in a series of patients affected by palmoplantar psoriasis.4Micali G. Nardone B. Scuderi A. Lacarrubba F. Videodermatoscopy enhances the diagnostic capability of palmar and/or plantar psoriasis.Am J Clin Dermatol. 2008; 9: 119-122Crossref PubMed Scopus (27) Google Scholar