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Disclosures

• Research funding from: – NIH Dermatologic Manifestations of STIs – CDC – Becton-Dickenson Laura H. Bachmann, M.D., M.P.H – Atlas Genetics, Inc. Professor of Medicine, Wake Forest University Health Sciences Winston-Salem, NC Medical Director Guilford County Department of Health

Objectives Outline

At the end of this presentation, each participant will be able to: • What’s Normal? 1. Describe at least two normal variants commonly found on • What is not… genital examination – Flesh-colored papules – 2. Implement appropriate treatment for contact dermatitis Inflammatory plaques and papules – Vesicles, bullae and erosions 3. Utilize CDC recommended treatment approaches for the – White patches and plaques management of scabies infection – Non-infectious genital ulcers • Ectoparasites

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Physiologic hyperpigmentation - Normal

Normal Variants

Perianal High-grade Dysplasia – Not Normal - Normal

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Pearly Penile Papules (post-circumcision) Vestibular Papillae

• Present in 1/3rd of women • Symmetrical • Rounded rather than acuminate tips • Discrete base • Rx - reassurance

Edwards L and Lynch PJ. Genital Dermatology Atlas and Manual. 3rd Edition. Wolters Kluwer 2018

Fordyce Spots

• Asymptomatic • Pin-point yellowish papules Flesh-colored papules • Normal sebaceous glands • Mucosal surfaces • Vermillion border of • No treatment

Edwards L and Lynch PJ. Genital Dermatology Atlas and Manual. 3rd Edition. Wolters Kluwer 2018

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? Molluscum

• Poxvirus (molluscum bodies) • Asymptomatic, self-limited • Flesh-colored, smooth, umbilicated • Rx – liquid NO2, TCA, curettage, cantharidin, imiquimod, podophyllotoxin cream (0.5%), tretinoin, 10% KOH

Edwards L and Lynch PJ. Genital Dermatology Atlas and Manual. 3rd Edition. Wolters Kluwer 2018

Disseminated cryptococcal infection Lichen Nitidus

• Inflammatory skin disorder • No age, race or gender predominance • Asymptomatic • Tiny flesh or pink-colored papules • Appear follicular • Kobner phenomenon • Treatment: reassurance

Edwards L and Lynch PJ. Genital Dermatology Atlas and Manual. 3rd Edition. Wolters Kluwer 2018

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Contact Dermatitis (cont.)

• Allergic - specific immunologic response (Type IV) Inflammatory papules and plaques • Irritant - direct effects of irritating substance • Diagnosis - clinical history and exam – Ask about habits of patient and sexual partner – Examine all skin

Contact Dermatitis Contact Dermatitis

• Characterized by irritation, itching, • Allergic • Irritant stinging, erythema – Topical medications – TCA – Liquid nitrogen • Scaling, blistering and exudation if – Spermicides – severe – Personal hygiene products Extreme heat – Chlorox – Materials (nail polish, sanitary • Contactant spread through – napkins, condoms) Feces/urine dampness/friction – Water – Etc. • Chronic phase - – Deodorant lichenification/hyper/hypopigment – Alcohol ation – Etc.

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Masturbation with anti-itch lotion – not a good idea!

Chronic contact dermatitis Contact Dermatitis - Treatment

• Removal of the offending agent • Moderate to severe inflammation – Mid-potency steroid (.1% triamcinolone) – Prednisone 40mg qd x several days • Lubricants (if dry) • Sitz baths (Burow’s soln) • Nighttime sedation

Edwards L and Lynch PJ. Genital Dermatology Atlas and Manual. 3rd Edition. Wolters Kluwer 2018

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General Therapeutic Measures • Avoid: • To cleanse – Irritating soaps – Cetaphil cleanser, Basis soap, • Unclear etiology – Sanitary napkins unscented Dove – Lotions – No wash cloths! • Onset around age 40 – Disposable wipes – Pat area dry, no rubbing – Feminine deodorant products • To moisturize (prn) • 25% of affected males with – Tight synthetic clothing – White petrolatum genital lesions – Pantyhose and girdles – Topical anesthetics • Unknown frequency of genital lesions in female Edwards L and Lynch PJ. Genital Dermatology Atlas and Manual. 3rd Edition. Wolters Kluwer 2018

Lichen Planus (cont.)

• Well-circumscribed violaceous or brown flat-topped papules with white striae and scale • Annular configuration • White papules or poorly marginated plaques with linear, fern-like or reticular pattern when mucous membranes affected • Severe itching

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Clinical Syndrome Triggered by an infectious agent in a genetically susceptible host

Enteric Arthritis STI

•M:F 1:1 •M:F 99:1 •Dysentery – Epidemic •Urethritis –Sporadic •Yersinia •C. trachomatis (1-3%) •Shigella ¨ Immune response •N. gonorrhoeae •Camplobacter important •U. urealyticum •Salmonella ¨ Autoimmune vs response to disseminated antigen ¨ HLA-B27 (3/4 of Urethritis Conjunctivitis patients) (Cervicitis)

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Reactive arthritis: Skin lesions

Reactive Arthritis: Clinical Manifestations Psoriasis • Asymmetrical arthritis (knee, ankle) • Red, sharply demarcated plaques • Other musculoskeletal pain (heel, with silver scale LBP) • Preferentially affects scalp, elbows, • Mucocutaneous Lesions knees, gluteal cleft and umbilicus – Balanitis circinata (23-50%) • 50% with nail involvement – Keratoderma blennorrhagica (30%) • Ocular lesions (conjunctivitis, • Genital lesions not as thick, less uveitis) scale • Urethritis/Cervicitis • Diagnosis: Exam, histology

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Psoriasis Name that rash!

Pityriasis Rosea Annular Syphilis

• Common disease of late childhood/early adulthood • Post-infectious? • Christmas tree pattern • Trunk and proximal extremities • Herald patch • Self-limited

Check an RPR if sexually active!!

Indian J Dermatol. 2014 May-Jun; 59(3): 316.

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Squamous Cell Carcinoma in Situ Squamous Cell Carcinoma in Situ

• Insidious onset (except Bowenoid papulosis) • HPV important (type 16)

• Biologic potential for local invasion and metastasis

Squamous Cell Carcinoma

• Males – <1% of all malignancies in Bowenoid Papulosis males – Almost all cases in uncircumcised males – Average age 55-65 • Females – Vulvar lesions similar to penile – Onset after age 60

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Condyloma lata – has been confused with SCCA!

Vesicles, Bullae, and Erosions

Erosive Lichen Planus

• Involves only genital and • Painful and pruritic • Purulent, malodorous vaginal discharge • Scarring • Diagnosis clinical with confirmatory histology

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Erythema Multiforme Stephens Johnson Syndrome

• “Target” or “iris” type lesions • Mucosal surface involvement frequent • Spectrum of severity – Stevens-Johnson syndrome – Toxic epidermal necrolysis • Etiology – HSV*, EBV, MTb, fungal infection, lymphoma – Drugs (sulfa, dilantin, nevirapine)

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Fixed Drug Eruption Fixed Drug Eruption • Lesions are “fixed” (occur at same site with each episode). • Tetracyclines

• No predilection for age, race or • Sulfonamides gender. • • One genital lesion with one or Barbiturates more extra-genital lesions. • Phenolphthalein • Glans penis most common site. • NSAIDS, Flagyl, Tylenol, Oral • Diagnosis based on clinical history. contraceptives, penicillins and salicylates also implicated. • History of drug use often present.

Lichen Sclerosus

• Chronic • Characterized by hypopigmentation, tissue White patches and plaques thinning/fragility and scarring • Middle-aged women most common • Etiology unknown • Pruritis most common symptom • Risk for squamous cell carcinoma (5%)

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Lichen Sclerosus

• Circumscribed whitish papules and plaques • Thin “cigarette paper” skin Ectoparasites • Purpura, erosions and excoriations common • Figure-of-eight pattern/phimosis • Scarring with obliteration of external genitalia (balanitis xerotica obliterans)

Pubic Lice (Pthirus pubis) Lice

• The most common symptom of infection is pruritus that is thought to be due to hypersensitivity to feeding lice. • Physical findings include visible opalescent nits or live lice and blue macules (maculae ceruleae) at feeding sites. • Diagnosis – live lice or viable nits http://www.cc.com/video-clips/cdnpoy/the-daily-show-with-jon-stewart-beasts-of-the- southern-wild Leone P. Clin Inf Dis 2007;44:S153-9 CDC Division of STD Prevention

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Pediculosis Pubis – Treatment Other measures 2015 CDC STD Treatment Guidelines • Preferred: • Pediculosis of the eyelashes should be treated with – Permethrin 1% cream rinse applied to affected areas and washed off ophthalmic ointment or petroleum jelly to the eyelid margins after 10 minutes OR twice a day for 10 days. – Pyrethrins with piperonyl butoxide applied to the affected area and • Bedding and clothing should be decontaminated or removed washed off after 10 minutes from body contact for at least 72 hours. • Alternative: • Sex partners within the previous month should be treated. – Malathion 0.5% lotion applied to affected areas and washed off after 8-12 hours OR – Ivermectin 250 ug/kg orally, repeated in 2 weeks Workowski KA and Bolan GA. Sexually Transmitted Diseases Treatment Workowski KA and Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR 3):1-138 Guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR 3):1-138

Scabies - mite Scabies

• An obligate human parasite that lives in burrowed tunnels in the stratum corneum of the epidermis. • It completes its entire life cycle on humans

Leone P. Clin Inf Dis 2007;44:S153-9 CDC Division of STD Prevention CMAJ. 2009; 181(5): 289

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Classic Scabies Scabies – Genital Involvement

• Involvement of the male genitalia in a patient with excoriated and papular scabies

• The genitalia should be examined in all instances of suspected scabies infestation

Currie B and McCarthy J. N Engl J Med 2010;362:717-725

Norwegian scabies Scabies Treatment 2015 CDC STD Treatment Guidelines • Recommended: – Permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours OR – Ivermectin 200ug/kg orally, repeated in 2 weeks • Alternative Regimen (not for infants and children <10 yo): – Lindane (1%) 1oz of lotion or 30g of cream applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours

Currie B and McCarthy J. N Engl J Med Workowski KA and Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2010;362:717-725 2015. MMWR Recomm Rep 2015;64(No. RR 3):1-138

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Other considerations Conclusions

• Bedding and clothing should be decontaminated or removed • Genital dermatoses are common from body contact for at least 72 hours • Many dermatological conditions affecting the genitalia are • Individuals with crusted scabies may need combination easily recognized therapy and additional treatment • The ability to recognize STI and non-STI related dermatologic • Persons who have had sexual, close personal or household conditions is important for optimal patient management contact with the index patient within the month preceding scabies infestation should be examined. Those found to be infested should be provided treatment.

Workowski KA and Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR 3):1-138

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