GRUESOME GROINS “Dermatology Down Under” Ted Rosen, MD Baylor College of Medicine

Home , Fournier gangrene

NONE

WHEN ITS NOT AN STD!

HSV-2 in HIV

Chancroid

Syphilis 40 year-old; Good health Gradual onset itchy rash

46 year-old; Tennis player Gradual onset itchy rash 40 year-old; Good health Gradual onset itchy rash

46 year-old; Tennis player Gradual onset itchy rash KOH PREP TINEA CRURIS

ANY topical allylamine, benzylamine, or imidazole cream/lotion/gel will clear in 1-4 weeks Oral alternatives: Terbinafine 250mg/d x 1-2 wks Itraconazole 200mg/d x 1 wk Fluconazole 150mg/wk x 4 wk (or 300mg/wk x 2 wk)

Mycopathologia 166:353-67, 2008 Br J Dermatol 172:616-41, 2015 Br J Dermatol 166:927, 2012

Meta-analysis: 135 studies, 15,795 patients NO difference between groups: efficacy NO difference between groups; safety NO difference between groups: tolerability Allylamines are faster in onset Sx relief Luliconazole cream has the shortest approved regimen (QD x 7 days) Lotrimin Ultra = Butenafine (= Mentax) Cheapest effective agent (Benzylamine) OTC $10-12 per tube LULICONAZOLE CREAM QD X 7 DAYS KEY POINT: CHECK THE FEET

TINEA CRURIS: ALWAYS CHECK THE FEET!

Patients with tinea cruris who also had onychomycosis: 100% of 116 (Poland)…..T. rubrum Arch Dermatol 142:1279, 2006 100% of 5 (Turkey)………T. rubrum Mycopathologia 159:347, 2005 90% of 395 (Japan)………T. rubrum Nippon Ishinkin Gakkai Zasshi 42:11, 2001 88.4% of 250 (Israel)…….T. rubrum Mycopathologia 83:115, 1983 6.4% of 60 (Iran)…………..E. floccosum Mycoses 43:41, 2000 GENITAL FUNGUS? PENILE TINEA

Pielop J, Rosen T. Penile dermatophytosis. J Am Acad Dermatol 44:864-67, 2001 Int J Dermatol 45:1375, 2006 Acta Dermatovenereol 2008; 17:86-89

PENILE TINEA VERSICOLOR! PENILE TINEA VERSICOLOR! (Renal Transplant) Ann Dermatol. 2012;24:345-7 42 year-old man Insidious onset Minimal itching Failed OTC terbinafine cream ERYTHRASMA Corynebacterium minutissimum Gram + diphtheroid bacteria Difficult to culture Mild Sx (pruritus) May be multifocal: groin, axilla, toe web Obesity & diabetes Trichomycosis axillaris and Pitted keratolysis associated

 J Am Acad Dermatol 58(Suppl 2):S57, 2008

ERYTHRASMA N Engl J Med. 351:1666, 2004

First described: Arch Derm Syphilol 65:614, 1952 WOOD’S LAMP ERYTHRASMA RX

Oral erythromycin 250mg QID x 5 days**** Single dose clarithromycin 1.0g PO Arch Dermatol 134:671,1998 ; Int J Dermatol 52:516, 2013 Topical clindamycin/erythromycin BID Int J Dermatol 20:562, 1981 Oxiconazole 1% cream QD x 14 days Dermatologica 175:293, 1987 Miconazole or Clotrimazole 1% Cream Clin Exp Dermatol 1:225, 1976 High intensity RED light (monotherapy) Photodermatol Photoimmunol Photomed22:153, 2006 R ERYTHRASMA: BID TOPICAL CLINDAMYCIN 1% SOLUTION

Cochran, Rosen, Landers Int J Derm 20:562, 1981 28 CANDIDA INTERTRIGO CANDIDA INTERTRIGO Differentiate Candida from Tinea and Erythrasma

Satellite lesions Involves scrotum Pseudohyphae CANDIDA INTERTRIGO RX 1

Any topical azole I prefer ketoconazole cream due to strongest inherent anti-inflammatory properties Topical ciclopirox 0.77% Highly anti-inflammatory and lower MIC for Candida albicans than ketoconazole Oral fluconazole 150mg QD x 3doses, QOD (cheapest)

Mycoses 51(Suppl 4):44-5, 2008 CANDIDA INTERTRIGO RX

Any topical azole 2 I prefer ketoconazole cream due to strongest inherent anti-inflammatory properties Topical ciclopirox 0.77% Highly anti-inflammatory and lower MIC for Candida albicans than ketoconazole Oral fluconazole 150mg QD x 3doses, QOD (cheapest) Look for and “fix” underlying problems (diabetes, immobility, obesity) Mycoses 51(Suppl 4):44-5, 2008 Extra-Mammary Paget’s Disease Extra-Mammary Paget’s Disease EMP EXTRAMAMMARY PAGET’S Twenty year experience: MD Anderson Ages 50-86; Men only Symptoms: 6 months-10 years 40% had underlying malignancy Work-up: CXR, CT abdomen-pelvis, PSA cystoscopy, occult blood, colonoscopy, pelvic exam Dermal invasion: poor prognosis Surgical resection to tumor-free margins is recommended therapy Chemotherapy not very helpful J Urol 186:97, 2011 Extramammary Paget’s Disease

PET scan Metastatic EMPD [PET scan] A BIG BUMP

CD30+ T-cell BCC Lymphoma

KS Leiomyosarcoma SCCA Vulva Perianal Scrotum Penis

SCCA 86% SCCA 85% SCCA 50% SCCA 95%

Melanoma Melanoma Sarcoma Sarcoma 5-11% 0.25-4.0% 13% 1-2% Sarcoma EM Paget’s EM Paget’s Melanoma 2% 1-2% 12% 1.4% EM Paget’s Sarcoma Melanoma EM Paget’s 1.5% 1% 8% <1% BCC BCC 0.2% BCC 1-2% BCC 0.1% 1.5-2.5% < 20 cases < 50 cases < 20 cases

Surg Clin North Am 2008;88:301-17 J Dtsch Dermatol Ges 2011; Sep 27 (e-pub) Scientific World J 2011;11:269-82 World J Urol 2009;27:141-50 Nat Rev Urol 2009;6:491-500 Br J Cancer 2010;103:1462-6 Clin Exp Dermatol 2007;32:603 Indian J Dermatol 2010;55:178 Gastroenterology 1993;104:174 J Urol 2005;173:1958 Obstet Gynecol Clin North Am. 2001 ;28:703 Vulva Perianal Scrotum Penis

SCCA 86% SCCA 85% SCCA 50% SCCA 95%

As a primary lesion…. Perianal lymphoma vanishingly rare J Gastrointest Cancer 2012;43:117-20 Penile/Scrotal lymphoma very rare Mod Pathol 2009;22:1057-65 Vulvar lymphoma very rare Am J Surg Pathol 2005;29:1512-20 Diffuse Large B-cell most common type in all ano-genital sites Non-diagnostic morphology Treatment per lymphoma type, not site A “BUMPY ULCER” SCCA UNTIL PROVEN OTHERWISE GENITAL MELANOMA GENITAL MELANOMA “KISSING” NEVUS OF PENIS

Plastic and Reconstructive Surgery - Global Open: May 2015 - Volume 3 - Issue 5 - p e389

72 year-old 58 year-old No GYN exam for 10 years 18 months s/p radical Acute onset ASx papulonodules prostatectomy (adenoCA) Asymptomatic nodules JONES C, ROSEN T: ARCH DERM 128:1535, 1992 CUTANEOUS METASTASES

Metastses to anogenital and surrounding skin are rare Prostate, Testes, Bladder (all <1%) Ovary, Cervix, Endometrium Of all of these, the OVARY is most likely; 1.9-5.1% metastasize to skin, mean 24 mo after Dx Gynecol Oncol 90:682, 2003 BJU Int 104:770, 2009 Poor prognostic sign* J Cutan Pathol 35:681, 2008 Int J Surg Pathol 19:597, 2011 TRANSITIONAL CELL BLADDER CA METASTATIC TO PENIS Negative KOH and fungal & viral cultures

42 year-old woman Long history of itching rash During “attack” may be painful Neck, axilla and groin Worse in summer

HAILEY-HAILEY: GROIN AND AXILLA HAILEY-HAILEY: (BENIGN FAMILIAL PEMPHIGUS)

Autosomal dominant genodermatosis  Arch Dermatol Syphilol 30:679, 1939 Mutation ATP2C1 gene (chromosome 3q) Ca+2/Mn+2 ATPase Defective calcium transport Defective desmosomes Defective cell-cell adhesion  Acantholysis JID 126:2370, 2006  Onset 20-40 year of age  Trauma (friction, sunburn) trigger HAILEY-HAILEY: RX  Medical versus Surgical therapy Topical or Systemic antibiotics Actas Dermosifiliogr. 2016 Jan 22 Topical or Systemic steroids Dapsone Arch Derm 103:262, 1971 Topical calcineurin inhibitors JAAD 47:797, 2002 and Arch Derm 139:1401, 2004 Ann Derm Venereol 133:475, 2006 Topical Vitamin-D analogues JAAD 51:475, 2004 Br J Dermatol 152:816, 2005 Retinoids (acitretin) J Drugs Dermatol 6:734, 2007 Biologics Etanercept JAAD 54 (3Suppl2): S139, 2006 HAILEY-HAILEY: RX

 Medical versus Surgical therapy Excision + grafting (Size limits) JAAD 25:342, 1991 Ann Derm Vener 111:699, 1984 Br J Plast Surg 42:230, 1989 and 40:557, 1987 Ann Plast Surg 9:337, 1982 Dermabrasion (Atrophy, Dyschromia) JAAD 27:136, 1992 and 28:784, 1993 Arch Dermatol 130:1143, 1994

CO2 or Erbium:YAG laser ablation Int J Derm 54:1309, 2015 Ann Derm Venereol 132:637, 2005 and 80:53, 2000; Dermatol Surg 25:661, 1999 and 13:1187, 1987 Arch Derm 135:423, 1999 and 128:646, 1992; JAAD 23:893, 1990 Electron beam (7.5 MeV: Lowest) JEADV 21:567, 2006 HAILEY-HAILEY: RX

 Medical versus Surgical therapy Botulinum toxin? Reduce sweating, thereby reducing maceration and irritation Potential for long remission (6-12 mo) based on hyperhidrosis experience  Dermatol Surg 26:371, 2000  J Cosmet Laser Ther 3:181, 2001  Dermatol Surg 28:543, 2002  J Dermatolog Treat 19:251, 2008  J Drugs Dermatol 14:68, 2015 PRE-Rx

TEST DOSE (d)

Rx: 50 units/axilla 4 weeks later… MORE BLISTERS In the older patient w/ erosions, look for intact bullae….

In the older patient w/ erosions, look for intact bullae…. Pemphigoid PEMPHIGOID RX

Elderly patients with CV disease, diabetes, stroke, dementia J Invest Dermatol 131:631, 2011 Arch Dermatol 141:691, 2005 Typical appearance about 80% but atypical forms in 20% (eczema-like) Think pemphigoid in ANY itchy, relapsing eruption in elderly Potent topical steroid first option, then low dose systemic steroid TCN-nicotinamide, mycophenolate, azathioprine, MTX, Dapsone: anecdotal Cochrane Database Systemic Rev 10:CD002292; Oct 6, 2010 INVERSE PSORIASIS

Psoriasis of intertriginous skin Axilla, Inframammary skin, gluteal & & inguinal folds, retro-auricular skin 3-7% of all psoriatics Eur J Dermatol 15:176, 2005 Clin Dermatol 33:456, 2015 More common in women INVERSE PSORIASIS Psoriasis of intertriginous skin Axilla, Inframammary skin, gluteal and inguinal folds, retro-auricular skin 3-7% of all psoriatics Eur J Dermatol 15:176, 2005 Clin Dermatol 33:456, 2015 More common in women Topical calcineurin inhibitors JAAD 48:564, 2003, 51:723, 735, 2004 Excimer Laser Dermatol Surg 33:361, 2007 USTEKINUMAB (45MG SQ; 0-4-Q12W) TWO INJECTIONS, BEFORE THIRD ADMINISTRATION

PRE Rx

1 Injection 2 injections Week 12 GENITAL LICHEN PLANUS

Typical of LP in men May be eroded in women Painful if erosion present Ultrapotent topical steroid Low risk of malignancy May be oral / skin lesions

Semin Cutan Med Surg. 2015;34:182-6 LICHEN PLANUS, PENIS (ANNULAR) 28 year-old man History of “boils” since age 19 Painful, drain purulent material Groin and….. axilla HIDRADENITIS SUPPURATIVA

Inflammatory disease of apocrine gland bearing areas “Acne inversa” Groin, perianal, buttocks, scrotum, suprapubic, axilla NO therapy is uniformly successful Surgical removal is treatment of choice for less severe or more localized disease

Br J Dermatol. 2016 Jan 23. Cochrane Database Syst Rev. 2015 Oct 7;10:CD010081 WHAT KIND OF SURGERY WOULD WORK HERE? WHAT KIND OF SURGERY WOULD WORK HERE? Adalimumab

Moul, D K, et al. Arch Dermatol 142:1110-1112, 2006 ADALIMUMAB AND HS

FDA approved moderate to severe Dose is twice psoriasis dosing Induction: 160mg Day 1 Induction: 80mg 2 weeks later Maintenance: 40mg weekly

J Eur Acad Dermatol Venereol. 2015 Jul 22 Ann Intern Med 2012;157:846 INFILIXIMAB 5MG/KG X 3 INFUSIONS

Mekkes JR and Bos JD Br J Dermatol 158:370, 2008 Zinc (60-90mg/day) Dermatology 214:325, 2007 PDT (with photosensitizer) Dermatol Clin 25:67, 2007 and J Drugs Dermatol 5:556, 2006 Metformin 500mg BID-TID 18/25 responded J Eur Acad Dermatol Venereol 27:1101, 2013 Finasteride 5mg/day (anti-androgen) 6 of 7 responded; 2 remission lasted over 2 yr J Cutan Med Surg 11:125, 2007 and J Derm Treat 16:25, 2005 Non-ablative radiofrequency heating Dermatol Surg 34:114, 2008  Minocycline (100mg/d) + Colchicine 0.6mg BID 20/20 responded Int J Dermatol. 2017;56:346-35 Exogenous Disorders 47 year-old woman 26 year-old man

Bizarre lesion which does not compute to be real disease Bizarre affect and Doctor shopper GENITAL SELF-MUTILATION

Subset of dermatitis artefacta Factitial disease more common in women; genital lesions = men Age 20-40; Bizarre pattern Neurotic, Psychotic (60%), Malingering, Monetary gain, Religious delusion or ritual (Klingsor Syndrome)

Sexual identity crisis, transsexual)  Gynecol Obstet Fertil 34:134, 2006; Int J Urol 13:1358, 2006 Immediate Psychiatric Evaluation! J Cut Med Surg 4:161, 2000; Am J Dermatol 1:47, 2000; Curr Med Chem. 2017 Dec 22. Immediate Psychiatric Evaluation! J Cut Med Surg 4:161, 2000; Am J Dermatol 1:47, 2000; Curr Med Chem. 2017 Dec 22.

Maybe some pimozide, olanzapine or risperidone? RED (ANGRY) SCROTUM SYNDROME RED (ANGRY) SCROTUM SYNDROME

Persistent redness of the scrotum May also involve base of penis Accompanied by severe itching or burning sensation Cause is unknown “Resistant” to treatment

 Cutis 60:139, 1997 Make sure not a contact (history) Make sure its not monilia Topical pramoxine + HC Neuroleptic drugs (gabapentin) STOP steroids; May be rebound! Sex Health 10:452, 2013 Retrospective chart review (n=7) Doxycycline 100mg BID led to 50-80% better J Dermatolog Treat 19:1, 2008 Case report (n=1) of resolution following Doxycycline 100mg BID Int J Dermatol 51:362, 2012 GENITAL 28 year-old woman PAINFUL erosions Appeared ~36 hours after “wild” sex No past history of genital lesions 66 year-old man ~48 hours after contact (fellatio) with prostitute PAINFUL ulcerations GENITAL BITE WOUND

Accidental sexual trauma or deliberate Physical damage Infection transmission (rarely): Lues, HSV, HIV Rapidly progressive ulcer likely due to normal oral flora Eikenella corrodens (gram negative faculative anerobe) Wound irrigation & tetanus prophylaxis Amoxicillin-clavulanate 1-1.5g/day FOR MORE INFORMATION…

Rosen T, Conrad N: Genital ulcer caused by human bite to the penis. Sex Transm Dis 1999;26:527-30

Rosen T: Penile ulcer from traumatic orogenital contact. Dermatol Online J 2005;11:18 1883

Jean Fournier FOURNIER’S GANGRENE

Synergistic (polymicrobial) necrotizing fasciitis of genital or perineal skin and soft tissues

Infection (trauma, instrumentation) leading to vascular thrombosis and tissue necrosis

 Source: lower GI tract > skin > urogenital tract Avg age 50-60; M : F = 10-25 : 1 Diabetes, alcoholism, CA, HIV+

 Scrotum > penile shaft = perineum > abdomen Vulva > perineum in women

 Infection 37:306, 2009 NZMJ 121:46, 2008 Plast Reconstr Surg 119:175, 2007 SWOLLEN PAINFUL ERYTHEMA → PURULENCE BLUE-BLACK ISCHEMIA → NECROSIS/SLOUGH

FOURNIER’S GANGRENE: EXTENSIVE FOURNIER’S IN WOMEN

Int Urogynecol J Pelvic Floor Dyfunc 20:1439, 2009 FOURNIER’S GANGRENE: THERAPY

Aggressive debridement necrotic tissue Antibiotic Rx based on culture results Adjunctive wound care maneuvers? - Hyperbaric oxygen

Singapore Med J 52:194, 2011 - Negative pressure wound therapy J Wound Ostomy Continence Nurs 39:98, 2012 Surgical repair (delayed), as needed PENILE CALCIPHYLAXIS

PENILE STRANGULATION

Genital constriction (penis + scrotum) Erotic or auto-erotic purposes > 72 hours more likely to be severe Venous outflow obstruction, then lymphatic and finally arterial Swelling,  sensation, ischemia, finally necrosis Metallic and non-metallic Penis ring, rubber band, hair, thread, wedding and other rings, clamp, hammer-head, soda bottle  J Sex Med 6:595, 2008 and 5:1747, 2008 and 4:1775, 2007 Urology 63:1183, 2004 PENILE STRANGULATION

J Sex Med 5:1747, 2008 J Sex Med 7:3793, 2010 Ghana Med J. 49:57, 2015 PENILE STRANGULATION RING USED DURING SEX BOLT PENTAETHYLENE-TEREPHTHALATE BOTTLE

Thermoplastic resin related to polyester VERY tough type of plastic Noted as number 1 on plastic symbol Difficult to cut with usual instruments PENILE STRANGULATION PENTAETHYLENE-TEREPHTHALATE BOTTLE PENILE STRANGULATION

Plastic bottle x 14 days

Urologe A 43:843, 2004 REMOVAL OF CONSTRICTING OBJECTS KNOW AN ORTHOPEDIC SURGEON OR PLUMBER Gigli Saw: The Best!

FOR MORE INFORMATION…

Rosen T: Genital emergencies for the dermatologist. Cutis 86:276, 2010 I hope you have enjoyed looking at some interesting groins…..

“Money buys a lot of attorneys and friends” –Sharon Stone Basic Instinct, 1992