Bilateral Linear Location of Condylomata Acuminata in the Groin: An Uncommon Presentation Aggravated by Topical Steroids

Sir,

A 32-year-old documentary film maker reported to this clinic with asymptomatic warty lesions on the groin since 2 months. He had travelled to China 6 months ago where he had protected sex with a commercial sex worker which involved fellatio and repeated licking of the groin and scrotum. About 4 months after that episode he noted a few skin colored warty asymptomatic lesions which he ignored. About a month later he also developed itchy, erythematous scaly, macular lesions just below the warty growths for which he took advice of a pharmacist and started applying a cream containing topical clobetasol proprionate, gentamicin and miconazole. That improved his itching but the warty lesions grew to the present size. On examination he had multiple erythematosus coalescing classic condylomata acuminata (CA) lesions in both the inguinal folds Figure 1. The lesions were more profuse in the right inguinal fold. He was uncircumcised and had no warty lesions on his penis, prepuce, scrotum, pubic region, anal and perianal region. He had no other signs of any sexually transmitted infection. His Venereal Diseases Laboratory Test for syphilis and Enzyme Linked Immunosorbent Assay for Human Immunodeficiency Virus were negative. He also had multiple pruritic, scaly, ill-defined lesions below the warts in both inguinal folds. A skin biopsy was neither thought necessary nor practical for confirming the diagnosis. A clinical diagnosis of multiple condylomata acuminata of the groin aggravated by application of topical steroid was made. The patient was treated with 20% podophyllotoxin resin twice a week. On the second week, upon the fourth application, all the lesions had resolved leaving behind some areas of mild erosion which healed during subsequent follow up. He is free from CA upon routine follow up after 3 weeks Figure 2.

Figure 1.

Bilateral linear arrangement of condylomata acuminata in the inguinal region with tinea incognito in the vicinity

Figure 2.

Lesions successfully treated with 20% podophyllotoxin resin. Mild necrosis seen in left groin

HPV infections in India are rising. Lesions of condylomata acuminata are most frequently found on the penis, anal and perianal region. When on the penis, the most frequent sites arefrenum, corona and glans, the areas which are subject to maximum coital friction.[1] Rarely they have been reported in sites like the groin where they can present as hyperpigmented lesions mimicking seborrheic keratosis.[1,2] While involvement of the groin along with genital localization is uncommonly seen, literature search shows that exclusive groin area involvement in CA is indeed rare. Arora et al. have described such localization twice but in one report there was only one lesion on the groin of an immunocompetent female.[3,4] There is an isolated report of condylomata as a complication of inframammary, inguinal and intragluteal intertrigo in a virgo intacta who was immunocompetent.[5] When they are located in areas like between the buttocks, perianal and inguinal fold they tend to become flattened laterally and have been described as rooster comb warts (Hahnenkamm) in German due to the flattening and the erythema, a very apt analogy. The lesions in our patient were located only in both inguinal areas and displayed a linear array. They were laterally flattened due to the pressure of inguinal fold. Koebnerisation aided by friction and the presence of moisture may have played a role in their configuration. CA are known to become macerated, weep or become foul smelling due to moisture and friction which did not happen in our patient. Additionally, he was applying a product containing clobetasol, gentamicin and miconazole off and on for coexisting tinea cruris for the past 2 months. While this relieved him of his itch and flattened out the lesions of tinea cruris, it would have contributed to the worsening of the warts due to the suppression of local immunity. Abuse of topical steroids is a well-known phenomenon in India and one of the adverse effects is aggravation of viral, fungal and bacterial infections or bizarre presentations.[6] The main aim however of this paper is to highlight a rare case of linear arrangement of condylomata acuminata confined only to the groin in an immunocompetent man. While treatment would be the same as in condylomata of the common locations the healing time in such location may be delayed due to the occlusion, friction and moisture.