History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include congenital or acquired dysfunctional foreskin, poor hygiene, over-washing, and human papillomavirus (HPV) infection.

uncircumcised state

Circumcision is protective against lichen sclerosus, penile cancer, UTIs, and STIs.

Other diagnostic factors

common

multiple sexual partners or high-risk sexual behaviours

Multiple sexual partners and/or high-risk sexual behaviours increase the risk of acquiring STIs.

post-inflammatory hypo- or hyper-pigmentation

May be seen following the resolution of any inflammatory dermatosis (e.g., eczema, psoriasis, contact dermatitis). Fixed-drug eruptions involving the genitalia often resolve with marked post-inflammatory hyper-pigmentation.

pruritus

Common complaint in cases of eczema, contact dermatitis, scabies.

red scaly patches

Present in inflammatory dermatoses such as eczema, seborrhoeic dermatitis, psoriasis, and reactive arthritis.

erosions

Seen in infections (herpes simplex, candidiasis, syphilis), lichen sclerosus, lichen planus, carcinoma in situ/penile intraepithelial neoplasia (PeIN), squamous cell carcinoma.

uncommon

personal/family history of atopy (eczema, hay fever, asthma, type I allergies)

Patients with atopic background have increased likelihood of experiencing irritant and/or allergic contact dermatitis. Atopic dermatitis uncommonly involves the genital area.

personal/family history of psoriasis

There is a strong genetic predisposition to psoriasis. Genital involvement may be the only manifestation of psoriasis, but examination of additional body sites often reveals other psoriatic lesions or signs (e.g., nail involvement).

urinary dribbling

Urinary incontinence can result in skin irritation/breakdown and is a causative factor in lichen sclerosus.[44] Urinary dribbling might be physiological or due to piercing and surgical procedures.[38][39]​ Chronic moisture can result in the acquisition of candidiasis. 

hypo-pigmentation

Markedly hypo-pigmented or de-pigmented patches on genitalia can be seen in vitiligo. Additional lesions of vitiligo are often found on examination at other body sites (especially peri-orificial and acral areas).

purpura

Common finding in lichen sclerosus; additional findings include skin atopy and hypo-pigmentation.

red plaques

Present in Zoon balanitis, erythroplasia of Queyrat, gonorrhoea.

blisters

Can be seen in cases of acute allergic or irritant contact dermatitis.

papules or micro-papules

Seen in lichen planus (flat papules with slight scale). If this diagnosis is suspected, examine the oral cavity and nails for findings of lichen planus.

pustules

Can be seen with candidiasis; diagnosis is confirmed with KOH preparation or culture.

Risk factors

strong

congenital or acquired dysfunctional foreskin

Risk factor for lichen sclerosus, Zoon balanitis, and non-specific balanoposthitis.

uncircumcised state

Risk factor for lichen sclerosus, Zoon balanitis, and non-specific balanoposthitis, especially if the foreskin is dysfunctional.

poor hygiene; urinary dribbling or leakage

Risk factor for lichen sclerosus, Zoon balanitis.

over-washing

Risk factor for irritant contact dermatitis.

human papillomavirus (HPV) infection

Risk factor for non-specific balanoposthitis, and penile pre-cancers and cancers.[25][26]

This applies only to certain HPV types; clinically obvious genital warts caused by non-oncogenic HPV types (principally 6 and 11) have negligible pre-cancerous potential.

weak

inflammatory skin diseases

Such as eczema, seborrhoeic dermatitis, and psoriasis. Risk factor for genital skin involvement and balanoposthitis.

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