History and exam

Key diagnostic factors

common

uncircumcised state

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

Other diagnostic factors

common

multiple sexual partners or high-risk sexual behaviors

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

postinflammatory hypo- or hyperpigmentation

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 postinflammatory hyperpigmentation.

pruritus

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

red scaly patches

Present in inflammatory dermatoses such as eczema, seborrheic 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.[45] Urinary dribbling might be physiologic or due to piercing and surgical procedures.[39][40]​ Chronic moisture can result in the acquisition of candidiasis. 

hypopigmentation

Markedly hypopigmented or depigmented patches on genitalia can be seen in vitiligo. Additional lesions of vitiligo are often found on examination at other body sites (especially periorificial and acral areas).

purpura

Common finding in lichen sclerosus; additional findings include skin atopy and hypopigmentation.

red plaques

Present in Zoon balanitis, erythroplasia of Queyrat, gonorrhea.

blisters

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

papules or micropapules

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 nonspecific balanoposthitis.

uncircumcised state

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

poor hygiene; urinary dribbling or leakage

Risk factor for lichen sclerosus, Zoon balanitis.

overwashing

Risk factor for irritant contact dermatitis.

human papillomavirus (HPV) infection

Risk factor for nonspecific balanoposthitis, and penile precancers and cancers.[25][26]

This applies only to certain HPV types; clinically obvious genital warts caused by nononcogenic HPV types (principally 6 and 11) have negligible precancerous potential.

weak

inflammatory skin diseases

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

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