|Year : 2018 | Volume
| Issue : 3 | Page : 255-257
Mimicker of perianal papular lesions
Department of Dermatology, Academia Title for Health Professional (QU Affiliation)
|Date of Web Publication||28-Jun-2018|
Dr. Ebtisam Elghblawi
Tripoli, PO. BOX 3232
Source of Support: None, Conflict of Interest: None
Perianal mimicker papular skin lesion in children is rare when the real cause cannot be found or justified. I report a young 4-year-old black Libyan girl who complaint of multiple itchy skin-colored nodules for the past 1 year around only the anus and increasing as her mother declared. Cutaneous examination revealed multiple, 0.5–1 cm flat-topped dry papules, at the perianal area not extending up to the labia majora. On histology marked focal epidermal hyperplasia and hyperkeratosis in the epidermis was seen. This confirmed the diagnosis of one condition stated in the literature called perianal pseudoverrucous papules and nodule. This rare condition can be mistaken with sexually transmitted diseases leading to unnecessary investigations and treatment and raising the question of sexual abuse in children.
Keywords: Condyloma accuminata, condyloma lata, genital warts, musllcum contagsnusm, perianal pseudoverrucous papules and nodules
|How to cite this article:|
Elghblawi E. Mimicker of perianal papular lesions. Indian J Paediatr Dermatol 2018;19:255-7
| Introduction|| |
Perianal pseudoverrucous papules and nodules (PPPN) is an exceptional entity encountered some times in the clinical setup and was initially explained in patients with spina bifida, urostomies, and attributed to chronic leakage of urine or stool. Such conditions can be sometimes misdiagnosed. There are only a few reported cases in the existing literature of pseudoverrucous lesions occurring on the perianal skin or around colostomies.
There are great discrepancies on the real incidence of perianal skin problems in the accessible literature and equally diverse are the lesions described papules or nodules.
| Case Report|| |
A 4-year-old black Libyan girl who is otherwise born healthy and still in remarkable health presented complaining of itchy skin-colored papules in the perianal skin lesions. One year before the mother observation; a few smooth papules started to appear on the perianal area, and she said it is increasing and kept relapsing as per to her say.
The mother stated that her daughter does not have any incontinence stool and urine since birth. She is not using a diaper at this age either. She denied having any explicit incident of rash, macerations, or constitutional symptoms.
She did consult her daughter to a doctor before seeing me, and she assumed it is a wart and asked about child abuse that the mother denied. This had led to a dermatological consultation even though surgical removal of the presumed “viral warts” had already been planned before inspection and based on mother words.
Cutaneous examination revealed multiple, well-defined dome-shaped, six in number, disperse flat-topped dry firm papules and nodules on tactile perception, with a shiny smooth surface, 0.5 mm to 1 cm in size, at the perianal area, not extending up to the labia majora [Figure 1].
|Figure 1: Six flat firm nodules perianal area (copyright: ©2017 Elghblawi)|
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The clinical appearance alone excluded genital warts, but a skin biopsy was planned to ascertain my suggested diagnosis.
Dermatoscopic examination revealed a white structureless highly attenuated with polarized specific multiple white lines in reticular arrangement (crossing over) with no other specific finding [Figure 2].
|Figure 2: Dermatoscopic white structureless areas with white lines in reticular arrangement (Copyright: ©2017 Elghblawi)|
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Blood and biochemical investigations including viral screen and VDRL were all normal.
One single punch 3 mm for a complete papule at the left upper side was taken for histopathological (HP) reading. The HP examination of a papule revealed focal epidermal hyperplasia with hyperkeratosis and focal marked acanthosis. The dermis was insignificance and did not show any infiltrate. The rest of the lesions were removed by electrocautery.
| Discussion|| |
There are a few reported of similar case in the existing literature.
It has been stated that children who wear diapers due to chronic urinary incontinence are prone more to such type of chronic irritation and thus dermatitis. However, diaper-related skin changes were excluded as the girl is not using diaper any more for 3 years as the mother affirmed.
In this patient, anogenital warts had to be ruled out; nonetheless, many skin diseases must be considered in the differential diagnosis of these misunderstood lesions.
The term PPPN was given to such cases with such peculiar presentation in the perianal area. It has been attributed and associated with urine and stool irritation and a diaper used where the area will be moist and exposed to chronic friction and irritation causing maceration which could be explained on the basis it might heal with hyperkeratosis and thickening of the skin at the affected area.,,, Furthermore, bacteria around skin might react and split around causing a secondary infection. There have been some terms which were proposed in the literature such - chronic papillomatous dermatitis, hyperkeratosis, pseudoverrucous hyperplasia, PPPN, pesudoepitheliomatous hyperplasia, and reactive acanthosis, where the inflicted area are subjected to chronic irritation from urine and stool leakage, often without concurrent erosions. The PPPN usually occurs in infants rather than newborns.
Histopathology of a lesion shows epidermal hyperplasia and hyperkeratosis with focal marked acanthosis and no dermal infiltrate.
Syphilis was ruled out by blood test, and it is well known that the morphology of large, moist papules more characteristic of condylomata lata than common anogenital warts where it has an intermittent course with spontaneous clearing when the general condition improves.
Moreover, in this peculiar case, a consensus appears to have been reached to define this case clinical picture as reactive acanthosis from the histological point of view, but much less accord can be made as for etiology as it cannot be found at the first place on exploring any possibility of any irritating factor.
PPPN clinically may mimic condylomata acuminata, molluscum, and verrucous condylomata lata (syphilis) which can raise the issue of sexual abuse in children. The closest differential diagnosis in my patient was condylomata acuminata, and Molluscum contagiosum (MC) where the biopsy was sent as a differential. Moreover, the mother gave a history of common warts in her fingers which had been treated and never recurred. Furthermore, the MC was a differential according to the vague dermatoscopic features encountered which not very much was convincing as it shown accentuated white structureless area like fibrous tissue.
The limitation of dermatoscope in such cases to reach a clinical diagnosis with confidence must be acknowledged and therefore any doubt must be ruled out by a biopsy.
In such cases, dermatoscope and biopsy must be supplemented by clinical findings to achieve and reach acceptable diagnosis accuracy.
Some authors argued that this condition is more common than expected, and this should be recognized by dermatologists to avoid unnecessary workups and it regress once the culprit is removed when it is found.
Appreciation of this entity is important because PPPN may imitate more serious dermatoses and needless workup may be initiated. Even though, this reaction involving perianal skin has not been reported previously, I still believe it is not scarce.
The actual cause was not found in this case despite inquiring the mother. Treatment was planned on removing all the skin nodules by electrocautery for each one separately. Moreover, I stress strongly on the importance of a thorough skin examination by a trained professional who is aware of these problems to avoid unnecessary investigations and treatments and anxiety to the parents.
| Conclusion|| |
This is a condition that mandates to be reevaluated, but an accepted terminology has to be carefully reached and chosen. A proper clinical inspection with a precise, meticulous history should be enough in a young patient to exclude other pathologies, even without histology or perhaps viral screening.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
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[Figure 1], [Figure 2]