What is the most likely diagnosis ? |
||||
a Tinea faciei |
||||
|
penis . Friction and heat are also believed to be contributing factors .
The diagnosis can be made clinically . However , biopsy and histopathological examination are indicated in certain situations . These include clinical diagnostic uncertainty and lesions that do not respond as expected to treatment or that are suspicious for malignancy . Biopsy characteristically shows eroded mucosa and underlying plasma cell infiltrate .
Plasma cell infiltrates can also occur in association with other skin conditions , and some cases of initially diagnosed Zoon ’ s balanitis are later determined to have other causes , such as infection , dermatitis , psoriasis or malignancy .
Management includes a combination of general measures and medical and surgical approaches .
General measures for balanitis include advice about appropriate genital hygiene , such as regularly retracting the foreskin and washing gently with warm water and / or moisturiser ( avoiding soap or chemicals ) and thoroughly patting dry the glans , prepuce and penis after washing .
Medical management includes the use of corticosteroids with topical antifungals and / or antibiotics if indicated .
|
Topical calcineurin inhibitors ( such as tacrolimus 0.1 % and pimecrolimus 1 %) can also be considered ; however , concerns have been raised about the potential risk for development of malignancy ( specifically erythroplasia of Queyrat — SCC in situ of the penile mucosa ). Malignancy should be carefully excluded prior to use .
Surgical management involves carbon dioxide laser therapy and / or circumcision . Zoon ’ s balanitis can relapse and recur even after general and medical management , so circumcision should be considered for patients with persistent symptoms despite medical management .
Resolution of symptoms can take weeks to months after circumcision .
Although Zoon ’ s balanitis is defined as a benign condition , regular follow-up , monitoring of progression and response to treatment are recommended , considering it has an association with pre-malignant conditions , such as erythroplasia of Queyrat . 1-4
|
b Dermatitis
c Psoriasis
d Rosacea
|
||
|
Zoon ’ s balanitis is an inflammatory condition of the glans penis that occurs almost exclusively in middle- to older-aged uncircumcised men .
atlasdermatologico . com . br
|
Online resources
• Dermatology Atlas : atlasdermatologico . com . br
References on request from kate . kelso @ adg . com . au
|
Have an interesting clinical case ?
Log CPD hours for preparing educational content for publication .
We pay $ 400 for each published case .
For details , email medical editor kate . kelso @ adg . com . au
|
Have an interesting spot diagnosis ?
Log CPD hours for preparing educational content for publication .
We pay $ 100 for each published quiz .
For details , email medical editor kate . kelso @ adg . com . au
|
ANSWER The answer is a . This facial rash , which appeared after waxing , with intermittent pruritus , is consistent with a clinical diagnosis of tinea faciei . Tinea faciei is caused by a variety of dermatophytes , which thrive in warm , moist environments . In this case , waxing the area likely resulted in disruption to the skin barrier and created an opportunity for fungal infection to occur . Pruritus is a characteristic symptom of cutaneous fungal infections .
Although the patient has features consistent with chronic atopic dermatitis of the neck and cubital fossa , dermatitis is less likely to be the cause of the periorbital rash . In this area , the rash is more sharply demarcated and demonstrates peripheral accentuation of the scale , which is more classic for a fungal infection .
Psoriasis is less likely because it typically presents with discrete , well demarcated , erythematous scaly papules and plaques . It can affect various parts of the body , including the face , but is more common over extensor surfaces and the scalp . The nails may also be involved .
Rosacea is less likely because it is characterised by facial erythema and flushing , with or without pustules and papules . In this setting , the facial and upper back comedones are most consistent with acne .
Skin scraping from the lesions for microscopy , culture and sensitivity , and PCR , will aid diagnosis of dermatophyte infection . Fungal hyphae may be seen on initial microscopy and cultured for identification . Some laboratories now also offer PCR testing which is more sensitive and specific . Topical terbinafine is the recommended treatment for tinea faciei such as in this case , due to its specific antifungal action , targeted application , and established efficacy . Combination topical steroids and antifungals are not recommended , and are thought to contribute to treatment-resistance , which is developing worldwide .
Generally , three weeks of therapy is sufficient for response . However , some cases of tinea faciei , particularly those that are more extensive , severe or unresponsive to initial treatment , may require an extended treatment course of up to six weeks . This longer duration is usually reserved for cases where the infection has proven to be more stubborn or widespread .
References on request from kate . kelso @ adg . com . au
|