What are the causes and treatments of white bumps on the scrotum?

White Bumps on the Scrotum: Causes and Management

The most common cause of white bumps on the scrotum is Fordyce spots (ectopic sebaceous glands), which are benign physiologic variants requiring no treatment unless causing significant cosmetic concern or discomfort. 1

Common Benign Causes

Fordyce Spots (Ectopic Sebaceous Glands)

• These are the most frequent benign white lesions on scrotal skin, appearing as 2-3 mm diameter white-to-yellowish papules 1
• They represent normal sebaceous glands in an ectopic location and are completely benign 1
• Most patients require reassurance only, as these are physiologic variants 2
• Treatment is indicated only if causing itching, discomfort during sexual activity, or significant aesthetic concern 1
• When treatment is desired, the micro-punch surgical technique has shown excellent results with no recurrence over 12-84 months of follow-up 1

Other Benign Scrotal Lesions

• Epidermoid cysts appear as firm, white-to-yellow subcutaneous nodules and are benign intratesticular or scrotal wall lesions 3
• Sebaceous cysts may present as white or skin-colored bumps on the scrotal skin 2
• Milia (small keratin-filled cysts) can appear as tiny white bumps 2

Infectious Causes to Exclude

Human Papillomavirus (HPV) Infection

• Genital warts from HPV (particularly types 6 and 11) may appear as white, flesh-colored, or pink papules 4, 5
• These lesions are sexually transmitted and contagious to uninfected partners 4
• Most sexual partners are already subclinically infected even without visible warts 4
• Treatment options exist but recurrence rates are high; imiquimod shows promise as first-line therapy 5

Molluscum Contagiosum

• Can present as white, umbilicated papules on genital skin 2
• This is a viral infection that may require treatment if symptomatic 2

Inflammatory Dermatoses

Contact Dermatitis

• Irritant or allergic contact dermatitis may cause white scaling or maceration, often from moisture, condoms, lubricants, or hygiene products 5
• Management involves identifying and removing the offending agent 5

Lichen Sclerosus

• Presents as atrophic white patches on the glans and foreskin, though can extend to scrotal skin 5
• This is a chronic inflammatory condition requiring biopsy confirmation and treatment to prevent complications 5

Critical Red Flags Requiring Urgent Evaluation

When to Suspect Serious Pathology

• Any scrotal mass with acute pain, swelling, or systemic symptoms requires immediate ultrasound with Doppler to exclude testicular torsion, which causes testicular loss if not treated within 6-8 hours 6, 7
• Persistent lesions that don't respond to conservative management within 3 days require reevaluation 6
• Erythroplasia of Queyrat and Bowen's disease (squamous cell carcinoma in situ) can appear as benign red-orange plaques but require biopsy to exclude malignancy 5

Diagnostic Approach

Physical Examination Specifics

• Assess the size, number, distribution, and texture of white bumps 2
• Palpate for tenderness, firmness, or fluctuance 8
• Examine for associated symptoms: pain, itching, discharge, or systemic signs 8

When Imaging Is Indicated

• Ultrasound with Doppler is first-line imaging for any uncertain scrotal mass or when infection/malignancy cannot be excluded clinically 6, 3
• Biopsy is required when squamous cell carcinoma in situ cannot be excluded clinically 5

Management Algorithm

For Asymptomatic White Bumps (Most Common Scenario)

1. If examination reveals typical 2-3 mm white papules consistent with Fordyce spots, provide reassurance that these are normal anatomic variants 1
2. No treatment is necessary unless the patient requests intervention for cosmetic or comfort reasons 1
3. If treatment desired, refer to dermatology or urology for micro-punch technique 1

For Symptomatic or Uncertain Lesions

1. If lesions are pruritic, painful, or have atypical features, consider infectious or inflammatory etiologies 2, 5
2. Obtain sexual history to assess STI risk; if wart-like lesions present, consider HPV infection 4, 5
3. If inflammatory dermatosis suspected (scaling, erythema, atrophy), consider dermatology referral for biopsy 5

For Acute Presentations with Pain/Swelling

1. Perform immediate ultrasound with Doppler to exclude testicular torsion, abscess, or tumor 6, 7
2. If infection suspected, initiate empiric antibiotics covering sexually transmitted and enteric organisms 6
3. Surgical consultation is required if no improvement within 3 days 6

Common Pitfalls to Avoid

• Do not dismiss persistent or changing lesions as benign without proper evaluation, as squamous cell carcinoma in situ can appear clinically benign 5
• Avoid treating subclinical HPV infection detected only by acetowhitening, as this test has high false-positive rates 4
• Do not delay imaging when testicular pathology is possible, as conditions like testicular cancer can be masked by overlying scrotal changes 9
• Recognize that most "white bumps" are Fordyce spots requiring only reassurance, avoiding unnecessary interventions 1