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Diagnosis and Management of Pearly Penile

Papules

Article in American Journal of Men s Health · June 2016

DOI: 10.1177/1557988316654138

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research-article2016
JMHXXX10.1177/1557988316654138American Journal of Men’s HealthAldahan et al

Article
American Journal of Men’s Health

Diagnosis and Management of Pearly

1­–4
© The Author(s) 2016
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DOI: 10.1177/1557988316654138
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Adam S. Aldahan, BS1, Tara K. Brah, MD1, and Keyvan Nouri, MD1

Abstract
Pearly penile papules (PPP) are common, benign lesions that appear on the corona of the glans penis during
adolescence or early adulthood. Despite their benign nature, PPP are known to cause significant distress because of
their resemblance to sexually transmitted infections such as condyloma acuminata. PPP can be clinically distinguished
based on their uniform, dome-shaped papules that orient in one to two rows around the glans penis. There is no
association between PPP and sexually transmitted infections, and treatment is generally reserved for patients with
excessive concern. Physicians should be aware of this distinction in order to adequately reassure anxious patients. For
patients who still desire treatment after counseling, cryotherapy and laser therapy represent two reliable treatment
options with low rates of recurrence.

Keywords
sexual health, male sexual anxiety, sexually transmitted diseases/infections

Introduction
Pearly penile papules (PPP) are painless and benign
lesions that present in rows around the corona of the glans
penis in late adolescence or early adulthood. Although
asymptomatic, they are often mistaken for sexually trans-
mitted infections such as condyloma acuminata (Oates,
1997).
Originally described by Littré and Morgagni in 1700,
PPP have been given various names throughout history,
including hirsutoid papilloma, papillomatosis corona
penis, and corona capillitii (Agrawal, Bhattacharya, &
Singh, 2004). Johnson and Baxter (1964) were the first to
coin the term PPP in 1964. Although the function of PPP
is poorly understood, it is thought that they are vestigial,
as similar structures are seen in other mammals (Callomon
& Wilson, 1956).
Presentation
PPP are present in 14% to 48% of males, although the
prevalence varies among specific populations (Agrawal
et al., 2004; Michajlowski, Sobjanek, Michajlowski,
Wlodarkiewicz, & Matuszewski, 2012; Sonnex &
Dockerty, 1999). The lesions usually present as pink or
white, dome-shaped or filiform papules that are one to two
millimeters in diameter and one to four millimeters in
height, orienting around the corona of the glans penis usu-
ally in one to two rows (Figure 1; Agrawal et al., 2004;
Michajlowski et al., 2012; Oates, 1997). PPP are most
prominent along the dorsal side of the corona and may
encircle the glans entirely, although lesions have also been
reported ectopically on the shaft of the penis (Neri,
Bardazzi, Raone, Negosanti, & Patrizi, 1997; O’Neil &
Hansen, 1995). Lesions are rarely seen in prepubertal chil-
dren and most often present during the late stages of
puberty (Glicksman & Freeman, 1966; Neri et al., 1997;
Oates, 1997). The prevalence declines in older patients,
suggesting that the lesions regress with age (Agha et al.,
2009; Glicksman & Freeman, 1966). Circumcised males
have lower rates of PPP, possibly due to chronic abrasion
to the exposed corona causing lesion regression (Agha
et al., 2009; Michajlowski et al., 2012; Neinstein &
Goldenring, 1984; Vesper, Messina, Glass, & Fenske,
1995). There is some evidence that PPP are more common
in the Black population (Rehbein, 1977), but many studies
have reported no association with race (Glicksman &
Freeman, 1966; Neinstein & Goldenring, 1984).
Unfamiliarity of the benign nature of PPP often leads
to significant anxiety and fear of having a sexually trans-
mitted infection. A retrospective study in Singapore
reported that more than 14% of men who initially pre-
sented to a sexually transmitted infection clinic had
1
University of Miami Miller School of Medicine, Miami, FL, USA
Corresponding Author:
Adam S. Aldahan, Department of Dermatology and Cutaneous
Surgery, University of Miami Miller School of Medicine, 1475 NW
12th Ave., Suite 2175, Miami, FL 33136, USA.
Email: AAldahan@med.miami.edu
2 American Journal of Men’s Health
Figure 1.  (a) Clinical photograph demonstrating dome-shaped papules along the corona of the glans penis. (b) Dermoscopic
image illustrating PPP with comma-shaped vessels.
exclusively PPP without any evidence of infection (Khoo
& Cheong, 1995). This misconception can also lead to
strained relationships, as fear of a possible sexually trans-
mitted infection calls into question the fidelity between
partners (Monroe, 2009). The degree of concern has even
been correlated to the size of the papules. In one question-
naire study, significant worry was reported in 63% of
patients with moderate or large papules, compared with
33% of patients with barely perceptible PPP (Sonnex &
Dockerty, 1999).
The differential diagnosis includes condyloma acumi-
nata, Tyson’s glands, or molluscum contagiosum. PPP do
not contain human papillomavirus (Ferenczy, Richart, &
Wright, 1991), and there is no association between con-
dyloma and the presence of PPP (Hogewoning et al.,
2003). Unlike Tyson’s glands, which are modified seba-
ceous glands in a parafrenular distribution, PPP are not
predominantly parafrenular and have no glandular com-
ponent (Ackerman & Kronberg, 1973). Molluscum con-
tagiosum can be distinguished clinically from PPP based
on their umbilicated papules that are larger in size
(Agrawal et al., 2004; O’Neil & Hansen, 1995). Despite
the fact that PPP can be easily distinguished from more
serious diagnoses, one study indicated that 38% of
affected men reported being concerned or worried about
their lesions, and nearly half of those who learned of their
benign nature still wanted them removed (Sonnex &
Dockerty, 1999).
On dermoscopy, PPP appear white or pink in a cobble-
stone or grape-like pattern with each papule containing
central dotted or comma-shaped vessels (Figure 1; Ozeki,
Saito, & Tanaka, 2008; Watanabe, Yoshida, & Yamamoto,
2010). This vessel architecture is nonspecific and can
also be seen in condyloma (Watanabe et al., 2010). Unlike
warts, however, PPP do not have desquamation, which is
seen as an irregular reflection on dermoscopy (Ozeki
et al., 2008).
The histology of PPP is similar to that of acral angio-
fibromas, and for this reason they have been proposed as
a subcategory (Oates, 1997; Ozeki et al., 2008). The his-
tological findings include increased epidermal melano-
cytes overlying a prominent granular zone with absent
basal layer pigment (Glicksman & Freeman, 1966;
Neinstein & Goldenring, 1984). Increased vasculature is
seen in the upper dermis with focally elongated rete
ridges (Oates, 1997; Ozeki et al., 2008; Vesper et al.,
1995; Watanabe et al., 2010). The dermis also contains
infiltration of lymphocytes and histiocytes (Oates, 1997;
Ozeki et al., 2008). Last, a whorled collagen pattern is
seen with increased spindle-shaped stellate fibroblasts
(Ackerman & Kronberg, 1973; Agrawal et al., 2004).
Treatment
Because of the benign nature of PPP as well as their
regression with age, treatment is generally reserved for
patients who suffer extensive embarrassment or concern.
Cryotherapy and lasers have been reported in such cases.
One study performed two sessions of cryotherapy in four
patients and cleared 80% to 90% of lesions without com-
plications (Ocampo-Candiani & Cueva-Rodriguez,
1996). Another case report of a patient with dark skin
described similarly successful results with no pigmenta-
tion changes and no lesion recurrence after 2 years (Porter
& Bunker, 2000).
Various groups have reported successful and com-
plete clearance of PPP with CO2 laser ablation. The high
vascularity of penile tissue allows for rapid healing after
laser-induced thermal injury, but this also predisposes
the patient to bleeding during the procedure. The
Aldahan et al 3
continuous wave mode of the CO2 laser provides better
hemostasis and operative field visualization than the
short pulse mode (McKinlay, Graham, & Ross, 1999).
Using the fractionated CO2 laser, one group reported
more than 90% resolution after a single treatment
(Krakowski, Feldstein, & Shumaker, 2015). Another
group concluded that two to three treatments were suffi-
cient to completely resolve lesions without adverse
effects in both light and dark skin types (Gan & Graber,
2015). While the CO2 laser exposes the underlying tis-
sue, reepithelialization generally occurs within 5 to 7
days (Krakowski et al., 2015). Nevertheless, the proce-
dure requires anesthesia and increases the risk of scar-
ring and infection. Additionally, the postoperative
management, including home dressing changes, can be
inconvenient to patients (Rokhsar & Ilyas, 2008). The
CO2 laser can also lead to postinflammatory pigmenta-
tion changes in dark skin types. Despite this fact, two
groups reported complete lesion resolution with no
adverse pigmentary events (Lane, Peterson, & Ratz,
2002; Magid & Garden, 1989).
Using the ablative 2940-nm Er:YAG laser,
Baumgartner treated 45 patients for one to six sessions.
All lesions were successfully cleared with no adverse
effects and no recurrence after 1 year. Notably, many of
the patients in this study had prior failed treatment
attempts with agents such as podophyllin, cryotherapy,
and topical fluorouracil plus salicylic acid. Ablated areas
healed within 2 weeks after treatment. Despite sustaining
up to six laser sessions, no scarring or pigmentation
changes were noted (Baumgartner, 2012).
Fractional resurfacing with the 1550-nm erbium laser
has shown complete clearance in one patient after five
treatment sessions. Unlike ablative approaches, this laser
was relatively painless and did not produce open wounds
in the skin. Additionally, there was no lesion recurrence
after 1 year (Rokhsar & Ilyas, 2008).
The pulsed dye laser has also shown significant
lesion clearance with minimal discomfort. In a study
involving four patients, Sapra, Sapra, and Singh (2013)
achieved complete resolution in three patients after two
to three treatments. The remaining patient was satisfied
with the results after one treatment. Future laser thera-
pies will likely focus on nonablative approaches, such
as the pulsed dye laser, to adequately and painlessly
treat PPP without the risk of infection or scarring.
Although typically reserved for special scenarios, laser
treatment of PPP produces favorable cosmetic results
with a low risk of adverse effects and recurrence.
Conclusion
PPP are common, asymptomatic lesions that can cause seri-
ous concern for patients despite their benign nature. The
fear of sexually transmitted infections can cause significant
distress in male and female patients alike, severely affecting
quality of life. Understandably, a new or recently discov-
ered genital lesion can send patients running to their doc-
tors. While frequent misdiagnosis of benign lesions such as
PPP perpetuates patient anxiety, these lesions can be both
clinically and histologically distinguished from more seri-
ous conditions such as condyloma acuminata. Reassurance
is the most appropriate course of action, although treatment
options such as laser and cryotherapy are available for
patients with significant distress. It is important for physi-
cians to be aware of this common mimicker in order to pro-
vide appropriate management.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
Ackerman, A. B., & Kronberg, R. (1973). Pearly penile pap-
ules. Acral angiofibromas. Archives of Dermatology, 108,
673-675.
Agha, K., Alderson, S., Samraj, S., Cottam, A., Merry, C., Lee,
V., & Patel, R. (2009). Pearly penile papules regress in
older patients and with circumcision. International Journal
of STD & AIDS, 20, 768-770.
Agrawal, S. K., Bhattacharya, S. N., & Singh, N. (2004).
Pearly penile papules: A review. International Journal of
Dermatology, 43, 199-201.
Baumgartner, J. (2012). Erbium: yttrium-aluminium-garnet
(Er:YAG) laser treatment of penile pearly papules. Journal
of Cosmetic and Laser Therapy, 14, 155-158.
Callomon, F. T., & Wilson, J. F. (1956). The nonvenereal dis-
eases of the genitals: Etiology, differential diagnosis, and
therapy. Springfield, IL: Thomas.
Ferenczy, A., Richart, R. M., & Wright, T. C. (1991). Pearly
penile papules: Absence of human papillomavirus DNA by
the polymerase chain reaction. Obstetrics & Gynecology,
78, 118-122.
Gan, S. D., & Graber, E. M. (2015). Treatment of pearly penile
papules with fractionated CO2 laser. Journal of Clinical
and Aesthetic Dermatology, 8(5), 50-52.
Glicksman, J. M., & Freeman, R. G. (1966). Pearly penile
papules. A statistical study of incidence. Archives of
Dermatology, 93, 56-59.
Hogewoning, C. J., Bleeker, M. C., van den Brule, A. J.,
Voorhorst, F. J., van Andel, R. E., Risse, E. K., . . .
Meijer, C. J. (2003). Pearly penile papules: Still no rea-
son for uneasiness. Journal of the American Academy of
Dermatology, 49, 50-54.
Johnson, B. L., Jr., & Baxter, D. L. (1964). Pearly penile papules.
Archives of Dermatology, 90, 166-167.
4 American Journal of Men’s Health
Khoo, L. S., & Cheong, W. K. (1995). Common genital derma-
toses in male patients attending a public sexually transmit-
ted disease clinic in Singapore. Annals of the Academy of
Medicine, Singapore, 24, 505-509.
Krakowski, A. C., Feldstein, S., & Shumaker, P. R. (2015).
Successful treatment of pearly penile papules with carbon
dioxide laser resurfacing after local anesthesia in an adoles-
cent patient. Pediatric Dermatology, 32, 433-435.
Lane, J. E., Peterson, C. M., & Ratz, J. L. (2002). Treatment
of pearly penile papules with CO2 laser. Dermatologic
Surgery, 28, 617-618.
Magid, M., & Garden, J. M. (1989). Pearly penile papules:
Treatment with the carbon dioxide laser. Journal of
Dermatologic Surgery and Oncology, 15, 552-554.
McKinlay, J. R., Graham, B. S., & Ross, E. V. (1999). The clin-
ical superiority of continuous exposure versus short-pulsed
carbon dioxide laser exposures for the treatment of pearly
penile papules. Dermatologic Surgery, 25, 124-126.
Michajlowski, I., Sobjanek, M., Michajlowski, J.,
Wlodarkiewicz, A., & Matuszewski, M. (2012). Normal
variants in patients consulted in the dermatology clinic for
lesions of the male external genitalia. Central European
Journal of Urology, 65(1), 17-20.
Monroe, J. R. (2009). Does this man have genital warts? Pearly
penile papules. Journal of the American Academy of
Physician Assistants, 22(2), 16.
Neinstein, L. S., & Goldenring, J. (1984). Pink pearly papules:
An epidemiologic study. Journal of Pediatrics, 105, 594-595.
Neri, I., Bardazzi, F., Raone, B., Negosanti, M., & Patrizi, A.
(1997). Ectopic pearly penile papules: A paediatric case.
Genitourinary Medicine, 73(2), 136.
View publication stats
Oates, J. K. (1997). Pearly penile papules. Genitourinary
Medicine, 73, 137-138.
Ocampo-Candiani, J., & Cueva-Rodriguez, J. A. (1996).
Cryosurgical treatment of pearly penile papules. Journal
of the American Academy of Dermatology, 35(3 Pt 1),
486-487.
O’Neil, C. A., & Hansen, R. C. (1995). Pearly penile papules on
the shaft. Archives of Dermatology, 131, 491-492.
Ozeki, M., Saito, R., & Tanaka, M. (2008). Dermoscopic fea-
tures of pearly penile papules. Dermatology, 217, 21-22.
Porter, W. M., & Bunker, C. B. (2000). Treatment of pearly
penile papules with cryotherapy. British Journal of
Dermatology, 142, 847-848.
Rehbein, H. M. (1977). Pearly penile papules: Incidence. Cutis,
19, 54-57.
Rokhsar, C. K., & Ilyas, H. (2008). Fractional resurfacing
for the treatment of pearly penile papules. Dermatologic
Surgery, 34, 1420-1422.
Sapra, P., Sapra, S., & Singh, A. (2013). Pearly penile pap-
ules: Effective therapy with pulsed dye laser. JAMA
Dermatology, 149, 748-750.
Sonnex, C., & Dockerty, W. G. (1999). Pearly penile papules:
A common cause of concern. International Journal of STD
& AIDS, 10, 726-727.
Vesper, J. L., Messina, J., Glass, L. F., & Fenske, N. A. (1995).
Profound proliferating pearly penile papules. International
Journal of Dermatology, 34, 425-426.
Watanabe, T., Yoshida, Y., & Yamamoto, O. (2010).
Differential diagnosis of pearly penile papules and penile
condyloma acuminatum by dermoscopy. European Journal
of Dermatology, 20, 414-415.