Pearly Penile Papules

Background

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 (see the images below) and commonly are arranged circumferentially in one or several rows.^[1] Although pearly penile papules often are wrongly assumed to be transmitted sexually, they 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.

View Image

Pearly penile papules. Image from Wikimedia Commons.

View Image

Pearly penile papules: close-up view. Image from Wikimedia Commons.

• References

Pathophysiology

Pearly penile papules are considered a normal variant and harbor no malignant potential. They are not contracted or spread through sexual activity. In the past, pearly penile papules were believed to contribute to the accumulation of smegma in uncircumcised men; however, subsequent study showed that this is not the case.^[2]

Pearly penile papules are observed more frequently in uncircumcised males than in circumcised males; however, the mechanisms underlying their development remain unknown. It is noteworthy that in uncircumcised males with pearly penile papules who undergo circumcision later in life, regression of the papules is commonly observed.^[3]

• References

Epidemiology

United States and international statistics

The reported incidence of pearly penile papules in the United States has been in the range of 8-48%.^[4]  As noted, several reports have suggested that the incidence is higher in uncircumcised men than in circumcised men (22% vs 12%). One study found an increase in frequency in Black men as compared with White men.^[5]

No geographic variations in prevalence have been noted for pearly penile papules.

Age-, sex-, and race-related demographics

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.^[3]

Because of their anatomic distribution, pearly penile papules are noted only in males. However, hirsutoid papillomas of the vulvae (also known as vestibular papillomatosis) is a benign, asymptomatic anatomic variant of the vulvar epithelium that is present in approximately 1% of women.^[6]  It is considered the female counterpart of pearly penile papules in men.^[7]

No racial predilection has been definitively confirmed for pearly penile papules. There have been reports suggesting an increased incidence in African American males, but this finding may be a reflection of a higher percentage of uncircumcised men in that population. In a study that included 840 men aged 10-66 years, the overall incidence of pearly penile papules was 30.1%.^[5]  Among the Black study subjects, the incidence of pearly penile papules was 32.7% (44% in uncircumcised subjects and 20.8% in circumcised subjects); among the White study subjects, the incidence was 13.9% (33.3% in uncircumcised subjects and 7.1% in circumcised subjects).

• References

Prognosis

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

• References

Patient Education

It is important to educate patients about the benign nature of pearly penile papules. Patients should be informed that the papules are not transmitted through sexual activity. It may be worthwhile to suggest that the patient's sexual partner consider counseling, which often helps alleviate anxiety.

• References

History

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

• References

Physical Examination

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 (see the images below).^[9] In order to visualize the corona and sulcus in an uncircumcised male, it is often necessary to retract the foreskin manually. Generally, pearly penile papules are readily visible in circumcised men in the same anatomic sites.

View Image

Pearly penile papules are seen clinically as multiple glistening, flesh-colored, dome-topped papules arranged circumferentially in two rows along coro....

View Image

Pearly penile papules. Image from Wikimedia Commons.

View Image

Pearly penile papules: close-up view. Image from Wikimedia Commons.

Uncommonly, lesions may extend onto the glans penis. A few cases have been reported in which multiple dense papules cover the entire glans, but this is rare.^[10]

Pearly penile papules typically are asymptomatic and persist throughout life; however, they gradually may become less noticeable with increased age.^[3] They are not known to be associated with any complications.

• References

Approach Considerations

Laboratory studies are not indicated for pearly penile papules, nor are imaging studies. No other tests are routinely indicated, though dermoscopic findings have been documented.^{[12, 11, 13, 14]}

Consultation with a dermatologist may prove useful when the diagnosis is not obvious. Confirmation of a diagnosis of pearly penile papules may be obtained by obtaining a biopsy specimen of a lesion for histopathologic analysis (see Histologic Findings).

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

• References

Histologic Findings

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 also 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 an adequate biopsy sample) may provide a specific diagnosis.

• References

Approach Considerations

Pearly penile papules typically are asymptomatic and require no therapy. Patient reassurance is the first line of care.^[15] Once the benign nature of the lesions is explained, most patients accept that treatment is not necessary. Those who insist on treatment may elect to undergo ablative therapy with conventional surgical excision or carbon dioxide laser resurfacing. Topical application of podophyllin largely has been ineffective for treatment of pearly penile papules.

• References

Surgical Care

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

Ablation using a carbon dioxide laser,^{[16, 17, 18]} electrodesiccation with curettage, and excisional surgery reportedly have successfully eliminated pearly penile papules.^[15] Technologic advances in lasers have resulted in promising outcomes using fractional ablative approaches,^{[19, 20]} including fractionated carbon dioxide lasers.^[21] Successful treatment with a pulsed dye laser has been reported,^[22] as has treatment with an erbium:yttrium-aluminium-garnet (Er:YAG) laser.^[23]

Mixed results have been noted with cryotherapy.^[24]

• References

Prevention

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

• References

Medication Summary

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

• References