An Unusual Post-Inflammatory Hyperpigmentation of MaleGenitalia

Funda Tamer,1 MD, Erol Koc,2 MD, Can Ergin,2 MD

1Ufuk University School of Medicine, Department of Dermatology, Ankara, 2Medical Park Hospital, Department ofDermatology, AnkaraE-mail: fundatmr@yahoo.com* Corresponding Author: Dr. Funda Tamer, Mevlana Bulvarı (Konya yolu) No:86-88, 06510 Balgat/ Ankara,Turkey.

Case Report DOI: 10.6003/jtad.17114c2

Published:J Turk Acad Dermatol 2017;11 (4): 17114c2This article is available from: http://www.jtad.org/2017/4/jtad17114c2.pdfKey Words: Genitalia, hyperpigmentation, post-inflammatory, pruritus

Abstract

Observation: Post-inflammatory hyperpigmentation is an epidermal or dermal hypermelanosis whichis characterized by brown-black colored macules and large patches. It usually occurs followinginflammatory skin diseases like lichen planus, atopic dermatitis or dermatologic procedures like lasertherapy and chemical peels. Post-inflammatory hyperpigmentation is usually asymptomatic. However,the condition can lead to cosmetic concerns, low self-esteem and depression. Herein, we presenteda 24-year-old Caucasian male patient with hyperpigmented lesions on the skin of his genitalia and wediscussed underlying inflammatory diseases.

Introduction Post-inflammatory hyperpigmentation is a re-active response to inflammatory skin diseaseslike lichen planus, psoriasis, atopic dermatitis, acne vulgaris and inflammatory conditions including non-ionizing radiation, photo-toxic reactions, laser therapy and chemicalpeels. Melanin can be deposited in ep ider-mis, dermis or both. Epidermal hypermelano-sis presents with brown colored macules andpatches. However, dermal hypermelanosispresents with gray-blue colored lesions. Di-stribution of the skin lesions depends onthe underlying condition. Post-inflammatoryhyperpigmentation is usually asymptomatic.However, the condition can influence pati-ent’s self-esteem [1].

Anogenital pruritus is described as itching ofthe anus, perianal region and genital skin. Itaffects men more than women. Pruritus las-ting more than six weeks is called chronicpruritus. Chronic anogenital pruritus can beidiopathic or psychogenic. Moreover, derma-toses like seborrheic dermatitis, psoriasis,atopic dermatitis, lichen sclerosus; malignan-cies like extramammary Paget’s disease, Bo-wen’s disease, erythroplasia of Queyrat, basalcell carcinoma; mechanical causes and syste-mic disorders including diabetes mellitus,liver diseases, iron deficiency, hyperthyroi-dism can cause anogenital pruritus. Chronicanogenital pruritus can result in excoriation,lichenification and hyperpigmentation [2].

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Case Report

A 24-year-old Caucasian male patient presentedwith a two-year history of hyperpigmentation onthe penis and scrotum. The patient admitted thatthe pigmentation first appeared on the penis andthen gradually spread to the scrotum. The lesionswere itchy and itching was more severe duringnight. He had been treated with oral terbinafine250 mg a day, topical isoconazole nitrate andmethylprednisolone twice daily for the last threemonths. However, no clinical improvement hasbeen achieved. The patient had a past medical his-tory of migraine and was taking oral flurbiprofenoccasionally. He had no known allergies. The fa-mily history was unremarkable. Dermatologicalexamination revealed hyperpigmented patches on

the corpus of the penis and scrotum (Figures 1a-b). The patient had a Fitzpatrick skin type IV.

The laboratory tests including complete bloodcount, sedimentation rate, blood chemistry panel,serum ferritin, vitamin B12, folate and thyroid sti-mulating hormone level were all in normal limits.Fixed drug eruption, lichen planus pigmentosus,Bowen’s disease, lichen amyloidosis and acantho-sis nigricans were considered in the differential di-agnosis. Therefore, a skin biopsy was performed toreach a definitive diagnosis. Histopathological exa-mination revealed orthokeratosis, hypermelanosisin the basal layer of the epidermis, perivascular in-flammatory infiltrate and melanophages in the pa-pillary dermis. Crystal violet stain didn’t showamyloid deposition (Figure 2). The diagnosis ofpost-inflammatory hyperpigmentation was madebased on the clinical and histopathological featu-res.

Discussion Post-inflammatory hyperpigmentation is cha-racterized by brown, black macules due to ex-cess melanin in epidermis or dermis. Manyinflammatory disorders including lichen pla-nus, morphea, contact dermatitis and mecha-nical trauma can induce melanin production[3]. Contact dermatitis of the scrotum is usu-ally defined as scrotal dermatitis. It presentswith pruritus, erythema, scaling and licheni-fication on the scrotal skin. However, Krish-nan et al. implicated that scrotal dermatitis isnot a type of contact dermatitis and it shouldbe considered as a distinct entity [4].

In our patient, hyperpigmented patches wereinduced by mechanical trauma due to chronic

J Turk Acad Dermatol 2017; 11(4): 17114c2. http://www.jtad.org/2017/4/jtad17114c2.pdf

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Figures 1a and b. Hyperpigmented patches on the penis and scrotum

Figure 2. Orthokeratosis, hypermelanosis in the basallayer of the epidermis, perivascular inflammatory infilt-

rate and melanophages in the papillary dermis(H&Ex200)

pruritus. There weren’t any underlying disea-ses. However, post-inflammatory hyperpig-mented lesions on the penis and scrotum ofthe patient can mimic various dermatoses in-cluding fixed drug eruption, lichen planus pigmentosus, Bowen’s disease, lichen amyloido-sis and acanthosis nigricans.

Besides, fixed drug eruption usually presentsas a solitary lesion; acanthosis nigricans isusually associated with obesity, diabetes andinsulin resistance; pigmented Bowen’s diseasehistopathologically shows epidermal dysplasiaand melanin rich cells, lichen amyloidosisshows amyloid deposition; lichen planus pig-mentosus usually presents on sun-exposedareas and it is characterized by dermal mela-nophages and pigment incontinence histopat-hologically [5,6].

Dermatoscopy may be helpful for diagnosis ofmalignant lesions. However, dermatoscopicevaluation of genital lesions is not always easyin clinical practice. Recently, Agozzino et al.reported that reflectance confocal microscopyis a useful diagnostic method in pigmented ge-nital lesions [7].

In conclusion, severe and chronic itching canresult in skin changes that lead to diagnosticdifficulties. In such cases, histopathologicalevaluation is important to reach a definitive di-agnosis. The case we presented summarize thedifferential diagnosis of hyperpigmented lesi-ons of male genitalia.

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J Turk Acad Dermatol 2017; 11(4): 17114c2. http://www.jtad.org/2017/4/jtad17114c2.pdf