Pearly Penile Papules

Pearly penile papules are small dome-shaped to filiform skin-colored papules that typically are located on the sulcus or corona of the glans penis. Commonly, pearly penile papules are arranged circumferentially in one or several rows and often are assumed wrongly to be transmitted sexually. Pearly penile papules are considered to be a normal variant and are unrelated to sexual activity. Often, lesions cause great anxiety to patients until their benign nature is clarified.

See the images below.

Pearly penile papules. Courtesy of Wiki Commons

Pearly penile papules; close-up view. Courtesy of Wiki Commons.

Also see the two related Medscape articles, Dermatologic Diseases of the Male Genitalia: Malignant and Dermatologic Diseases of the Male Genitalia: Nonmalignant.

Pearly penile papules are considered a normal variant and harbor no malignant potential. They are not contracted or spread through sexual activity.

Pearly penile papules are observed more frequently in uncircumcised males; however, the mechanisms underlying their development remain unknown. Interestingly, in uncircumcised males with pearly penile papules who undergo circumcision later in life, regression of the papules is commonly observed.[1]

Some evidence suggests that pearly penile papules may be observed more frequently in uncircumcised men (22%) than in circumcised men (12%). In the past, pearly penile papules were believed to contribute to the accumulation of smegma in uncircumcised men; currently however, this is known to be not true.[2]

Frequency

United States

The incidence of pearly penile papules reportedly ranges from 8-48%.[3] Several reports suggest an increased incidence of pearly penile papules in uncircumcised versus circumcised men (22% vs 12%, respectively). One study found an increase in frequency in black versus white men, in those circumcised (21% vs 7%, respectively) and uncircumcised (44% vs 33%, respectively).

International

No geographic variation in prevalence has been noted for pearly penile papules.

Race

No racial predilection has been confirmed for pearly penile papules. Reports suggesting an increased incidence in African American males may reflect an increase in uncircumcised men in that population.

Rehbein[4] studied 840 men aged 10-66 years and found an overall incidence of pearly penile papules of 30.1% in this group. Black men in the study demonstrated a rate of pearly penile papules of 32.7% (44% in uncircumcised, 20.8% in circumcised black males). White men in the study demonstrated a rate of 13.9% (33.3% in uncircumcised, 7.1% in circumcised white males).

Sex

Because of their anatomic distribution, pearly penile papules are noted only in men. However, hirsutoid papillomas of the vulvae, also known as vestibular papillomatosis, is a benign, asymptomatic anatomical variant of the vulvar epithelium present in approximately 1% of women.[5] It is considered the female counterpart of pearly penile papules in men.[6]

Age

Pearly penile papules are noted most commonly in males in their second or third decades of life, with a gradual decrease in frequency with aging.[1, 7]

Pearly penile papules typically are asymptomatic and persist throughout life, although lesions gradually may become less noticeable with advancing age.

Educate patients about the benign nature of pearly penile papules. Inform patients that lesions are not transmitted through sexual activity. Consider counseling for the patient's sexual partner, which often helps alleviate anxiety.

Most patients with pearly penile papules seek dermatologic consultation because they are concerned about a sexually transmitted disease. Pearly penile papules most commonly are confused with condyloma acuminatum (genital warts) or less often, with molluscum contagiosum.[8]

Upon physical examination, pearly penile papules appear as one or several rows of small, flesh-colored, smooth, dome-topped to filiform papules situated circumferentially around the corona or sulcus of the glans penis.[9] Uncommonly, lesions may extend onto the glans penis. In order to visualize the corona and sulcus of the penis in an uncircumcised male, it is often necessary to manually retract the foreskin. Generally, pearly penile papules are readily visible in circumcised men in the same anatomical sites.

Pearly penile papules typically are asymptomatic and persist throughout life; however, they gradually may become less noticeable with increased age.[1]

See the images below.

Pearly penile papules are seen clinically as multiple, glistening, flesh-colored, dome-topped papules arranged circumferentially in 2 rows along the corona of the glans penis.

Pearly penile papules. Courtesy of Wiki Commons

Pearly penile papules; close-up view. Courtesy of Wiki Commons.

Pearly penile papules are not known to be associated with any complications.

Laboratory studies are not indicated for pearly penile papules.

Imaging studies are not indicated for pearly penile papules.

No other tests are indicated, although dermoscopic findings have been documented,[10, 11, 12]

Confirmation of a diagnosis of pearly penile papules may be obtained by obtaining a biopsy specimen of a lesion for histopathologic analysis.

Histopathologic analysis of lesions demonstrates a variable number of thin-walled ectatic vessels in the dermis in association with a fibroblastic proliferation. Lesional fibroblasts may appear stellate or multinucleated. Concentric fibrosis surrounding adnexal structures is an additional characteristic.

These features are seen in angiofibromas and are not specific for pearly penile papules. Angiofibromas associated with tuberous sclerosis (adenoma sebaceum) and fibrous papules may show identical histologic findings. Clinical history or recognition of genital skin (in adequate biopsy sample) may provide a specific diagnosis.

No staging system exists or is necessary, given the benign and innocuous nature of pearly penile papules.

Pearly penile papules typically are asymptomatic and require no therapy.

Some patients with pearly penile papules may request therapy to alleviate anxiety.

Ablation using carbon dioxide laser,[13, 14, 15] electrodesiccation with curettage, and excisional surgery reportedly have successfully eliminated pearly penile papules. Recent technological advancements in lasers have resulted in promising outcomes using newer fractional ablative approaches,[16, 17] including fractionated carbon dioxide lasers.[18] Successful treatment with pulsed dye laser has been reported,[19] as has treatment with erbium:yttrium-aluminium-garnet (Er:YAG) laser.[20]

Mixed results have been noted with cryotherapy.[21]

Topical application of podophyllin largely has been ineffective for pearly penile papules.

Consultation with a dermatologist may prove useful when the diagnosis is not obvious.

Diet is not known to be a factor influencing the development or course of pearly penile papules.

Pearly penile papules are not associated with personal hygiene or sexual activity.

Circumcision at birth may decrease the incidence of pearly penile papules, since the frequency of lesions is fewer in circumcised males (12%) versus uncircumcised males (22%).

Most patients accept that treatment is not necessary for pearly penile papules once the benign nature of the lesions is explained. Patients who insist on treatment may elect to undergo ablative therapy with conventional surgical excision or carbon dioxide laser resurfacing.

No effective topical or oral medical therapies are known for the treatment of pearly penile papules.