Photo Quiz

Itchy and Painful Ulceration on the Penis

Am Fam Physician. 2006 Jan 1;73(1):133-134.

A 61-year-old man presented with a five-day history of a penile ulceration. It began as an itchy, erythematous lesion and gradually became pigmented, blistered, and ulcerated (see accompanying figure). He had a history of benign prostatic hyperplasia for which he took tamsulosin (Flomax). He also had been taking ciprofloxacin (Cipro) during the preceding week to treat a urinary tract infection. He took no other prescription, over-the-counter, or herbal medications. The physical examination was normal except for the penile lesion. The patient denied any penile discharge and had one sexual partner who denied having any skin lesions or pruritus.

Question

Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis?

A. Syphilis.

B. Genital herpes.

C. Erythroplasia of Queyrat.

D. Fixed drug eruption.

E. Chancroid.

Discussion

The answer is D: Fixed drug eruption. The characteristic presentation is a pruritic or burning, sharply circumscribed, round-to-oval patch with violaceous or dusky erythema. The lesion appears within days to weeks of initiating a culprit drug and resolves after withdrawal of the medication. Lesions often recur at the same sites within hours of drug rechallenge and heal with residual hyperpigmentation. This eruption has a predilection for the face, sacral skin, genitalia, and acral locations. Bullous, ulcerative, or hemorrhagic components may develop occasionally. Less common variants are urticarial, erythematous, eczematous, or linear fixed drug eruption. Rarely, it may present as periorbital or generalized hypermelanosis.1

The most common causative agents of fixed drug eruption are antibiotics, in particular sulfonamides (trimethoprim/sulfamethoxazole [Bactrim, Septra]) and tetracycline. Others include penicillins, cephalosporins, clindamycin (Cleocin), antifungal agents, antimalarials, dapsone, fluoroquinolones, nonsteroidal anti-inflammatory drugs (e.g., acetaminophen, acetylsalicylic acid, ibuprofen [Motrin], indomethacin [Indocin], naproxen [Naprosyn], phenylbutazone [Cotylbutazone]), and sedatives (e.g., anticonvulsants, benzodiazepines, barbiturates, opiates). Similar chemical structures may cause cross-sensitivity among drugs.1,2 Drug rechallenge is the preferred method for confirming the causative drug. Patch testing and intradermal skin testing are other options.3,4

Initial treatment involves identifying and discontinuing the culprit drug. Systemic antihistamines with topical corticosteroids can be used to treat the lesions; however, extensive lesions with bullae often require treatment with systemic corticosteroids. Eroded lesions should be observed for bacterial superinfection.3

Syphilis causes genital ulceration (chancre). However, syphilitic chancres are painless and indurated.

Genital herpes has a prodrome of pain, itching, or other dysesthesia before lesions erupt. Lesions usually are clustered in one area and are composed of many tiny vesicles or ulcers without pigmentation.

Erythroplasia of Queyrat is squamous cell carcinoma in situ of the oral or genital mucosa. The glans penis often is involved. However, it is a moist, raised, erythematous plaque rather than an ulcer.

Chancroid, which is caused by Haemophilus ducreyi, is characterized by deep, painful ulcers and tender, enlarged, and sometimes suppurative regional lymphadenopathy.

Selected Differential Diagnosis of a Penile Lesion

Condition Characteristics

Syphilis

Single, rigid, painless, elevated ulceration with a red areola and rolled edges with a flat base

Genital herpes

Grouped vesicles or small ulcerations covered with serous secretion

Erythroplasia of Queyrat

Erythematous, moist plaque on the glans, shaft, and foreskin

Fixed drug eruption

Violaceous or dark erythema, may be associated with a bulla or ulceration

Chancroid (soft chancre)

Painful, undermined, open sore with gray-yellow, necrotic, “dirty” base; usually accompanied by inguinal adenopathy

Selected Differential Diagnosis of a Penile Lesion

View Table

Selected Differential Diagnosis of a Penile Lesion

Condition Characteristics

Syphilis

Single, rigid, painless, elevated ulceration with a red areola and rolled edges with a flat base

Genital herpes

Grouped vesicles or small ulcerations covered with serous secretion

Erythroplasia of Queyrat

Erythematous, moist plaque on the glans, shaft, and foreskin

Fixed drug eruption

Violaceous or dark erythema, may be associated with a bulla or ulceration

Chancroid (soft chancre)

Painful, undermined, open sore with gray-yellow, necrotic, “dirty” base; usually accompanied by inguinal adenopathy

REFERENCES

1. Crowson AN, Brown TJ, Magro CM. Progress in the understanding of the pathology and pathogenesis of cutaneous drug eruptions: implications for management. Am J Clin Dermatol. 2003;4:407–28.

2. Mahboob A, Haroon TS. Drugs causing fixed eruptions: a study of 450 cases. Int J Dermatol. 1998;37:833–8.

3. Lee AY. Fixed drug eruptions. Incidence, recognition, and avoidance. Am J Clin Dermatol. 2000;1:277–85.

4. Ozkaya-Bayazit E. Specific site involvement in fixed drug eruption. J Am Acad Dermatol. 2003;49:1003–7.

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