"Genital Dermatology "
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Genital Genital Dermatology Dermatology “Hey doc…can I get some more of that cream?”
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Genital DermatologyGenital Dermatology
“Hey doc…can I get some more of that cream?”
LCDR Ron Perry, MSC, USN
ObjectivesObjectives
• Discuss the proper clinical evaluation of the patient requesting “jock itch cream refills”
• Review the differential diagnoses for genital rashes and lesions
• Review the initial management of selected conditions
Genital DermatologyGenital Dermatology
• You have just completed a new patient evaluation on a 30 year-old male with hypertension. As he is leaving your exam room, he turns around and asks you for “some of that jock itch cream.”
• What do you do?
Genital DermatologyGenital Dermatology
• Let’s review the ground rules– Establish privacy and get a standby PRN– Perform a H & P– Labs PRN– R/O DDx, Dx and tx– Failure to respond to tx
• Re-eval patient…wrong dx, wrong tx…or both?• Biopsy
Genital DermatologyGenital Dermatology
• When patients refer to “genitalia” they may be talking about:– Upper medial thighs – Crural folds – Penis– Scrotum– Vulva– Perineal – Perianal– Intergluteal
Genital DermatologyGenital Dermatology
• Ask about pain, pruritis, other symptoms• Is there any PMH of systemic disease?• Is there a PMH of similar rash or lesion?• FHx of something similar, or atopy?• What are they currently/prev. using for tx?
– Where did they get it?– Does it help or make condition worse?– Has the morphology changed? – How long have they been treating condition?
Genital DermatologyGenital Dermatology
• Don’t forget allergies, meds, occupation, sex hx• Anything affecting the genitalia leads to great
concern by the patient…patient’s partner • Skin in this region is thin, moist, easily damaged• Scale may not form in this region, which can make
things challenging• STDs and staph infections in your ddx, but
covered by other speakers
Genital DermatologyGenital Dermatology
• Let’s take a at some genital rashes and lesions
19 year-old male reports h/o “recurrent jock itch 19 year-old male reports h/o “recurrent jock itch since the beginning of football season”since the beginning of football season”
What do you think?
A. ErythrasmaB. Tinea crurisC. Candida intertrigo
Treatment options?
33 year-old male with h/o “groin rash” for last 4 33 year-old male with h/o “groin rash” for last 4 months. He states it was improving with use of OTC months. He states it was improving with use of OTC
hydrocortisone, but he ran out and now wants hydrocortisone, but he ran out and now wants “something stronger”“something stronger”
What do you think?
A. Tinea crurisB. Tinea incognitoC. Candida intertrigo
Treatment options?
40 year-old male reports h/o pruritic rash for the past 40 year-old male reports h/o pruritic rash for the past month. He has h/o same and was given “some cream” month. He has h/o same and was given “some cream”
which worked well last timewhich worked well last time
What do you think?
A. Erythrasma
B. Tinea cruris
C. Candida intertrigo
Treatment options?
27 year-old desires eval for “red rash.” She states it 27 year-old desires eval for “red rash.” She states it has been there “for some time” and is often pruritic at has been there “for some time” and is often pruritic at
night. She states heat and friction make condition night. She states heat and friction make condition worse. FHx positive for “red scaly rashes”worse. FHx positive for “red scaly rashes”
What do you think?
A. Vestibulitis
B. Inverse psoriasis
C. Candida intertrigo
Treatment options?
42 year-old male with c/o non-tender, brown rash 42 year-old male with c/o non-tender, brown rash affecting groin and left foot (4affecting groin and left foot (4thth toe interspace). He states toe interspace). He states
he has had this for about 3 months and using OTC he has had this for about 3 months and using OTC “antifungal cream” with no change“antifungal cream” with no change
What do you think?
A. Tinea cruris
B. Erythrasma
C. Candida intertrigo
Treatment options?
33 year-old male with a 2 week h/o intensely pruritic 33 year-old male with a 2 week h/o intensely pruritic scrotal rash. Recalls using an antibiotic ointment on scrotal rash. Recalls using an antibiotic ointment on
scrotum approximately 3 weeks ago for tx of “ingrown scrotum approximately 3 weeks ago for tx of “ingrown hair”hair”
What do you think?
A. Atopic dermatitis
B. Irritant contact dermatitis
C. Allergic contact dermatitis
Treatment options?
18 year-old female with 2 year history of chronic 18 year-old female with 2 year history of chronic vulvar pruritis, rubbing and scratching. Her PMH and vulvar pruritis, rubbing and scratching. Her PMH and
FHx are significant for asthmaFHx are significant for asthma
What do you think?
A. Lichen planus B. Atopic dermatitisC. Lichen simplex chronicus
Treatment options?
30 year-old in for pap test and evaluation for groin rash 30 year-old in for pap test and evaluation for groin rash which “comes and goes” over the past 15 years. She which “comes and goes” over the past 15 years. She
also has chronic dandruffalso has chronic dandruff
What do you think?
A. PsoriasisB. Atopic dermatitisC. Seborrheic dermatitis
Treatment options?
56 year-old female reports a 3 month h/o genital lesions 56 year-old female reports a 3 month h/o genital lesions and progressive dyspareunia. She also has painful oral and progressive dyspareunia. She also has painful oral
lesions. Denies prior h/o samelesions. Denies prior h/o same
What do you think?
A. Lichen planus
B. Lichen sclerosis
C. Behcet’s syndrome
Treatment options?
59 year-old female reports progressive vulvovaginal 59 year-old female reports progressive vulvovaginal pain, pruritis, and dyspareunia. She also notes a slight pain, pruritis, and dyspareunia. She also notes a slight
watery discharge and admits to habitual vulvar watery discharge and admits to habitual vulvar scratchingscratching
What do you think?
A. Lichen planusB. Lichen sclerosisC. Squamous cell carcinoma
Treatment options?
20 year-old obese female with chronic pelvic 20 year-old obese female with chronic pelvic discomfort and disability related to recurrent cystic discomfort and disability related to recurrent cystic
masses, nodules, and sinus tract drainagemasses, nodules, and sinus tract drainage
What do you think?
A. FolliculitisB. Keratosis pilarisC. Hidradenitis suppurativa
Treatment options?
21 year-old male with recent weight gain has noticed 21 year-old male with recent weight gain has noticed dark, thickened skin in the groin and axillaedark, thickened skin in the groin and axillae
What do you think?
A. Lentigo B. Candida intertrigo C. Acanthosis nigricans
Treatment options?
25 year-old male reports hypopigmentation after using 25 year-old male reports hypopigmentation after using “some cream” prescribed at another clinic several “some cream” prescribed at another clinic several
weeks agoweeks ago
What do you think?
A. VitiligoB. Nevus anemicusC. Chemical-induced
leukoderma
Treatment options?
22 year-old male and his newlywed wife are in your 22 year-old male and his newlywed wife are in your exam room. She is concerned he has been involved with exam room. She is concerned he has been involved with
extracurricular activitiesextracurricular activities
What do you think?
A. WartsB. Bowenoid papulosisC. Pearly penile papules
Treatment options?
44 year-old male with these “purple bumps” on 44 year-old male with these “purple bumps” on scrotum since he was in high school. States may bleed scrotum since he was in high school. States may bleed
if traumatizedif traumatized
What do you think?
A. Scrotal cysts B. Lichen planusC. Angiokeratomas
Treatment options?
21 year-old female with long h/o “bump down there” 21 year-old female with long h/o “bump down there” and would like it removed. She states embarrassment and would like it removed. She states embarrassment regarding possibility of STD and being “contagious”regarding possibility of STD and being “contagious”
What do you think?
A. WartB. Skin tagC. Vulvar cancer
Treatment options?
62 year-old male has had a penile ulceration for the past 62 year-old male has had a penile ulceration for the past 7 days. He has a h/o chronic bacterial prostatitis and is 7 days. He has a h/o chronic bacterial prostatitis and is
taking trimethoprim sulfamethoxazoletaking trimethoprim sulfamethoxazole
What do you think?
A. Candida balanitis B. Fixed drug eruptionC. Erythroplasia of queyrat
Treatment options?
67 year-old female with long history of progressive 67 year-old female with long history of progressive vulvar discomfort, dyspareunia, intermittent bleeding vulvar discomfort, dyspareunia, intermittent bleeding
and “growing bump”and “growing bump”
What do you think?
A. Vulvar cancerB. Lichen sclerosisC. Bartholin’s cyst
Treatment options?
50 year-old uncircumsized male with 4 year history of 50 year-old uncircumsized male with 4 year history of “sore” and recent onset of weight loss and inguinal “sore” and recent onset of weight loss and inguinal
swellingswelling
What do you think?
A. Psoriasis B. Penile cancerC. Candida balanitis
Treatment options?
Genital DermatologyGenital Dermatology
• Hang in there…we’re almost done!
Genital DermatologyGenital Dermatology
• Don’t forget to examine other areas for clues to the diagnosis
• Consider KOH, wood’s lamp, dermatoscope, culture, bloodwork
• Do not tx unless you know the dx• If give steroid rx, don’t give refills• Patient ed is important. Reinforce tx compliance
and need for patient to keep an eye on things• Ensure f/up
Genital DermatologyGenital Dermatology
• Get a biopsy PRN. I would refer for bx if– Aggressive skin cancer– A large lesion– A lesion located in sensitive area– A lesion that is beyond scope of your skills– The patient has a higher chance of having a
complication or may require close monitoring during or after surgery
Genital DermatologyGenital Dermatology
• References– Habif– Fitzpatrick– Dermatlas.org – UpToDate.com– Derm-Challenger PA– eMedicine.com– Dermnet.com– Dermnet.org.nz
