Derma Case: 23-year-old Man with Bumps on His Penis

00:01 Alright, I think it's time we moved on to case number 2.

00:05 A 23-year-old man now presents to your office, concerned about some bumps on his penis.

00:11 He noticed them several weeks ago in the shower.

00:13 He tried rubbing alcohol, God knows why, and then a topical antifungal, to no avail.

00:19 These lesions are not itchy or painful, he denies any fevers or chills, no dysuria, no penile discharge.

00:26 His social and family history is essentially non-contributory, except that he has been sexually active with 5 female partners in the past 12 months.

00:35 Review of systems is negative, his vital signs are over the normal limits.

00:39 And then on exam of his genitourinary system, he has numerous, nontender, skin colored, fleshy papules, scattered on the shaft and base of his penis.

00:49 No mucosal involvement and no inguinal lymphadenopathy.

00:53 So, highlighting a few key features here, the time course appears to be subacute.

00:58 He noticed them several weeks ago.

01:00 In terms of the pattern of skin involvement, it is asymmetric involvement exclusively of his genitalia.

01:06 Skin inflammation, they're nontender, there don't appear to be pustules so doesn't sound there's much skin inflammation.

01:13 And lastly, systemic involvement - we're not seeing any.

01:16 So, that's basically what we've got at this point.

01:20 Alright, let's take a look at our differential diagnosis.

01:23 Condyloma acuminata, acrochordon, genital herpes, verruca vulgaris and chancres.

01:30 Well that's a mess of Greek and Latin.

01:32 Let's see if we can make our way through it all.

01:34 First off, condylomata acuminata, that's a fancy term for genital warts.

01:40 The etymology actually means pointed, round tumor which distinguishes a genital wart from the more flat appearance of plantar and common warts which are also caused by HPV.

01:52 In any event, these asymptomatic lesions are incredibly common.

01:56 In fact, they're the most common sexually transmitted disease above all else and they manifest on the shaft of the penis.

02:02 They're more common in sexually active men and women so this one clearly is gonna stay on our list.

02:10 Next stop, acrochordon.

02:12 What's with the fancy words? Okay, an acrochordon is the official term for a skin tag which is depicted here in our image.

02:20 It's a fleshy papilloma that most often occurs in flexural creases, like the nape of the neck, the axilla, the groin.

02:26 We should probably keep this one on our list for now.

02:30 Genital herpes, finally some english.

02:33 Genital herpes is typically caused by herpes simplex virus 2, though it can also be caused by HSV 1.

02:40 It's relatively common viral infection with myriad skin manifestations but the lesions of HSV 2 are more of the painful vesicular or ulcerative type rather than our patient's painless, fleshy papules.

02:54 So I think we can safely take HSV-2 and genital herpes off the list.

03:01 And here we're back to the latin.

03:02 Verruca vulgaris This is a fancy word for common wart.

03:07 Common warts is one subtype of cutaneous warts.

03:11 The others of which include plantar warts and flat warts, we've already mentioned another type of wart above.

03:16 Cutaneous wart is an umbrella term for warts caused by HPV that are not occuring in the anogenital region which is we've already discussed are called condylomata acuminata.

03:27 see above.

03:28 Hence, since our patient's lesions are in fact in the anogenital area, if they were gonna have any kind of wart, it would be condylomata acuminata.

03:37 So we can safely take verruca vulgaris off of our list.

03:41 A bit of taxonomy goes a long way.

03:44 Lastly, chancre.

03:46 A chancre is the classic lesion of primary syphilis.

03:50 Now it starts as a painless papule, similar to our patient at the site of inoculation.

03:56 though it eventually progresses to a painless ulcer.

04:00 It'd be unusual to have multiple lesions like we have on our patient and also, you'd more likely have some accompanying lymphadenopathy.

04:07 Now, while the chancre represents the primary syphilis lesion, the spirochete bacterium of syphilis, Treponema palliidum, soon goes systemic even as the ulcer heals over several weeks.

04:18 So, patients develop some systemic manifestations.

04:21 And later, secondary syphilis can occur with a diffuse, classic, maculopapular rash eruption on the trunk and extremities, including the palms and soles.

04:30 It's really not sounding at all like what our patient has had for the past several weeks, so I think we can safely take off chancre and syphilis.