Perigenital warty lesions-what is your diagnosis?

Perigenital warty lesions can be of diverse origin. An attempt should be made to rule out sexually transmitted disease (STD). If the diagnosis is not settled, biopsy may clinch the diagnosis.

INTRODUCTION

Perigenital warty lesions can be of diverse origin. An attempt should be made to rule out sexually transmitted disease (STD). If the diagnosis is not settled, biopsy may clinch the diagnosis.

PRESENT CASE

A 36-year-old married male patient presented to dermatology outpatient department with complaints of multiple skin lesion over inguinal region for 1 year. He had associated itching which was moderate in severity, with no diurnal variation. There was no history of extra marital sexual exposure. He had consulted various family physicians for the same, with no response.

Cutaneous examination revealed multiple hyperpigmented hyperkeratotic plaques over the lower abdomen, inner thighs, and scrotum Figures 1–3. Nail, hair, and oral mucosa were normal. Regional lymph nodes were not palpable, and the rest of the systemic examination was normal. Peri anal region was insignificant. Differential diagnosis was considered as genital molluscum contagiosum, genital warts, and keratoacanthoma.

Figure 1

Cutaneous examination-hyperpigmented hyperkeratotic plaques over lower abdomen, inner thighs and scrotum

Figure 3

Hyperkeratotic plaques over inner thigh

Investigations

Serum venereal disease research laboratory and serum HIV were negative. Complete blood count and urine routine were within normal limits. Punch Biopsy was taken and sent for Histopathological examination.

What is your diagnosis?

HPE revealed moderately dense superficial perivascular lymphocytic infiltrate along with irregular epidermal hyperplasia which obscures the dermoepidermal junction. The dermoepidermal junction at those spots shows occasional colloid bodies. Figures 4 and 5 shows wedge-shaped hypergranulosis seen within hyperplastic appendages.

Figure 4

Histopathology showing perivascular lymphocytic infiltrate

Figure 5

Histopathology showing wedge shaped hypergranulosis

FINAL DIAGNOSIS-HYPERTROPHIC LICHEN PLANUS

Treatment given

In this case, intralesional steroid (triamcinolone 10 mg/ml) fornightly along with cryotherapy have been used to treat the patient with improvement [Figures 6 and 7]. Patient responsed well after 4 weeks.

Figure 6

Posttreatment-4 weeks follow up

Figure 7

Posttreatment -6 weeks follow up

DISCUSSION

In the case discussed, predominantly warty lesions were suggestive of venereal warts, but there was no history of exposure, no other marker of STD and serology for HIV and syphilis were nonreactive.

Non-venereal conditions considered were keratoacanthosis and seborrheic keratosis. Surprisingly biopsy suggested hypertrophic lichen planus (HLP)

Lichen planus (LP) is an inflammatory, papulosquamous disorder affecting either or all of the skin, mucous membranes, hair, and nail.[1]

HLP is a subacute or chronic variant of lichen planus, better known as lichen planus hypertrophicus (LPH), characterized by hypertrophic or warty lesions, most often found on the pretibial area of the lower limbs.[2] There is a dearth of a report on the occurrence of hypertrophic lesions over scrotum and inguinal region. Neoplastic transformation in cutaneous LP is very rare, although the incidence of cancer in oral LP is about 1.3%.[3] The underlying mechanism of this malignant conversion is not exactly known, but speculatively, chronic inflammatory processes show an overdrive of growth factors that constantly stimulate epithelial cell proliferation into neoplastic conditions.[45] An average time of 12 years may lapse between the diagnosis of hypertrophic LP and the onset of squamous cell carcinoma (SCC), prompting regular follow up of HLP cases for long period is essential. There should be no reservation for biopsy.

The majority of reported neoplasms have been histologically well-differentiated SCCs. Two cases of keratoacanthoma, both occurring on the lower legs in association with HLP have been reported.[4]

Histopathology of hypertrophic LP shows pseudoepitheliomatous hyperplasia with hyperkeratosis and irregular acanthosis. The interface infiltrate is less band-like. Cystic dilatation of hair follicles. In long-standing cases, vertical streaking of collagen bundles similar to lichen simplex chronicus and dermal fibrosis is seen.

Potent corticosteroid ointments (e.g., fluocinonide 0.05% and clobetasol propionate, 0.05%) are the main-stay of therapy for localized lesions of LP. In hypertrophic and palmoplantar lesions, these can be administered under occlusion. Intralesional injection of a long-acting steroid (triamcinolone acetonide, 40 mg/ml) once in 3–4 weeks is effective in hypertrophic LP. Calcineurin inhibitors such as cyclosporine, tacrolimus, and pimecrolimus have been used to treat LP

LP runs a chronic course, over months to several years. Relapse occurs in 15%–20% of cases.

Learning points

In case of genital and inguinal warty lesions, both sexually acquired and nonsexually acquired causes should be ruled out

Biopsy may rule the roost like in present case

Intralesional corticosteroid can give gratifying result and can be considered as first line therapy

There is potential for malignant transformation which is very slow

Such cases should be followed for long term to detect malignant transformation at an early stage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.