Strawberry nevus, usually appears after birth. It is most commonly noticed at a few days of life. It may be superficial, mixed or deep. There are usually 3 phases of growth. The first being a rapid growth or proliferative phase at around 5 to 8 weeks. The next phase is a resting or plateau phase occurring at around the first year of life. Last of which, is the involution phase

There are 2 other hemangiomas, namely the rapidly involuting congenital hemangioma (RICH) and non- involuting congenital hemangioma (NICH) which do not follow this classical growth phases. The former is fully formed at birth, then involutes spontaneously and resolves by the child’s first or second birthday. The latter is fully formed at birth but does not involute and shrink.

When do we worry?

Most of these infantile hemangiomas do not need treatment and we can look forward to spontaneous involution. However, do seek EARLY treatment if the following are present:

1. Ulceration, bleeding or pain
2. Locations that may affect function such as being near or at the eyes, lips, nose, ears, jawline, diaper area, scalp especially if > 2 cm
3. Segmental involvement of the face (may need to evaluate for PHACES syndrome -posterior fossa malformations, hemangiomas, arterial abnormalities, cardiac abnormalities, eye abnormalities, sternal cleft defect) or over the lower back or perineum (LUMBAR syndrome – Lower body hemangioma, urogenital anomalies, myelopathy, bony deformities, anorectal anomalies, renal anomalies or PELVIS syndrome – Perineal hemangioma, external genital malformations, lipomyelomeningocele, vesicorenal abnormalities, imperforate anus, skin tag)
4. Multiple > 5 (will need screening liver ultrasound, if multiple liver IH, will need to check for hypothyroidism)
5. Concern about cosmesis

How do we treat?

Local treatments

• Topical timolol for small (<2cm) and superficial lesions
• Topical steroid (used less these days)
• Steroid injection (used less these days)

Oral treatments

• Propranolol
  • Useful in superficial lesions that are large, and especially if there are the above complications
  • Most often used in mixed (both superficial and deep) and deeper lesions
• Steroids

Laser therapy

• Pulsed dye laser
  • Can help as an adjunct to the above treatments in selected cases which are ulcerated or bleeding
  • Helps to reduce redness and improve textural changes that may be left behind after the hemangioma involutes

Port-Wine Stain

A port wine stain, a type of capillary malformation, is a red mark or patch that is usually present at birth. This can darken, thicken and enlarge as the child grows older. There is usually no family history although recently, a small genetic change occurring in the birthmark in a gene called GNAQ has been discovered.

How are they treated?

Pulsed dye laser is the treatment of choice. Treatments given early in life, preferably below the age of one year, provide better outcome as there is a risk the lesions thicken with time and become more stubborn to treatment. The treatments are given around 6 to 8 weeks apart and around 8 to 10 sessions may be required. Not all lesions will improve but the aim is to lighten them significantly before school going age.

Nevus Simplex

A nevus simplex, another type of capillary malformation, is commonly known by a few names such as salmon patch, stork bite (nape of neck) and angel kiss (forehead, eyelids) depending on their location. These are also present at birth and fade with time.

How are they treated?

Most of the time there are no underlying associated conditions and these lighten with time. One may choose to treat with pulsed dye laser if it doesn’t fade and affects cosmesis. Although, the eyelid, forehead patches tend to fade by the second year of life.

Café au lait macules (CALMs) are flat, pigmented brown spots on the skin. They may not necessarily be present right at birth but usually first occur in infancy and early childhood.

When do we worry?

Having one or two café au lait is not uncommon. However, having 6 or more (>0.5 cm in children or >1.5 cm in adults) may herald an underlying genetic condition known as Neurofibromatosis (NF) Type 1. Up to 50 % of patients with NF 1 do not have a family history. There are also a number of other syndromes that may also be associated with CALMs.

How do we treat?

If the patient does not have any other signs to suggest an underlying syndrome, and cosmesis is of concern, we can consider laser treatment to lighten the CALMs. Response is variable and there is always a potential for the CALMs to recur or darken with laser treatment.

Reference

1. Artzi O et al. Picosecond 532 nm neodymium-doped yttrium aluminium garnet laser – a novel and promising modality for the treatment of café au lait macules. Lasers Med Sci 2018;33:693-697.

An epidermal nevus is an overgrowth of the epidermal layer of skin. Half of them can be present at birth and the other half may develop during childhood. It tends to follow the lines of Blashko.

When do we worry?

It can be part of a syndrome if associated with neurological, skeletal and eye abnormalities.

How do we treat?

If cosmesis is of concern, we can cauterise or laser these lesions.

Congenital melanocytic nevi (CMN) are moles that are present at birth or become visible during the first year of life.

They enlarge with the child and are classified as small, medium, large or giant based on their projected final adult size.

When do we worry?

Location

-Over the lower back/ buttock/ garment location as there is higher association with neurocutaneous melanosis
-This in turn leads to neurodevelopmental disorders and risk of leptomeningeal melanoma

Size

-Large/Giant CMN have higher risk of melanoma

Satellite nevi

-Large CMN and more than 20 satellites had a 5.1 fold increased risk of neurocutaneous melanosis compared with large CMN with 20 or fewer satellites. 1

How do we treat?

If cosmesis is a concern, treatments with carbon dioxide laser or surgery can be performed. More than anything, sun protection and being familiar with the ABCDE (asymmetry, border irregularity, colour variegation, diameter greater than 0.6 cm, evolution) rule for melanoma skin surveillance is of paramount importance. However, of even greater importance, is to regularly feel the mole for any nodules/lumps. In addition, in children, a modified ABCD (amelanotic, bleeding, bump, colour uniformity, de novo, any diameter) has been introduced to be used together with the conventional ABCDE (asymmetry, irregular borders, varying colours, diameter of more than 6mm and evolving in size, shape or colour) as paediatric melanoma can present differently from adults.2

References

1. Marghoob AA et al. Number of Satellite Nevi as a correlate for neurocutaneous melanocytosis in patients with large congenital melanocytic nevi. Arch Dermatol. 2004;140:171-175.
2. Cordoro KM et al. Paediatric melanoma: Results of a large cohort study and proposal for modified ABCD detection criteria for children. J Am Acad Dermatol. 2013;68:913-925.

 

Nevus of Ota, otherwise termed as Oculodermal melanosis, is an uncommon brown, bluish grey pigmented birthmark which has a higher predilection for Asians. It usually occurs on one side of the face

It affects females more than males. Up to two thirds present at birth or shortly thereafter, with the remaining third presenting at puberty.

When do we worry?

Location

-If the eyes are affected, melanocytosis may rarely lead to glaucoma

Cutaneous malignant change (4.6%) 1-3

-Presence of subcutaneous nodules as opposed to following the ABCDE rule (asymmetry, border irregularity, color variegation, diameter > 6mm, evolution) to survey for melanoma
-Malignant change can rarely occur within the brain

How do we treat?

If cosmesis is of concern, laser treatment can be performed. Lasers performed in children at a mean age of 3 years old, required fewer treatment sessions and had greater response rates with lower complications compared with adults.4,5 Picosecond lasers have also helped revolutionise the treatment of this condition, with lesser number of treatments, shorter treatment intervals and lesser risk of post inflammatory hyperpigmentation.6 Treatment at an early age before school going age helps with clinical and psychological outcome. Although, recurrence can occur a few years later.

References

1. Patel BC et al. Cutaneous malignant melanoma and oculodermal melanocytosis (nevus of ota): report of a case and review of the literature. J Am Acad Dermatol. 1998;38:862-865.
2. Shaffer D et al. Malignant melanoma in a Hispanic male with nevus of Ota. Dermatology. 1992;185:146-150.
3. Baroody M et al. Extensive locoregional malignant melanoma transformation in a patient with oculodermal melanocytosis. Plast Recontr Surg. 2004;113:317-322.
4. Belkin D et al. Sucessful and safe use of Q-switched lasers in the treatment of Ota in children with phototypes IV – VI. Lasers Surg Med. 2018;15:1:56-60.
5. Zong WK, Tong L. A retrospective study on laser treatment in Nevus of Ota in Chinese Children – A seven year follow up. J Cosmet Laser Therapy. 2014;16:4:156-160.
6. Loh TY, Wu DC. Novel application of the 730 and 785 nm Picosecond Titanium Sapphire Lasers for the treatment of Nevus of Ota. Lasers in Surg and Med. 2021

The Candela Picoway® delivers high peak power within the shortest pulse durations using photoacoustic laser energy rather than photothermal laser energy to fracture pigment particles. This is done with minimal damage to the surrounding skin tissue. This also allows lower energy and lesser number of treatments. Frequency of treatments range from once a month to once every 2 to 3 months depending on the condition being treated.

 

Indications:

Tattoo removal
Scars
Enlarged pores
Melasma
Lentigenes
Freckles
Rejuvenation

Please visit https://candelamedical.com/na/patient/product/picoway for more information

Genital dermatology is both a fascinating and unfamiliar area of medicine to most doctors. Fascinating because the myriad of skin conditions that can afflict that part of the body is simply astounding; unfamiliar because this area is one of the most under-examined parts of the body. This stems from a need to preserve patient’s modesty, avoiding embarrassment, stigma associated with genital conditions, and practitioners’ general discomfort at examining the genital region.

When a patient mentions about a rash “down there”, there is often a reflex association with sexually transmitted infections (STIs). This is, however, not the case. Whilst STIs will often manifest in the genital and perineal area, there are also quite a wide range of non-STI genital dermatoses. These genital dermatoses may occur uniquely to the region, or they may be part of wider dermatoses that also affects other parts of the body.
In this article, we will explore some of the commoner genital dermatoses as well as those with more sinister implications.

I. SEXUALLY TRANSMITTED INFECTIONS (STIs)

The presentation of STIs can broadly be classified into four main groups, namely 1) ulcerative, 2) those with discharges, 3) growths and 4) miscellaneous.

A) Ulcerative STI

• • Ano-Genital Herpes

This is the leading cause of ano-genital ulcer disease worldwide. This is caused by the Herpes Simplex Virus (HSV). HSV, like other members of the herpes family (Herpesviridae), has the ability to remain dormant (ganglion cells in this case) and it can reactivate from time to time. HSV type 2 accounts for the majority of ano-genital herpes, whilst a smaller proportion is due to HSV type 1. Transmission is via direct contact with infected skin or genital fluid, and viral shedding is highest during a disease outbreak.

Herpes outbreak presents with rapidly forming clusters of painful vesicles that would rupture, leaving behind painful shallow erosions over the subsequent days. These erosions generally heal without scarring. Recurrence is common especially during the first two years of infection.

• • Primary Syphilis

Although not strictly an ulcerative STI, syphilis may present as an ulcer (chancre) during the first stage of the infection. During primary syphilis, the patient may notice a solitary ulcer appearing on the genitalia or perineum. This ulcer is generally larger than the erosions seen in ano-genital herpes, and feels indurated when examined. Despite its size and appearance, it is usually painless unless super-imposed by a secondary bacterial infection. As a result, chancres may develop unnoticed by the patient, especially if they occur in the scrotum, perineum, perianal region or vaginal walls. This highlights the importance of a thorough examination; a genital examination should always include the perineum and perianal region.

Patients with untreated primary syphilis may go on to develop secondary syphilis. In secondary syphilis, patients may present with a generalized scaly, erythematous rash or patchy hair loss.

 

B) Genital Growths

• • Ano-genital Warts

Ano-genital warts are fleshy, warty growths caused by the Human Papilloma Virus (HPV). There are about one hundred strains of HPV that can infect the human skin. In the ano-genital region, certain strains are far commoner. Type 6 and 11 are the commonest non-oncogenic strains, whilst type 16 and 18 are the commonest oncogenic strains affecting the ano-genital region.
Transmission is through direct skin contact of uninfected skin with infected skin. The infected skin does not necessarily need to manifest with clinically apparent disease in order to transmit. HPV infection can occur anywhere in the ano-genital region. Hence, again, the importance of a detailed examination.

• • Molluscum Contagiosum

Molluscum contagiosum (MC) virus belongs to the family of pox viruses. It presents clinically with discrete, pearly, smooth papules, some of which may be umbilicated. It is transmitted via direct skin to skin contact.

 

C) Other STIs

• • Peduiculosis Pubis
    Patients sometimes may present with a pruritic groin rash, and close examination of the pubic region will reveal the presence of pubic lice (Phthirus pubis). Because pubic lice are well-adapted to the characteristics of pubic hair, they are often sexually transmitted. Occasionally, they may be found in other parts of the body that share similar hair characteristics, such as the axillae, eyelashes and eyebrows.

 

• Scabies
  Although strictly not a STI, under good sanitary conditions, most adults would acquire scabies sexually. Patients will complain of an extremely pruritic skin eruption that affects the groin which can then quickly spread to the rest of the body. Because it is highly contagious, household members often need to be screened and started on prophylactic treatment.

 

II. NON-STI GENITAL DERMATOSES

The wide range of non-STI genital dermatoses include inflammatory dermatoses, pigmentary disorders, iatrogenic conditions, non-STI infections, pre-malignant and malignant conditions as well as benign variations of normal anatomy. Because of space constraint, this article will highlight the more important or common conditions.

A) Inflammatory Dermatoses

• • Psoriasis

Psoriasis is a systemic inflammatory condition that often presents with a skin rash and sometimes joint involvement. The typical rash is that of thickened erythematous plaques with silvery scales on the extensors and the scalp. It can sometimes affect the genitalia. Common genital sites include the glans penis, scrotum, vulva and the pubis

• • Lichen Planus

This is another inflammatory skin condition that presents with discrete violaceous, shiny, flat-topped plaques with may be pruritic. Common sites include the wrist, buccal mucosa and penile shaft and glans penis.

• • Behcet’s Disease

This inflammatory condition is characterised by recurrent painful oral and genital ulcers that may heal with scarring. It may be accompanied by other skin manifestations such as erythema nodusum, acneiform lesions and pseudo-folliculitis.

• • Lichen sclerosus

Lichen sclerosus is a slow chronic inflammatory dermatosis that presents with ivory-white sclerotic plaques on the genitalia. Common sites include the vulva, prepuce and frenulum. In advanced stages, there may be distortion of the normal architecture with loss of the usual vulva folds or frenulum. There is a risk of malignant change in chronic lesions.

• • Zoon’s balanitis

This is a benign, plasma cell-mediated inflammatory dermatosis presenting usually as a solitary smooth, ill-defined erythematous patch on the glans penis. As this is often clinically indistinguishable from erythroplasia of Queyrat (see below), a skin biopsy is usually warranted. Treatment is with topical creams and prognosis is excellent.

 

B)Pre-malignant and Malignant Dermatoses

• • Erythroplasia of Queyrat

Erythroplasia of Queyrat is also known as squamous cell carcinoma in-situ of the skin occurring in the glans penis. Patients may present with a moist, superficially eroded patch on the glans penis. As it is indistinguishable from the benign Zoon’s balanitis, a skin biopsy is imperative, as it determines very different management of the condition. A skin biopsy should be considered in any case of a long-standing, non-healing balanitis.
Fig. H. Erythroplasia of Queyrat. Similar moist erythematous plaque on the glans penis. A biopsy is needed to distinguish this from the benign Zoon’s balanitis.

• • Squamous Cell Carcinoma of the Skin

This is the classical squamous cell carcinoma of the skin. It can affect the genitalia, presenting as a highly irregular, variegated hypertrophic plaque.

• • Extra-mammary Paget’s disease

Extra-mammary Paget’s disease (EMPD) often presents as a long-standing, poorly healing eczematous plaque on the scrotum or vulva that does not respond well to eczema treatment (see lichen simplex chronicus).

EMPD is a type of cutaneous adenocarcinoma. Whilst it is often a primary cutaneous adenocarcinoma, secondary EMPD may account for about a quarter of EMPD patients. In such cases, the primary lesions are usually visceral malignancies arising from the urogenital or lower gastrointestinal tract. Hence, all patients diagnosed with EMPD would require careful evaluation of these organ systems.

 

C) Other Genital Dermatoses

• • Lichen simplex chronicus

Lichen simplex chronic (LSC) is a type of endogenous eczema. Patients often complain an intensely pruritic patch of rash in the groin area. Repeated scratching often leads to thickening of the affected skin with increased skin folds. Treatment of LSC is the same as for endogenous eczema. Breaking the itch-scratch-itch cycle is important in LSC management

• • Fixed Drug Eruption

Whilst we are familiar with the mucosal involvement in erythema multiforme (EM) and Steven-Johnson Syndrome (SJS), cutaneous drug rash may present in a myriad of ways. Fixed drug eruption (FDE) is a type of cutaneous drug eruption that is more likely to present to primary health care.
Patients with FDE will present with erythematous erosions on the glans penis and prepuce that is followed by crusting and desquamation. FDE has a predilection for the lips and genitalia.
An antecedent drug use will be highly suggestive. Common offending drugs include tetracyclines, co-trimoxazole, penicillins, aspirins, NSAIDs and paracetamol.

 

SUMMARY

There is more to genital dermatoses than just sexually transmitted infections. Unfortunately, due to factors inherent to its location, this area of the body is often under-examined and under-diagnosed. As STI is part of dermatology training, it may be prudent to send patients to a dermatologist when in doubt.

References

1. http://www.dermnetnz.org/
2. http://emedicine.medscape.com/

Viral Warts

Warts are common viral infections caused by the human papilloma virus (HPV). There are different strains which affect certain predominant sites
Warts can go away spontaneously in about 60 % of patients within about 2 years. However, during that time it is contagious and can spread.

How do we treat?

Over the counter

Topical salicylic acid via liquid or ointment, pads and tape

Prescription

Off label use of topical retinoids, imiquimod cream (labelled for treatment of warts in genital and perianal region from 12 years old and above), 5-fluorouracil cream to flat warts or warts on cosmetically sensitive areas

Destructive “in office” treatments

Paring and cryotherapy (or liquid nitrogen) every one to two weeks
Electrosurgery (if more superficial)
Carbon dioxide laser (if deeper, especially over thicker areas of the soles)

Molluscum are viral infections caused by a poxvirus. They cause small, flesh-coloured to pink bumps with a slightly depressed or umbilicated centre

Molluscum can go away spontaneously over months to years. However, during that time it is contagious and may be itchy. It may also become redder and more swollen when the immune system is trying to clear the infection.

How do we treat?

Prescription

Off label use of topical retinoids, to irritate the skin, and imiquimod cream can help trigger the immune system to clear the infection sooner

Destructive “in office” treatments

Curettage
– Helps to express the molluscum body

Cryotherapy

Cantharidin (derived from blistering beetles)
– Off label use
– Forms a blister within 24 to 48 hours

Pulsed dye laser 1-2
– Usually for multiple lesions
– Especially in immunocompromised patients

References

1. Hancox JG et al. Treatment of molluscum contagiosum with the pulsed dye laser over a 28-month period. Cutis 2003;71:414-416.
2. Forbat E et al. Molluscum Contagiosum: Review and Update on Management. Paediatric Dermatol. 2017;34:504-515.