Blackwell Science, LtdOxford, UK
BJUBJU International1464-4096BJU International
905September 2002
2962
COMMON SKIN DISORDERS OF THE PENIS
S.A. BUECHNER
10.1046/j.1464-4096.2002.02962.x
Update EUUS Review Article498506BEES SGML
BJU International (2002), 90, 498–506
Common skin disorders of the penis
S.A. BUECHNER
Department of Dermatology, University of Basel, Basel, Switzerland
Summary
Diseases of the male genitalia range from infectious
lesions to inflammatory and neoplastic conditions,
including many genital manifestations of more general
skin diseases. This review highlights the clinical features,
diagnosis and treatment of the most common dermatoses
of the male genitalia. Herpes genitalis and infections
caused by human papillomavirus (HPV) are increasing,
particularly in young sexually active people. Herpes sim-
plex virus infection is the commonest infectious cause of
genital ulceration, with evidence that many infections are
asymptomatic. HPV infection may be latent, subclinical
and clinical. The most common causal agents for condy-
loma acuminatum are low-risk HPV 6 and 11; high-risk
HPV types 16 and 18 are associated with premalignant
and malignant lesions. Treatment for genital warts
remains unsatisfactory; recurrences are common. Imi-
quimod, a new topical immunotherapeutic agent, which
induces interferon and other cytokines, has the potential
to be a first-line therapy for genital warts. Scabies and
pediculosis are transmitted by skin-to-skin contact and
sexual transmission is common, with the penis and scro-
tum favourite locations for scabious lesions. Oral ivermec-
tin, a highly active antiparasitic drug, is likely to be the
treatment of choice, but until approval is granted it
should be reserved for special forms of scabies. Common
skin diseases, e.g. psoriasis and lichen planus, may have
an atypical appearance in the genital area. The typical
psoriatic scale is usually not apparent because of moisture
and maceration. Allergic contact dermatitis of the genital
area may result from condoms, lubricants, feminine
hygiene deodorant spray and spermicides. More often,
contact dermatitis is irritant, resulting from persistent
moisture and maceration. Lichen sclerosus is a chronic
inflammatory disease that occurs as atrophic white
patches on the glans penis and foreskin. The penile form
is a common cause of phimosis in uncircumcised men;
involvement of the urethral meatus may lead to progres-
sive meatal stenosis. Plasma cell balanitis is a benign, idio-
pathic condition presenting as a solitary, smooth, shiny,
red-orange plaque of the glans and prepuce of a middle-
aged to older man. Squamous cell carcinoma (SCC) in situ,
e.g. erythroplasia of Queyrat and Bowen’s disease, cannot
be excluded clinically; their apparent clinical benignity
498
doi:10.1046/j.1464-4096.2002.02962.x
may lead to lengthy periods of misdiagnosis and biopsy is
required to confirm the diagnosis. SCC is the most com-
mon malignancy of the penis and the role of oncogenic
HPV-types has been also established in SCC of the penis.
Prevention of SCC of the penis presupposes an identifica-
tion of risk factors, early detection of all pre-cancerous
lesions and treatment of phimosis.
Introduction
A wide range of infectious, neoplastic and inflammatory
dermatoses can affect the male genitalia. Several common
diseases may involve the genital region only incidentally,
while others present in this region with unusual features.
In addition, there are some conditions that are entirely or
predominantly confined to these regions.
Viral infections
Genital warts
These lesions are caused by infection with human papil-
lomavirus (HPV); the incidence of genital HPV infection
among sexually active people aged 15–25 years has been
estimated at 1%. However, the prevalence of virologically
detectable subclinical or latent infection may be as high as
30–50% [1,2]. The prevalence of HPV DNA in healthy
men is estimated to be 5%, with a peak of 8–11% occur-
ring at 16–35 years of age [2,3]. Currently there are over
90 different HPV types, with genital types characterized as
either low- or high-risk [4]. Common genital warts are
usually the manifestation of infection with low-risk HPV
types, most commonly types 6 and 11. HPV 6 and 11 have
a strong tendency to induce condyloma, but are rarely
associated with genital cancer. HPV types 16, 18, 31, 33,
39, 42 and 51–54 are linked with cervical carcinoma and
termed ‘high-risk’ [5]. HPV 16 and 18 are more likely
to be present in subclinical infection, and are the types
most commonly associated with genital cancer. Genital
warts are predominantly a sexually transmitted disease
although other modes of HPV transmission exist. The in-
fectivity of HPV between sexual partners is estimated to be
60% [6]. There are three major types of anogenital warts:
condyloma acuminata are pedunculated, cauliflower-like,
skin-coloured to reddish verrucous papules [7]; genital
© 2002 BJU International

warts may also manifest as dome-shaped, usually flesh-
coloured papules; flat warts are flat-topped papules which
may vary in colour from pink-red to reddish-brown [1,3].
Lesions are frequently multifocal. Areas with increased
friction are most commonly affected by condylomas; the
commonest location of primary infection in uncircum-
cised men is the subpreputial region. Other sites of predi-
lection are the glans penis, coronal sulcus, frenulum,
prepuce, shaft and the scrotum (Fig. 1). They may also
occur on the urethral meatus and can be intraurethral
(Fig. 2). The urethra is involved in 10–28% of patients
[1,8]; condom users often have suprapubic warts.
Subclinical lesions are detected by applying 3–5% acetic
acid to the genital area for up to 5 min [6]. The acetic acid
produces white changes in HPV infected areas. However,
aceto-whitening is not a specific method for diagnosis,
with false-positive results in up to 25% [6]. Subclinical
involvement is especially common in uncircumcised men.
Treatment options for genital warts are [3,9]:
Fig. 1. Multiple papular pigmented condylomata acuminata on the
penile shaft.
Fig. 2. Numerous whitish condylomata acuminata on the tip of the
penis.
© 2002 BJU International 90, 498–506
COMMON SKIN DISORDERS OF THE PENIS 499
• Podophyllotoxin 0.5% solution or gel;
• Cryotherapy withtrichloroacetic
Bichloroacetic or acid 35–85%;
• liquid nitrogen;
• Electrofulguration;
• CO 2laser;
• Imiquimod 5% cream.
Treatment is not confirmed to reduce transmission to
sexual partners nor to prevent progression to dysplasia or
cancer. Treatments with antiviral or immunomodulatory
agents are associated with much lower rates of recurrence
[5]. It is estimated that 10–30% of genital warts resolve
spontaneously within 3 months as a result of cell-
mediated immunity [6].
Genital herpes
Herpes simplex virus (HSV) is the most common cause of
genital ulceration [10]. Genital herpes simplex is predom-
inantly caused by HSV type 2, although HSV-1 is respon-
sible for 5–30% of cases of first-episode genital herpes
[10,11]. After infection, the viral genome remains in a
latent state in the nuclei of sensory neurones for the life of
the host [11]. Genital HSV-1 infections are usually less
severe and less prone to recur than those caused by HSV-
2. Genital herpes caused by HSV-1 is characterized by
lower rates of asymptomatic shedding and transmission.
From seroprevalence studies, genital herpes has increased
by ≈ 30% during the last two decades [10]. Transmission
of HSV occurs through both symptomatic lesions and
asymptomatic viral shedding. In 50–90% of transmis-
sions the infected partner is unaware of the herpes infec-
tion [10]. A recent study showed that condom use offers
significant protection against HSV-2 infection in suscep-
tible women [12].
Clinically, true primary genital herpes appears as mac-
ules and papules, followed by vesicles, pustules and ulcers
[7]. Systemic complaints including fever, myalgias and
lethargy may be present, but are rare in men. Patients will
often have accompanying tender lymphadenitis. Recur-
rent episodes of genital herpes are characteristically less
severe and undergo rapid involution, healing within 5–
10 days [10,11]. Recurrent male genital infection may
present as three to five vesicles on the shaft of the penis.
Of those with a symptomatic first episode of HSV-2 genital
infection will recur in 80–90% within the following year,
but many patients will have unrecognized recurrent infec-
tions with asymptomatic viral shedding [13]. Asymptom-
atic shedding occurs most commonly in the first year after
the primary episode. The diagnosis of ulceration caused by
herpes may be highly suggestive when the usually
grouped blisters rupture and form coalescent grouped
erosions (Fig. 3). However, atypical clinical manifestations
including deep, persistent ulcerations may occur in
500 S.A. BUECHNER

Table 1 Recommendations for treating genital herpes

Patient/state Treatment, mg, ×/day, duration in days

Immunocompetent oral acyclovir 200, ×5, 5

First episode
Recurrent episode
Continuous suppression
Immunocompromised
patients
Fig. 3. Genital herpes; grouped vesicles and erosions are located on
the penis shaft and scrotum.
oral valacyclovir 500, ×2, 5
oral famciclovir 250, ×3, 5
oral acyclovir 200, ×5, 5
oral valacyclovir 500, ×2, 5
oral famciclovir 125, ×2, 5
oral acyclovir 400, ×2
oral valacyclovir 500, ×1
oral famciclovir 250, ×2
oral aciclovir, 200–400, ×5, 10
oral acyclovir 400, ×5, 7–14
oral acyclovir 500, ×2
oral famciclovir 250, ×3

immunocompromised patients, especially in those who

are co-infected with HIV [14]. Recently, a first clinical epi-
sode of genital herpes presenting as non-gonococcal ure-
thritis was described [15]. A diagnosis of genital herpes
infection can be confirmed by virus isolation in cell culture
or PCR detection of HSV DNA [10,11]. Serologic diagnosis
of HSV infection is of value only to determine past expo-
sure. Serological tests that distinguish between HSV-1 and
HSV-2 will soon be commercially available. The treatment
given depends on several factors, including the frequency
and severity of recurrences, and the infection status of the
sexual partner. Because the herpes virus cannot be elimi-
nated from neurones treatment is aimed at controlling the
mucocutaneous expression of the disease. The regimens
for treating genital herpes are summarized in Table 1
[10,11].

Infestations

Scabies
Scabies is an infestation with a mite, Sarcoptes scabiei var
hominis. The mites burrow tunnels into the horny layer of
the epidermis. The female lays 2–3 eggs in the tunnels
each day; within 3–5 days the eggs hatch into larvae Fig. 4. Scabies; multiple erythematous papules.
which transform into nymphs, and these in turn meta-
morphose into adults [6]. Classic areas of infestation
include the web spaces of the hands, axillae, and the flexor
surfaces of the wrists [16]. Burrows are small, crooked lesions may be few or many, but it is very rare not to have
lines 4–6 mm long most frequently found in the web penile lesions in scabies (Fig. 4). The chief clinical symp-
spaces of the fingers, sides of the hands and flexor surfaces tom is pruritus, that is usually worse at night or after hot
of the wrist. With the development of the immune baths. Patients with very good hygiene have fewer specific
response to scabies, the patient develops erythematous lesions, making the diagnosis of scabies more difficult [6].
papules and nodules. Non-specific secondary, eczematous Generalized crusted scabies is found in immunocompro-
lesions are very common [16]. Multiple typical scabetic mised or physically incapacitated individuals; it has been
burrows and papules are often present on the glans penis, reported in patients with HIV infection and in organ-
scrotum and penis shaft [7]. Elsewhere on the skin the transplant recipients. These patients present with wide-

© 2002 BJU International 90, 498–506


spread crusting and psoriasis-like scaling, especially
around and under the nails. Crusts and scales contains
tremendous numbers of mites. Pruritus may be minimal
in crusted scabies. Scabies occurs in at least 2–4% of
patients with HIV infection. Burrow scraping is the best
technique for detecting mites. The preferred treatment for
scabies is permethrin 5% cream applied from neck to the
feet, with particular attention given to the perianal and
genital areas, and to the free nail edge and folds; the cream
is rinsed off after 8–14 h [16]. Lindane 1% lotion or cream
is another recommended medication for scabies. Ivermec-
tin, an oral semisynthetic derivative of a family of macro-
cyclic lactones, is a promising new therapeutic agent
[16,17]; it interrupts the γ−aminobutyric acid-induced
neurotransmission of many parasites, including scabies
mites, and is given as a single dose of 200 µg/kg. However,
in severe cases two or three doses at 1 or 2 week intervals
should be given. Topical ivermectin 1% solution, in two
doses of 400 µg/kg applied weekly, was highly effective,
with complete cure and no signs of recurrence 6 weeks
after completing therapy [18]. All household members of
the scabetic patient, and any sexual partners, should be
treated concomitantly.
Pediculosis pubis
Pediculosis pubis, caused by the ectoparasite Phthirus
pubis, also known as the crab louse, is a sexually transmit-
ted infection that frequently coexists with other sexually
transmitted diseases [6,16]. Therefore, a search for other
sexually transmitted diseases, including HIV, should be
initiated. Pediculosis pubis is a likely diagnosis for any
patient who complains of pruritis of the pubic area. The
lice are 1–2 mm long, appearing as brown or grey specks,
and are attached to the hair base [7,16]. Maculae caer-
uleae are bluish-grey macules that represent the feeding
sites of the louse. Rarely, the axillae and eyelashes are also
involved. Pediculosis and scabies may coexist in the same
individual. Treatment of pediculosis pubis is with topical
permethrin or lindane [16]. Permethrin shampoo should
be applied to the pubic area for 10 min and then washed
off. Sexual partners should also be treated to prevent
recurrent infestation.
Genital manifestations of cutaneous diseases
Psoriasis
Psoriasis is the most common inflammatory reaction that
affects the male genitalia. In many cases, male genital
involvement with psoriasis is part of a more general-
ized cutaneous disorder. The lesions manifest as well-
demarcated, bright red plaques, with no scale in the
inguinal folds and intergluteal cleft, known as inverse pso-
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COMMON SKIN DISORDERS OF THE PENIS 501
Fig. 5. Psoriasis; red scaly patches on the glans penis.
riasis [19]. Occasionally, the entire scrotum and penis are
involved. Psoriasis may occur solely on the penis (Fig. 5).
Usually, in circumcised males red scaly patches are present
on the glans and corona [7]. In uncircumcised individu-
als, well-defined non-scaling plaques are most common
under the prepuce and on the proximal glans. The diag-
nosis of genital psoriasis can usually be made from the
local clinical findings. Occasionally, patients may have a
coincidental fungal infection in the flexures, and it is
always wise to take samples to rule out Tinea or Candida.
The presence of typical red scaly patches, particularly in
such areas as the elbows, knees and scalp, help to establish
the clinical diagnosis. The management of genital psoria-
sis can sometimes be a vexing problem; control may be
satisfactory with low-potency corticosteroid creams. A
preparation of 3% liquor carbonis detergens in 1% hydro-
cortisone cream may be very helpful [7]. Topical vitamin
D analogues such as calcipotriene or tacalcitol can be tried
as monotherapy or combined with topical steroids. A
common side-effect of calcipotriene treatment is the devel-
opment of an irritant contact dermatitis. Treatment
regimens in which topical vitamin analogues and corti-
costeroids are both used may minimize the side-effects of
either agent, while maximising the beneficial effects.
Lichen planus
The male genitalia are involved in 25% of cases of this con-
dition and the glans penis is most commonly affected, with
annular lesions frequently present [7,19]. Typically, the
patient presents with violaceous flat-topped papules on
the glans and shaft of the penis (Fig. 6). The lesions may
also develop as arcuate groupings of individual papules
that develop rings or peripheral extension of clustered
papules with central clearing. Fine white streaks are
usually visible on the surface, so-called Wickham’s striae.
Usually the glans penis is involved as a part of a more
generalized disorder with typical lichen planus lesions at
502 S.A. BUECHNER
Fig. 6. Lichen planus; numerous annular violaceous papules on the
glans penis.
other sites. However, it may occur as the initial or sole
manifestation. Rarely, lesions may become eroded similar
to the erosive lichen planus of the oral mucosa. The diag-
nosis is helped by the finding of typical lichen planus
papules, particularly on the wrists, hands, forearms,
shins, ankles and lumbosacral region. Oral lesions are
common and occur either as white reticulate streaks or
as erosive lesions. In atypical cases biopsy may be neces-
sary to confirm the diagnosis. Most cases of genital
lichen planus respond to short courses of mild topical
glucocorticoids [7].
Penile lichen sclerosus
Lichen sclerosus of the male genitalia is a chronic inflam-
matory disorder presenting as a chronic, sclerosing atro-
phic process of the glans and foreskin, leading to meatal
stenosis and acquired phimosis. Most authors consider
lichen sclerosus of the penis synonymous with balanitis
xerotica obliterans [20]. However, the latter can be a con-
sequence of other scarring dermatoses such as lichen pla-
nus and bullous disorders. The incidence of genital lichen
sclerosus in young boys with phimosis has been estimated
at ≈ 15%, but the exact frequency in men is unknown
[20,21]. Of 357 patients referred for diagnosis of genital
skin disease, 52 had lichen sclerosus [22]. Penile lichen
sclerosus is most common in middle-aged uncircumcised
men. In a prospective study of 43 men with narrowing of
the prepuce referred for circumcision, lichen sclerosus
was present in 32% [23]. Only 21% of the men had been
clinically diagnosed as having lichen sclerosus. The initial
lesions of lichen sclerosus are white, polygonal and flat-
topped papules or plaques. The lesions progress to ivory-
coloured atrophic and sclerotic white plaques. In men, the
glans and foreskin are usually affected, but not the peria-
nal region. However, the frenulum, urethral meatus and
the anterior urethra may also be involved [7,20,21].
Fig. 7. Lichen sclerosus; a typical white sclerotic ring at the tip of
foreskin.
Uncommonly, lichen sclerosus involves only the shaft of
the penis. If the glans is involved, haemorrhage is com-
mon. In addition, haemorrhagic bullae, erosions and fis-
sures may also be present [7,20]. A very typical finding
is the presence of a sclerotic white ring at the tip of the
prepuce (Fig. 7). With disease progression, the sclerotic
lesions lead to contraction of the genital mucosa with sub-
sequent paraphimosis or phimosis with inability to retract
the prepuce. Gradual narrowing of the external meatus
results in varying degrees of stricture and urinary flow
may be obstructed [1,24]. Presenting symptoms are
pruritus, burning, painful erections, difficulty in retract-
ing the foreskin, dysuria, and a poor urinary stream. The
aetiopathology of lichen sclerosus is still unknown but
genetic factors, an association with auto-immunity,
several infective agents such as borrelia, and local factors
are postulated. The course of penile lichen sclerosus is
chronic. The association between lichen sclerosus and
squamous cell carcinoma (SCC) is a well-known phenom-
enon in women, and it has been observed in 3–6% of
patients with vulvar involvement. There are anecdotal
reports of men developing penile SCC in association with
lichen sclerosus. In a retrospective study of 86 uncircum-
cised patients with lichen sclerosus, five (6%) developed
malignant changes [25]. Three patients had SCC, one had
in situ carcinoma and one had verrucous carcinoma. The
presence of HPV 16 was shown by PCR in four of the five
cases. In a recent study of 20 patients with penile SCC, half
had histological evidence of lichen sclerosus [26]. Periodic
follow-up of patients with lichen sclerosus is advisable,
including biopsy of any clinically suspicious lesions. A
potent or ultra-potent topical steroid is the treatment of
choice for adults and children [21,27]. Topical clobetasol
proprionate 0.05% was helpful in ameliorating the symp-
toms and lesions of lichen sclerosus. In men and young
boys the most frequent surgical procedure required is
circumcision for a phimosis.
© 2002 BJU International 90, 498–506

Allergic and irritant dermatitis
Clinically, genital allergic contact dermatitis is character-
ized by erythema and marked oedema and, in time, with
microvesiculation and exudation. Acute contact dermati-
tis of the penis is usually associated with marked oedema
because the skin covering the genitalia is thin and elastic
[7,20]. Sensitisation to applied medicaments, contracep-
tives, lubricants, feminine hygiene deodorant spray, or
industrial or other contact agents transferred by hand,
may be responsible, especially if the scrotum and thighs
are also involved [19,20]. The list of possible sensitising
agents is long. Allergy to latex contraceptive products can
manifest as a contact urticaria which occurs within an
hour of exposure as a result of immediate IgE-mediated
hypersensitivity to natural rubber latex. Immediate reac-
tions may be life-threatening [28]. Anaphylaxis has been
reported from contact with condoms. Men with latex
allergy may present with oedematous, weeping eruption
of acute contact dermatitis, which is a delayed-type hyper-
sensitivity to latex or to chemicals added to natural rubber
latex during manufacturing. Other frequently involved
contact allergens are lubricants from condoms, feminine
hygiene deodorants, local anaesthetics such as ben-
zocaine, and spermicides. Elimination of the suspected
offending allergen and appropriate treatment with topical
corticosteroids usually serve to manage patients with
allergic contact dermatitis. Mild cases can be treated with
low potency corticosteroid creams. Severe cases of allergic
contact dermatitis may require treatment with systemic
corticosteroids. The identification of the contact allergen
depends on history and usually requires ‘patch’ testing.
This procedure is especially indicated for cases in which
inflammation persists despite avoiding the suspected aller-
gens and after appropriate topical therapy. Irritant contact
dermatitis results from non-immunological physical or
chemical damage to the skin. The eruption primarily
occurs in the area of contact with irritants, and may
develop from the use of certain soaps, detergents or topical
medications. In the acute phase the lesions are erythema-
tous and may be weeping and crusted. With recurrent or
prolonged exposure to irritants the skin becomes licheni-
fied, hyperkeratotic and inflamed.
Fixed-drug eruptions
Fixed-drug eruptions are relatively common and distinc-
tive; they characteristically recur in the same site each
time the drug is administered. Usually just one drug is
involved, although independent lesions from more than
one drug have been described. Clinically, the lesions
present as sharply marginated, round or oval dusky
erythematous and oedematous plaques [7,19,20]. A cen-
tral bulla may be present within the lesion. The lesions
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COMMON SKIN DISORDERS OF THE PENIS 50 3
Fig. 8. Fixed drug eruption caused by ingestion of trimethoprim-
sulphamethoxazole, showing the dusky erythematous solitary
lesion.
heal with time, leaving a hyperpigmented patch. The penis
is a frequent site for fixed-drug eruption (Fig. 8). The
lesions usually develop within a few days of drug admin-
istration. Fixed-drug eruptions have been reported in
association with several drugs, the most frequently impli-
cated being barbiturates, sulphonamides, salicylates,
phenazones and tetracyclines. In a study of 450 patients
with fixed-drug eruption, 20% had genital lesions; in 73%
cotrimoxazole was the commonest incriminated drug
[29].
Balanitis and balanoposthitis
Plasma cell balanitis
Plasma cell balanitis or balanitis circumscripta plasmacel-
lularis, originally described by Zoon [30] in 1952, is a
benign chronic balanitis of unknown origin. Plasma cell
balanitis is characterized by a solitary red-orange plaque
of the glans and prepuce [7,20]. The condition usually
manifests in middle-aged or elderly uncircumcised men.
The plaque surface is shiny and smooth, reddish brown,
slightly moist and stippled with minute red specks, i.e.
‘cayenne pepper’ surface spotting (Fig. 9). The disease
tends to be chronic and may persist for months to years.
It is important to verify the diagnosis by biopsy. The his-
topathology is characteristic showing a band-like infiltrate
of plasma cells. Clinically, plasma cell balanitis may be
confused with an erythroplasia of Queyrat (SCC in situ),
but a case of penile carcinoma preceded by Zoon’s balan-
itis has been reported [31]. The treatment of choice for
plasma cell balanitis is circumcision. A topical antibiotic
cream (e.g. fusidic acid or mupirocin) can be helpful. Tem-
porary relief is usually achieved by a topical steroid. Resis-
tant cases can be treated with the carbon dioxide laser or
erbium-YAG laser ablation.
504 S.A. BUECHNER
Fig. 9. Balanitis circumscripta plasmacellularis Zoon; a well-
circumscribed, shiny red plaque.
Balanitis circinata
Balanitis circinata is a mucocutaneous manifestation of
Reiter’s syndrome, a multisystem disease, that is clinically
characterized by the triad of nongonococcal urethritis,
arthritis and conjunctivitis [20]. Balanitis circinata has
been reported in 12–70% of men with Reiter’s disease.
Circinate balanitis manifests as a well-demarcated, moist,
erythematous plaque with a ragged or scalloped white
border on the glans penis (Fig. 10). In circumcised
patients the lesions are dry and hyperkeratotic, and may
appear as psoriasiform plaques [7]. The initial lesion is an
erythematous macule developing into a small papule and
pustule with hyperkeratotic appearance. Lesions are fre-
quently present around the urethra, and are not necessar-
ily annular or circinate. The histopathological findings
may be indistinguishable from psoriasis.
Premalignant and malignant genital tumours
Giant condyloma (Buschke-Löwenstein tumour)
Giant carcinoma-like condyloma was described in 1925
by Buschke and Löwenstein [32]. This variant of condy-
loma is characterized by deep growth, causing local
destruction of underlying tissue. Patients frequently have
a history of balanitis, ulceration or phimosis. The tumour
may enlarge to 5 cm in diameter and tends to occur in
uncircumcised men, usually involving the penile glans
and prepuce, but these tumours may involve the groin,
urethra and anal canal. Lesions may ulcerate and form fis-
tulous tracts. Most cases are caused by infection with low-
risk HPV 6 and 11 [1,4,20]. The tumours also have been
termed giant malignant condyloma, verrucous carci-
noma, and carcinoma-like condyloma. In most cases
Buschke-Loewenstein tumours represent a subtype of
Fig. 10. Balanitis circinata; well-demarcated, erythematous plaque
with a ragged border on the glans penis.
low-grade SCC. Although true giant condylomas exist, the
histological features of benign condyloma and foci of frank
SCC may occur concomitantly in some tumours. Because
of the clinical overlap in the appearance of giant condy-
loma and verrucous squamous carcinoma, the presence
of rapidly proliferating large warty lesions requires multi-
ple, large and deep biopsy specimens. Recently it was
postulated that giant condyloma and verrucous SCC are
separate and different pathological lesions.
Bowenoid papulosis
Bowenoid papulosis is characterized by flat, skin-coloured,
pink or often hyperpigmented papules with the histologi-
cal features of Bowen’s disease [1,33,34]. The condition is
strongly associated with HPV 16, but other HPV types,
e.g. 18 and 31, may be involved. The disease occurs
mainly in young sexually active adults, with lesions on the
glans penis and prepuce. The papules are often multiple
and tend to coalesce into plaques; they are often more pig-
mented on the penis shaft and scrotum (Fig. 11). Brown-
ish or greyish-white lesions occur on the inner side of the
foreskin, and the lesions are 2–10 mm. The natural course
of bowenoid papulosis is not well defined. The papules may
increase, decrease or the lesions may disappear with time.
However, coexistence of bowenoid papulosis with and
transmission into invasive carcinoma have been reported.
Bowenoid papulosis should be differentiated from flat
condylomas, lichen planus and psoriasis. Bowenoid papu-
losis represents a high risk for neoplasia and should be
treated, the most effective treatment being excision of
the papules. However, cryosurgery with liquid nitrogen
and carbon dioxide laser are the most frequently used
methods. The recurrence rate after treatment with a laser
is 0–33% [9]. Imiquimod, an immune-response modifier,
may be tried but the efficacy against bowenoid papulosis
has not been evaluated in large studies [35].
© 2002 BJU International 90, 498–506

Fig. 11. Bowenoid papulosis; multiple flat pigmented papules.
Erythroplasia of Queyrat
Erythroplasia of the glans penis, described in 1911 by
Queyrat [36], is a carcinoma in situ presenting as a
sharply demarcated, slightly raised erythematous plaque
on the glans penis or the inner side of the foreskin [1]. An
individual lesion may be 10–15 mm in diameter, and sol-
itary or multiple lesions occur; they are usually bright
red, glistening and not tender. Their surface may be some-
what smooth, scaly to frankly warty. Patients usually
complain of pruritus, pain, bleeding and difficulty in
retracting the foreskin. With time clinical ulceration may
occur and tends to correlate with histological evidence of
invasive SCC. Most patients are in their fifth decade or
older. In one series of 100 patients, 90% of cases occurred
in men with a median age of 51 years. Erythroplasia is
usually seen in uncircumcised men, who account for 80–
90% of reported cases. A definite diagnosis is made by a
biopsy showing the typical histological picture of intra-
epidermal carcinoma in situ. Early invasion should be
excluded by obtaining several biopsies. Transformation of
erythroplasia into SCC has been reported to occur in 10–
33% of cases [37]. Surgical excision is the treatment of
choice, but topical 5-fluorouracil and the CO2 laser may
also be used.
Bowen’s disease
Bowen’s disease refers to SCC in situ and may arise any-
where on the skin. Bowens’ disease of the glans penis is
termed erythroplasia of Queyrat [1] and is usually found
on the shaft of the penis as a solitary, sharply defined
plaque of scaly erythema. Clinical variants include
crusted and ulcerated plaques, keratotic plaques and ele-
vated flesh-coloured plaques. The skin of the inguinal and
suprapubic areas may also be involved. Patients may have
more than one lesion. Bowen’s disease may be confused
with bowenoid papulosis, nummular eczema, psoriasis
© 2002 BJU International 90, 498–506
COMMON SKIN DISORDERS OF THE PENIS 50 5
Fig. 12. Penile SCC presenting as an erythematous, nodular, erosive
lesion on the glans penis.
and superficial basal cell carcinoma. Lesions may some-
times be heavily pigmented and thus may resemble mela-
noma in these cases. Biopsy is required to confirm the
diagnosis. If untreated, invasive SCC may arise in ≈ 5% of
cases. Surgical excision is the best treatment option for
small lesions [9], preferably by cryosurgery or CO2 laser;
both methods have been used for many years with excel-
lent results.
Penile SCC
Of all cancers affecting the penis 95% are SCC; the disease
is rare, with age-standardized incidence rates of 0.3–1.0/
100 000 men. However, the incidence rates are 10–20%
in some countries of Africa and South America [37]. The
age at the onset of penile SCC has a wide range (20–
90 years) with a peak around the fifth decade. Risk factors
are phimosis, lack of circumcision, chronic inflammatory
conditions, multiple sexual partners and HPV infection
[33,38]. Penile SCC is extraordinarily rare in circumcised
males; the relative risk for developing penile cancer in
uncircumcised compared with those circumcised at birth
is 3.2. Phimosis has been reported to be present in 44–
85% of men with penile SCC [38]. In a series of studies,
HPV DNA was identified in 40–50% of cases with penile
cancer, most being of high-risk HPV 16 [2,38]. Prevention
of SCC includes early detection and treatment of pre-
cancerous lesions. The clinical appearance of penile SCC
varies from erythematous plaque, induration to more
verrucous and exophytic lesions that may coalesce into an
irregularly shaped mass (Fig. 12). As it increases in size,
superficial ulceration, necrosis and bleeding may become
evident; it may become large, developing into a locally
destructive mass [37]. The primary lesion may occur on
the glans or may be hidden under the foreskin. Primary
tumour pathological staging and grading, and the
involvement of pelvic and inguinal lymph nodes, are the
506 S.A. BUECHNER
main factors used to predict the prognosis of patients with
penile SCC. The treatment of penile SCC depends on
tumour staging and includes surgery, radiotherapy, laser
surgery and chemotherapy [39]. Moh’s micrographic
surgery has been used to advantage.
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Correspondence: Prof Dr S. Buechner, Department of Derma-
tology, University of Basel, Petersgraben 4, CH-4031 Basel,
Switzerland.
e-mail: Stanislaw.buechner@hin.ch
Abbreviations: HPV, human papillomavirus; HSV, herpes
simplex virus; SCC, squamous cell carcinoma.
© 2002 BJU International 90, 498–506