4/7/18 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 1 4/7/18 Physiologic hyperpigmentation - Normal Normal Variants Perianal High-grade Dysplasia – Not Normal Angiokeratomas - Normal 2 4/7/18 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 lips • No treatment Edwards L and Lynch PJ. Genital Dermatology Atlas and Manual. 3rd Edition. Wolters Kluwer 2018 3 4/7/18 ? Molluscum Molluscum Contagiosum • 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 4 4/7/18 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. 5 4/7/18 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 6 4/7/18 General Therapeutic Measures Lichen Planus • 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 7 4/7/18 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) 8 4/7/18 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 9 4/7/18 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. 10 4/7/18 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 11 4/7/18 Condyloma lata – has been confused with SCCA! Vesicles, Bullae, and Erosions Erosive Lichen Planus • Involves only genital and oral mucosa • Painful and pruritic • Purulent, malodorous vaginal discharge • Scarring • Diagnosis clinical with confirmatory histology 12 4/7/18 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) 13 4/7/18 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%) 14 4/7/18 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 15 4/7/18 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 16 4/7/18 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