Genital ulcers in a middle-aged male

A 40-year-old male presented for the evaluation of painless ulcers over the glans penis for 1-week duration. The ulcers were insidious in onset and he denied a history of high-risk sexual behavior or any oral drug intake. No oral mucosal lesions or conjunctival redness, no significant medical history, and he did not have any pain or itching over his skin lesions. Dermatological examination of the penis revealed an ulcer measuring 1 cm × 1.5 cm on the coronal sulcus. The ulcer had an erythematous base, a necrotic center covered with fibrin, and red borders [Figure 1]. There was no inguinal lymphadenopathy. Histopathology of the ulcer revealed granulomas surrounding the extensive zones of degenerated collagen and mucin [Figure 2]. Additional investigations revealed his hemoglobin A1c of 9.2 and a random blood sugar of 288 mg/dl. He was treated with oral medicines with glycemic control, and in 1 week, the ulcer healed without any sequela [Figure 3].

Figure 1.

An ulcer measuring 1 cm × 1.5 cm on the coronal sulcus

Figure 2.

Healed lesion after 7 days without any sequela

Figure 3.

Histopathology (H and E stain) showing granulomas surrounding the extensive zones of degenerated collagen and mucin (×40)

Question

What is your diagnosis?

Options:

1. Behcet's disease

2. Chancroid

3. Genital necrobiosis lipoidica

4. Granuloma annulare.

Answer

Genital necrobiosis lipoidica.

Discussion

Necrobiosis lipoidica on the glans penis is an uncommon condition – only six cases have been reported to date [Table 1].[1,2,3,4,5,6] The mean age of previous cases was in their 60s and our patient was 42 years old. All but one of the previous cases presented with multiple lesions of 2–5 mm in diameter with well-defined borders and yellowish necrotic bases. Our patient also had similar morphological features. In all cases, the diagnosis was based on microscopic so-called “necrobiotic granulomas,” which was diagnostic in our case. The presence of degenerative collagen fibers surrounded by palisading histiocytes in the deep dermis was the principal histological feature. The plasma cells were absent in all cases, including our case, which is a predominant cell in pretibial necrobiosis lipoidica. During microscopic diagnosis, various granulomatous conditions, including Behcet's disease, granuloma annulare, foreign-body reactions, and rheumatoid nodules were considered. The last two were ruled out due to the patient's clinical history and negative results for rheumatoid factor, and no findings in polarizing microscopic analyses, respectively. Granuloma annulare has better defined, smaller granulomas separated by the normal dermis. The granulomas are typically more superficial with larger amounts of mucin in their centers.

Table 1.

Reported cases of necrobiosis lipoidica of the glans penis[6]

Reference	Age (years)	Site	Clinical features	Duration	Diabetes	Treatment
Lecroq, 1984[1]	73	Glans and inguinal folds	Ulcers	3 months	Yes	Acetylsalicylic acid+dipyridamole
España, 1994[2]	81	Glans only	Ulcers, depressed scars	15 years	No	Pentoxifylline
España, Velasco-Pastor, 1996[3]	57	Glans only	Ulcers, depressed scars	2 years	No	Pentoxifylline+dipyridamole
el Sayed, 1997[4]	48	Prepuce	Ulcers, depressed scars	4 years	No	Circumcision
Tokura, 2003[5]	65	Glans only	Ulcers, depressed scars	6 months	Yes	Pentoxifylline
Alonso, 2011[6]	72	Glans only	Ulcers, depressed scars	1 year	No	Spontaneous healing
Current case	42	Glans only	Ulcers	1 week	Yes	Antidiabetic drugs

Behcet's disease was differential diagnosis, but histopathology and response to antidiabetic medicines were diagnostic of necrobiosis lipoidica. Sexually transmitted diseases were ruled out by Gram staining of the discharge and the histopathology. HIV, VDRL, and other sexually transmitted illness workup were negative. The treatment of underlying diabetes led to a complete resolution of the lesions in 1 week [Figure 3].

Declaration of patient consent

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