Reply to: Erosive balanitis caused by Staphylococcus haemolyticus in a healthy, circumcised adult male.

In this short letter of correspondence, we provide our specialist interpretation of what has been described in a previously published case report. We argue that this case describes a patient with chronic, undertreated male genital lichen sclerosus. If left unchecked, as in this case, lichen sclerosus can cause permanent architectural changes and damage to the affected tissues, and can thus predisposes to secondary infections, including bacterial, such as with Staphylococcus haemolyticus.

Nailbed HPV-related Bowen's disease in a man living with HIV.

Human papillomavirus (HPV) is a common sexually transmitted infection with wide-ranging clinical manifestations. High-risk anogenital HPV genotypes have also been reported to cause extragenital disease. We describe the case of a 69-year-old male patient living with HIV who was diagnosed with HPV-16 associated Bowen's Disease (BD) of the right middle finger nailbed, despite good virologic control and immune reconstitution. The lesion was managed surgically with adjunctive post-exposure HPV vaccination. This case adds to the growing body of evidence of extra-genital HPV disease attributable to anogenital genotypes in people living with HIV.

Is the presence of Merkel cell polyomavirus and human papillomavirus DNA in keratinocyte cancers and precancers associated with HIV status? A case-control study.

The epidemiology and potential pathogenic roles of human papillomavirus (HPV) and Merkel cell polyomavirus (MCV) in keratinocyte cancers (KCs) arising in people living with HIV (PLWH) compared with HIV-negative individuals are poorly understood. These issues were investigated by a case-control study in which the presence of MCV and HPV DNA was identified by polymerase chain reaction in microdissected formalin-fixed paraffin-embedded tissue from PLWH and HIV-negative individuals. The samples comprised 190 cutaneous and genital KCs/precancers (actinic keratoses, n = 43; cutaneous squamous cell carcinoma (cSCC) in situ, n = 24; basal cell carcinoma, n = 78; cSCC, n = 34; penile carcinoma in situ, n = 9; penile SCC, n = 2 from 104 individuals (PLWH, n = 51; HIV-negative, n = 53). Almost one-quarter of samples were positive for MCV: this was not significantly associated with either HIV status (P = 0.06) nor lesion type. Overall, 36% (16/44) of MCV-positive lesions were coinfected with HPV; this was also not associated with HIV status. These findings indicate that if these viruses do contribute to the pathogenesis of KCs, it is likely to be independent of HIV status.

Primary penile melanoma and genital lichen sclerosus.

Background: There is a well-established association between squamous cell cancer and genital lichen sclerosus (GLSc). Although there have been several reported cases of vulval melanoma (MM) associated with LSc, particularly in the paediatric population, fewer cases of male genital (M) GLSc and penile (Pe)MM have been published. Objectives: The aim of this study was to explore further the relationship between PeMM and MGLSc by reviewing all the cases managed by our multidisciplinary service over a finite period. Methods: All patients known to our tertiary urology and male genital dermatology service with a diagnosis of PeMM and where histology was available for review were identified over an 11-year period (2011-2022). The histology was reviewed by two independent, mutually 'blinded' histopathologists. Photographs and clinical notes, where available, were retrospectively reviewed by two independent dermatologists for signs or symptoms of LSc. Results: Eleven patients with PeMM were identified for review. Histopathological examination found evidence of LSc in nine patients, and review of clinical photos corroborated the presence of LSc in three. Overall, features of LSc were present in nine out of eleven cases (82%). Conclusion: The presence of LSc in 9 out of 11 cases of PeMM is suggestive of a causative relationship between LSc and PeMM. This may be due to chronic melanocytic distress created by chronic inflammation secondary to LSc.

Genital lichen sclerosus and melanoma; a systematic review.

Background: Lichen sclerosus (LSc) is a chronic, inflammatory, destructive skin disease with a predilection for the genitalia (GLSc). An association with vulval (Vu) and penile (Pe) squamous carcinoma (SCC) is now well established but melanoma (MM) has only rarely been reported complicating GLSc. Methods: We have performed a systematic literature review of GLSc in patients with genital melanoma (GMM). Only articles that mentioned both GMM and LSc affecting either the penis or vulva were included. Results: Twelve studies with a total of 20 patients were included. Our review shows that an association of GLSc with GMM has been more frequently reported in women and female children than men viz, 17 cases compared with three. It is notable that five of the cases (27.8%) concerned female children aged under twelve. Discussion: These data suggest a rare association between GLSc and GMM. If proven, there arise intriguing questions about pathogenesis and consequences for counselling of patients and follow-up.

2022 European guideline for the management of balanoposthitis.

BACKGROUND: This guideline is an update to the 2014 edition of the European guideline for the management of balanoposthitis. Balanoposthitis describes inflammation of the glans penis and prepuce and is caused by a range of disparate conditions including infection, dermatoses and premalignancy. OBJECTIVE: The main objectives of this guideline are to aid recognition of the symptoms and signs and complications of penile skin conditions and to offer recommendations on the diagnostic tests and treatment for a selected group of these conditions. METHODS: The previous guideline was updated following a literature review and priority was given to randomized controlled trial and systematic review evidence. RESULTS: The updated guideline includes amended management for infective balanitis to provide clear guidance for Group A streptococcal infections, management of on going Lichen sclerosus (to include circumcision and supportive management to reduce the recurrence of genital herpes and warts), additional regimens for Zoonoid change, use of calcineurin inhibitors in management and risk of premalignancy and change of nomenclaturefrom Premalignant conditions to Penile Intraepithelial neoplasia (PeIN). CONCLUSION: Balanoposthitis has a widerange of causes high quality evidence specific to the management of penile disease is not available for all the conditions described.

The risk of osteopenia/osteoporosis and psoriatic disease: A systematic review.

Background: Psoriasis (Ps) is a multisystem inflammatory disease associated with several comorbidities; however, its effect on bone health remains uncertain. This systematic review aimed to evaluate the risks of osteopenia (OPe) and osteoporosis (OP) in psoriasis. Methods: A systematic search was performed for published studies evaluating cutaneous Ps and psoriatic arthritis (PsA) compared with healthy control groups utilizing a validated bone mineral density (BMD) assessment score. Meta-analysis was performed using a random-effects model; pooled estimates and their confidence intervals (CIs) were calculated. For analysis, Ps and PsA groups were combined due to the small number of studies. Results: Twenty-one studies were included for final analysis; three Ps only, 15 PsA and three both. There was a significant difference between psoriatic disease (combination Ps and PsA group) compared with controls relating to an association with OP/OPe, with an overall odds ratio (OR) of 1.71 (95% CI 1.07-2.74: p-value = 0.026). The Ps group had significantly lower BMD than the control group at both the lumbar spine and femoral neck (mean difference -0.04; 95% CI -0.090 to 0.002 and -0.03; 95% CI -0.059 to 0.003 respectively). Conclusion: Putative risks of OPe and OP in both Ps and PsA are supported but not confirmed. Significant heterogeneity of reported data limits definitive conclusions in this meta-analysis. This review contributes to the further understanding of Ps as a multisystem disease and future management of potential comorbidities, but highlights key gaps in the literature. Further studies addressing standardised OP reporting, specific disease group characteristics comparing Ps with PsA, patient characteristics and medication use, are required in order to make more certain conclusions with greater clinical impact.

The association between penile cancer and HIV infection: A literature review.

Penile cancer is a rare malignancy which HIV infection appears to increase the risk of. The magnitude of this risk and the pathogenesis remain unclear. A comprehensive review of the literature was undertaken using conventional search strategies. Twenty-four publications were identified by this methodology, of which nine were case reports and 15 were observational studies. These studies were highly heterogeneous, with varying study designs, populations, and objectives. The risk of penile cancer within HIV-positive individuals is significantly greater than in those without HIV (RR = 3 .7 to 5.8, 3 studies; SIR = 3.8 to 11.1, 4 studies). HIV is also shown to influence disease characteristics, with a four-fold increased risk of death from penile cancer. Moreover, progression from intraepithelial neoplasia occurs earlier in HIV, six years sooner than in HIV-negative men. HIV-positive men have a higher prevalence of HPV infection. Ethnicity is also shown to modulate the relationship between HIV and penile carcinoma, with a higher risk of cancer in Hispanic, compared with Caucasian, HIV-positive men. This review has collated data from diverse sources to improve understanding of the relationship between HIV and penile cancer. This relationship has been quantitatively and qualitatively characterised and highlights areas deserving further enquiry.

Accelerated photocarcinogenesis and multifocal squamous cell carcinomas associated with voriconazole and human papillomavirus in HIV - case report.

Voriconazole is an antifungal with known side effects of phototoxicity and photocarcinogenesis. We present a case of HPV-related multifocal squamous cell carcinoma in a 68-year-old man with HIV, due to accelerated photocarcinogenesis associated with long-term use of voriconazole. Histology confirmed SCC with HPV-related features and he was found to have metastases. Multifocal SCC is unusual in association with voriconazole and HIV infection and only one other case has been reported. It is important for clinicians to be aware of the photocarcinogenic effects of voriconazole, especially in patients with HIV.

Psychotherapeutic interventions for burns patients and the potential use with Stevens-Johnson syndrome and toxic epidermal necrolysis patients: A systematic integrative review.

BACKGROUND: The existing evidence demonstrates that survivors of SJS/TEN have reported long-lasting psychological effects of their condition. Burns patients experience similar psychological effects. It is important to look at ways to help allay the psychological complications of SJS/TEN. As there is an absence of evidence on SJS/TEN psychotherapeutic interventions, it was judged to be beneficial to determine the evidence underpinning psychotherapeutic interventions used with burns patients. AIMS AND OBJECTIVES: The aim of this systematic integrative review was to synthesize the evidence relating to psychotherapeutic interventions used with adult burns patients and patients with SJS/TEN. METHOD: The systematic review was guided by Whittemore and Knafl's integrative review process and the PRISMA guidelines. Nine databases were searched for English and French language papers published January 2008 to January 2021. The protocol for the review was registered with PROSPERO. RESULTS: Following a screening process, 17 studies were included in the review. Two themes were identified using content analysis, (i) Empirically supported psychotherapeutic treatments, (ii) Alternative psychotherapeutic treatments. This review revealed no evidence on specific psychotherapeutic interventions for patients with SJS/TEN. Some of the interventions used with burns patients, viz. relaxation therapy, hypnosis and cognitive behavioral therapy showed some significant benefits. However, the evidence for burns patients is mainly focused on pain and pain anxiety as outcomes. CONCLUSION: Following further research, some of the interventions deployed in burns patients may be applicable to SJS/TEN patients, particularly stress reduction techniques. In addition, the caring behaviours such as compassion, respect, and getting to know the patient as a person are important components to psychological care.

Eruptive naevi associated with encorafenib for metastatic colorectal cancer: two cases.

Encorafenib is a BRAF inhibitor increasingly used as a second-line treatment for metastatic melanoma and colorectal cancer. BRAF inhibitors have been reported to be associated with new and changing melanocytic lesions, including eruptive naevi. We describe two cases of eruptive naevi secondary to encorafenib used for the treatment of BRAF-mutant metastatic colorectal cancer.

Male genital lichen sclerosus, microincontinence and occlusion: mapping the disease across the prepuce.

BACKGROUND: Male genital lichen sclerosus (MGLSc) can lead to significant sexual dysfunction and urological morbidity, and is also a risk factor for premalignant disease (penile intraepithelial neoplasia and penile cancer), particularly squamous cell carcinoma. Although the precise aetiopathogenesis of MGLSc remains controversial, accumulated evidence indicates that it is related to chronic, intermittent, occluded exposure to urine. AIM: To perform spatial mapping of MGLSc across the human prepuce and assess how this supports the urinary occlusion hypothesis. METHODS: Preputial samples were collected from 10 patients with clinically diagnosed MGLSc undergoing circumcision. The samples were then divided into a grid pattern and 10 punch biopsies were obtained from each section to determine the extent and distribution of the disease process across each prepuce. RESULTS: All 10 patients reported having urinary microincontinence, and all were histologically confirmed as having MGLSc. The most proximal aspect of the prepuce was found to be universally affected by MGLSc in all patients, whereas the most distal part was overwhelmingly shown to be the least affected area. Of the 63 MGLSc-affected regions, 62 were in direct physical contiguity with one another. The histological extent of the disease was not found to be congruent with either the severity of the symptoms reported by the patients or the clinical examination. CONCLUSION: In uncircumcised men with urinary microincontinence, after the prepuce has been replaced post micturition, small amounts of urine can pool between the juxtaposed epithelial surfaces. The proximal aspect of the prepuce is subjected to the maximum amount of occlusion and maximal contact with accumulated urine, whereas the distal prepuce is subjected to the least. Our findings suggest that accentuated contact between urine and susceptible penile epithelium due to occlusion can lead to MGLSc. Furthermore, contiguity data suggest that once established, it is possible that MGLSc advances across tissues by physical contact. This is the first study examining the changes in the preputial landscape in patients with LSc and contributes to our understanding of disease aetiology and progression.

Anogenital Crohn's Disease and Granulomatosis: A Systematic Review of Epidemiology, Clinical Manifestations, and Treatment.

BACKGROUND AND AIMS: Metastatic Crohn's disease is an extraintestinal cutaneous manifestation characterised by non-specific inflammatory lesions anatomically separate from the gut; genital involvement is rare. We conducted a systematic review of anogenital Crohn's disease and granulomatosis, to provide a synthesis of epidemiology, clinical features, and treatment outcomes. METHODS: A systematic search of the literature was conducted via MEDLINE, EMBASE, and the Cochrane database from inception to December 1, 2020. Two investigators extracted and analysed study data. Response and remission were defined as partial improvement or complete resolution of symptoms and examination findings, respectively. RESULTS: Of 9381 screened studies, 185 articles, [410 cases: 273 female, 137 male] were included. The predominant clinical features were oedema, ulcers, fissures, and hypertrophic lesions. Adults and children present similarly. Luminal Crohn's disease was diagnosed in nearly 80% of cases including 45-80% patients without gastrointestinal symptoms (time to inflammatory bowel disease [IBD] from anogenital Crohn's disease diagnosis [range] -43 to 11 years). Antibiotics, corticosteroids, thiopurines, and anti-tumour necrosis factor [TNF] therapy were the most frequently prescribed agents. At final follow-up, non-response, response, and remission rates were 37/304 [12%], 267/304 [88%], and 114/304 [38%], respectively. Oedema was associated with a poor response to topical therapy. Greater response rates to anti-TNF therapy were seen in patients prescribed concomitant immunomodulation [24/25, 96% vs 67/90, 74%, p = 0.02]. CONCLUSIONS: We provide an illustrative summary of the clinical presentation and treatment effectiveness of this rare, under-recognised condition, and a proposed algorithm for approach and management. Prospective studies with longer follow-up are required to define optimal treatment strategies.

Prurigo excoriée treated with low dose naltrexone.

A 53-year-old woman presented with a 25-year history of acne excoriée and prurigo excoriée. Her symptoms began in 1988 coinciding with her husband's death from a brain tumour when she was 27. The pruritus affected her quality of life and disturbed her sleep. She had scarring on her face and body resulting from persistent scratching. The pruritus proved refractory to treatment despite a multi-modal treatment approach including multiple topicals, phototherapy and systemic agents such as isotretinoin, antibiotics, anxiolytic agents and neuromodulators. She was extremely frustrated that various treatments had been ineffective at controlling the itch-scratch cycle. She was commenced on low dose naltrexone (LDN), 3 mg nocte, and she became itch free within a few weeks. She reports that the LDN has had a beneficial impact on her quality of life.