What is the diagnosis and management of pearly penile papules in a 19-year-old male with a history of urethritis and fungal balanitis?

Diagnosis and Management of Pearly Penile Papules

Pearly penile papules (PPP) are benign, normal anatomical variants that require no medical treatment beyond reassurance. 1

Diagnosis

Pearly penile papules present with distinctive clinical features:

• Uniform, dome-shaped papules measuring 1-3mm in diameter
• Typically arranged in one or two rows around the corona of the glans penis
• Flesh-colored to whitish in appearance
• Asymptomatic (no pain, itching, or discharge)

Differential Diagnosis

It's important to distinguish PPP from other conditions:

• Condyloma acuminata (genital warts): Irregular, cauliflower-like appearance; Ki-67 immunostaining can help differentiate (positive in condyloma, negative in PPP) 2
• Penile intraepithelial neoplasia (PIN): Presents as red, moist plaques or scaly patches 3
• Bowenoid papulosis: Occurs in younger sexually active men, often on the shaft 3
• Molluscum contagiosum: Central umbilication is characteristic

Management

First-line Approach

• Patient education and reassurance is the primary management strategy
• Emphasize that PPP are:
  • Normal anatomical variants present in 14-48% of men 4
  • Not sexually transmitted
  • Not infectious
  • Not precancerous
  • Not associated with any medical complications

For Patients Requesting Treatment (Cosmetic Concerns)

When patients experience significant psychological distress despite reassurance, treatment options include:

1. Laser therapy (most effective with minimal complications):

   • CO2 laser: Complete clearance with excellent cosmetic results 5
   • Erbium:YAG laser: Highly effective with minimal discomfort 4
   • Pulsed dye laser: Good option with minimal adverse effects 4

2. Other options (less preferred):

   • Cryotherapy: May cause scarring or pigmentary changes 6
   • Electrodesiccation and curettage: Higher risk of adverse cosmetic effects 4

Important Considerations

• Unlike lichen sclerosus or penile intraepithelial neoplasia, PPP have no malignant potential and do not require follow-up 3
• Biopsy is rarely indicated unless the diagnosis is uncertain
• Patients with a recent history of urethritis and fungal balanitis (as in this case) should be reassured that PPP are unrelated to these previous conditions
• Treatment should only be considered for significant psychological distress, as interventions carry risks of scarring and other complications

Pitfalls to Avoid

• Misdiagnosing PPP as a sexually transmitted infection, causing unnecessary anxiety
• Recommending treatment for a benign, normal anatomical variant
• Failing to distinguish PPP from conditions requiring treatment (like condyloma acuminata)
• Using combination steroid-antifungal creams, which are not indicated for PPP 7

In the case of this 19-year-old patient with a history of urethritis and resolved fungal balanitis, reassurance about the benign nature of PPP is the appropriate management strategy.