LETTER TO THE EDITOR
Ahead of print publication  

Postcircumcision psoriatic balanoposthitis: an undescribed expression of Koebner's phenomenon


 Dermatology Department, Virgen del Rocío University Hospital, Seville 41013, Spain

Date of Submission03-Mar-2021
Date of Acceptance31-May-2021
Date of Web Publication03-Aug-2021

Correspondence Address:
Juan Ortiz-Álvarez,
Dermatology Department, Virgen del Rocío University Hospital, Seville 41013
Spain

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aja.aja_65_21

PMID: 34380863


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How to cite this URL:
Ortiz-Álvarez J, Hernández-Rodríguez JC, Sánchez JC, Barabash-Neila R. Postcircumcision psoriatic balanoposthitis: an undescribed expression of Koebner's phenomenon. Asian J Androl [Epub ahead of print] [cited 2021 Dec 8]. Available from: https://www.ajandrology.com/preprintarticle.asp?id=322983

Dear Editor,

Although penile lesions tend to be attributed to sexually transmitted diseases in sexually active patients, there are various inflammatory skin diseases that can occur in this area.[1] Among them, psoriasis is one of the most frequent, being the most common or third most common according to some studies, making it a potential reason for consulting an andrologist.[2],[3] It can become a disease that impacts the quality of life and sexual function.[4]

The genital involvement of psoriasis, which can affect 60% of patients during the course of the disease, seems to be more frequent in men and can be the initial and only manifestation of the disease.[5] Lesions can appear on the penile shaft, foreskin, or glans. In the genital area, we can find slightly different features than the classic features of the disease. There are also differences between uncircumcised patients and those who have undergone circumcision, the latter presenting scaly lesions more often that can result in bleeding.[1],[3]

As in many chronic inflammatory diseases, it has not been possible to establish a single cause that explains the development of psoriasis. However, multiple genetic, infectious, psychological, and environmental triggers have been established.[6]

We present the case of a 24-year-old male with no personal or family history of known skin diseases, who reported penile skin dryness and lesions on the glans and attended our emergency dermatology consultation (Virgen del Rocío University Hospital, Seville, Spain) in September 2020. He denied high-risk sexual encounters and stated that he had a female partner with whom he maintained a closed relationship and that they used barrier methods of contraception consistently and correctly. He reported that the lesions appeared a year prior in the second postoperative week of his postectomy intervention to treat phimosis. The lesions caused stinging, itching, and significant dyspareunia. The patient in this study has given written informed consent to the publication of his case details.

On examination, he presented with confluent, erythematous plaques with fine superficial pearly scaling that affected the entire glans but not the rest of the penile skin [Figure 1]a. Polarized light dermoscopy was performed, which showed a punctate vascular pattern of homogeneous distribution [Figure 1]b. Examination of the rest of the body, including nails and scalp, revealed no evidence of any other lesions.
Figure 1: Appearance of the penis showing (a) clinical and (b) dermoscopic findings.

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Based on clinical findings and with the support of dermoscopy, the diagnosis of psoriasis was established, and 0.1% topical tacrolimus (Protopic®, Leo Pharma, Denmark) was prescribed every 24 h for a month and, subsequently, three times a week for two months together with emollients. This led to substantial improvement in the condition.

To date, multiple cases of psoriatic balanoposthitis have been published in circumcised patients. However, none of them showed such a clear and evident spatiotemporal relationship with the performance of postectomy.[7],[8]

In 1872, Heinrich Koebner described the appearance of psoriatic lesions in areas of healthy skin subjected to trauma, which was called an isomorphic phenomenon.[9] Radiotherapy, rubbing of prostheses after amputations, and surgical incisions have been described as triggers for this phenomenon.[10] Nonetheless, to our knowledge, the development of this phenomenon after postectomy has not been described. In the present case, there appear to be two factors contributing to the aetiopathogenesis of this phenomenon. On the one hand, there was trauma during the operation, and on the other hand, there was a re-epithelialization process in the postoperative period. The fact that a region previously protected by the foreskin has become exposed to continuous friction must be added to this scenario. Therefore, the urologist and andrologist ought to be aware of this phenomenon to be able to identify not only the onset of the disease but also to prevent a new outbreak in the case of an already diagnosed patient.

Furthermore, in this case, the use of dermoscopy was especially useful for us to achieve the diagnosis. The development of this technique and the description of patterns in inflammatory diseases has been a very important advance.[11] In the case of psoriasis, a pattern consisting of the presence of pinpoint vessels of regular distribution on a slightly erythematous background is described, which seems to be very specific for this dermatosis.[12] In this way, if the clinical findings and dermoscopy concur, a diagnosis can be reached sooner, avoiding the performance of biopsies in a delicate area, such as the genital area, and thus avoiding subsequent trauma, which can lead to a worsening of the process.

In conclusion, we report a case of psoriasis onset after circumcision. This was the only postoperative adverse event, and its manifestation may have been triggered by Koebner's phenomenon. The presence of erythematous and scaly lesions with a characteristic vascular pattern should make us suspect the disease, which can significantly affect the quality of life and sexual functioning of the patient.


  Author Contributions Top


JOA, JCHR, and RBN contributed to conceptualization, data curation, analysis, and writing. JOA, RBN, and JCMS contributed to conceptualization, writing, and review. All authors have read and approved the final manuscript and agree with the order of presentation of the authors.


  Competing Interests Top


All authors declare no competing interests.



 
  References Top

1.
Andreassi L, Bilenchi R. Non-infectious inflammatory genital lesions. Clin Dermatol 2014; 32: 307–14.  Back to cited text no. 1
    
2.
Elakis JA, Hall AP. Skin disease of penis and male genitalia is linked to atopy and circumcision: caseload in a male genital dermatology clinic. Australas J Dermatol 2017; 58: e68–72.  Back to cited text no. 2
    
3.
Buechner SA. Common skin disorders of the penis. BJU Int 2002; 90: 498–506.  Back to cited text no. 3
    
4.
Ryan C, Sadlier M, De Vol E, Patel M, Lloyd AA, et al. Genital psoriasis is associated with significant impairment in quality of life and sexual functioning. J Am Acad Dermatol 2015; 72: 978–83.  Back to cited text no. 4
    
5.
Meeuwis KA, Potts Bleakman A, van de Kerkhof PC, Dutronc Y, Henneges C, et al. Prevalence of genital psoriasis in patients with psoriasis. J Dermatolog Treat 2018; 29: 754–60.  Back to cited text no. 5
    
6.
Lee EB, Wu KK, Lee MP, Bhutani T, Wu JJ. Psoriasis risk factors and triggers. Cutis 2018; 102: 18–20.  Back to cited text no. 6
    
7.
Yao XJ, Zhang TD. Psoriasis localized to the glans penis in a 37-year-old man. CMAJ 2018; 190: E747.  Back to cited text no. 7
    
8.
Ennaciri S, Farih MH. Psoriasis of the glans penis in circumcised subjects. Pan Afr Med J 2020; 35: 1–2.  Back to cited text no. 8
    
9.
Diani M, Cozzi C, Altomare G. Heinrich Koebner and his phenomenon. JAMA Dermatol 2016; 152: 919.  Back to cited text no. 9
    
10.
Ji YZ, Liu SR. Koebner phenomenon leading to the formation of new psoriatic lesions: evidences and mechanisms. Biosci Rep 2019; 39: 1–12.  Back to cited text no. 10
    
11.
Conforti C, Giuffrida R, Di Meo N, Longone M, Vichi S, et al. Benign dermatoses of the male genital areas: a review of the literature. Dermatol Ther 2020; 33: 1–12.  Back to cited text no. 11
    
12.
Borghi A, Virgili A, Corazza M. Dermoscopy of inflammatory genital diseases: practical insights. Dermatol Clin 2018; 36: 451–61.  Back to cited text no. 12
    


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