Penile Melanosis Associated with Lichen Sclerosus et Atrophicus: First Description in the Medical Literature

We present a 74-year-old male patient with 3-years history of visible discoloration of the glans penis, without subjective complaints. Histopathological examination after incision biopsy revealed a moderate increase in the number of melanocytes in the basal layer with irregular distribution, without melanocytic nests, melanophages in the superficial dermis, and subepidermal sclerosus. No cytologic atypia of melanocytes was detectable. The diagnosis of melanosis of the genitalia in association with lichen sclerosus was made. The importance of the presented cases implicated the unique clinical manifestation of penile melanosis, associated with lichen sclerosus of the penis in one hand, the essential differentiation between malignant melanoma via careful histological examination for diagnosis confirmation in other, in order to optimize the therapeutic behavior.


Abstract
We present a 74-y ear-old male patient with 3-y ears history of v isible discoloration of the glans penis, without subjectiv e complaints. Histopathological examination af ter incision biopsy rev ealed a moderate increase in the number of melanocytes in the basal lay er with irr egular distribution, witho ut melanocy tic nests, melanophages in the superf icial dermis, and subepidermal sclerosus. No cytologic aty pia of melanocy tes was detectable. The diagnosis of melanosis of the genitalia in association with lichen sclerosus was made. Th e importance of the presented cases implicated the unique clinical manif estation of penile melanosis, associated with lichen sclerosus of the penis in one ha nd, the essential diff erentiation between maligna nt melanoma v ia caref ul histological examination f or diagnosis conf irmation in other, in order to optimize the therapeutic behav ior.
We present a 74-year-old male patient presented with 3-y ears history of visible discoloration of the glans penis, without subjective complaints. Arterial hypertension, glaucoma and asthma were also reported. An irregularly bordered hyper pigmented macule, unequally coloured, was clinically observed in the peripheral part o f the glans penis, while apigmented macule was established in the central area. A n erythemat ous macule with irregular borders was also present ed (Fig. 1a, 1b). Histopathological examination after incision biopsy revealed a moderate increase in the number of melanocytes in the basal layer wit h irregular distribution, without melanocytic nests, melanophages in the superficial dermis, and subepidermal sclerosus. No cytologic atypia of melanocytes was detectable. (Fig. 1c, 1d). The diagnosis of melanosis of the genitalia in association wit h lichen sclerosus was made. Topical application of tacrolimus 0.1% ointment was initiat ed in a therapeutic regimen twice daily, while systemic administration of chloroquine was planned to be initiated in one month.
Mucosal melanoses always require exclusion of malignant melanoma, via excisional or incisional biopsy, because it is usually not possible to differentiate them on clinical inspection alone [1]. Despite superficial spreading melanoma, a lentigo maligna should also be considered as differential diagnoses in cases with penile hyperpigment ations, because of their atypical clinical manifestation [2].
In contrast, lichen sclerosus et at rophicus is not unusual findings in the genital area, and usually, do not dare diagnostic difficulties [3]. As a c hronic inflammatory disorder with a predilection for the anogenital area, lichen sclerosus play a key role in the arising of a human papilloma virusnegative neoplasms, whic h makes its early detection and treatment beneficial to the further prognosis [3]. Turnbull N. et al. described three c ases of a primary melanoma of the penis in patients with lichen sclerosus, which highlight the importance of the chronic inflammation in all -kind of malignant transformations with penile localization [4]. The aggressive management of pigmented penile macules is based on the principle that they represent junctional naevi and hence, have a higher incidence of malignant change [5]. In contrast, some authors highlight the statement that most cases of penile and urethral melanomas arise de novo and prec ursor lesions are not identified which makes the prophylactic excision unnecessary [5]. We support the view of B arnhill et al. which require individualized therapeutic behaviour with multiple biopsies when needed [5]. The import ance of t he pres ented cases implicated the unique clinical manifestation of penile melanosis, associated with lichen sclerosus of the penis in one hand (Fig. 1a, 1b), the essential differentiation bet ween malignant melanoma via careful histological examination for diagnosis confirmation in other, in order to optimize the therapeutic behavior.
We treated the presented patient with topic al tacrolimus 0.1% ointment twice daily, while systemic administration of chloroquin was planned to be initiated in one month. Further regular screening and monitoring is mandatory, regarding the high malignant transformational pot ential of genital lichen sclerosus, as well as the higher incidence of malignant changes of the pigmented naevi on t he palms, soles and genitalia [5].