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OBSERVATION

Pearly Penile Papules


Effective Therapy With Pulsed Dye Laser
Priya Sapra; Sheetal Sapra, MD, FRCPC; Amanda Singh, RPN

Importance: Pearly penile papules (PPPs) are benign, 3 treatments in 2 patients and a reduction of the pap-
dome-shaped lesions found around the corona of the pe- ules in 2 patients.
nis. Treatments have varied in the past; however, to our
knowledge, the use of the pulsed dye laser (PDL) for this Conclusions and Relevance: These 4 case reports il-
condition has never been reported in the literature. Such lustrate the advantages of using PDL when treating PPP.
papules are histologically analogous to angiofibromas; In each patient, the appearance of the papules was either
thus, we report PDL is an appropriate, effective, and
completely diminished or significantly reduced after the
nonablative method of treatment.
procedure. This result was achieved with only minimal dis-
comfort felt by the patients. The use of PDL offers derma-
Observations: Four patients diagnosed with PPPs
were treated with PDL. Each patient reported little to tologists a new treatment modality for PPPs that is safe, eas-
no discomfort during the procedure. Minimal bruising ily performed, and produces excellent aesthetic results.
was found in all 4 patients, which diminished over
time. One patient stated slight discomfort after the JAMA Dermatol. 2013;149(6):748-750.
procedure; this however, resolved in a weeks’ time. Published online April 17, 2013.
Complete clearance of the papules was noted after 2 to doi:10.1001/jamadermatol.2013.3130

P
EARLY PENILE PAPULES (PPPS) fort in the affected area; however, they did
are benign lesions analo- state that the appearance of the lesions af-
gous to angiofibromas lo- fected them emotionally. After being ad-
cated on the male genita- vised about treatment options, the deci-
lia.1-3 Clinically, PPPs may sion was made to treat the areas with PDL.
appear as pink, white, yellow, or almost Photographs were taken prior to treat-
translucent lesions, 1 to 2 mm in width and ment, and the area was cleansed with a nor-
1 to 4 mm in length.1 The PPPs are be- mal sterile saline solution (Figure 1 and
nign and cause no physiological discom- Figure 2). A topical anesthetic (a combi-
fort to the individual. Clinicians examine nation of lidocaine/tetracaine in lio-
and diagnose this condition on a regular pothen, 23%/7%) was applied to the co-
basis; the condition is reported to have an rona of the penis and occluded with a wrap
occurrence of approximately 15% in post- for approximately 1 hour until the area was
pubertal males.4 In addition, many treat- adequately anesthetized. All treatments
ments have been used to reduce the ap- were performed using a PDL, 5-mm spot
pearance of or abolish PPPs. To our size and 0.50-ms pulse duration, with flu-
knowledge, treatment with a pulsed dye ence ranging from 6 J/cm2 to 10 J/cm2. Mini-
laser (PDL) has never been reported in the mal to no discomfort was reported during
literature. Herein, we report the success- the treatments, and minimal purpura or
ful treatment of PPPs with PDL. In all 4 bruising immediately after the procedure
cases, a PDL (Mini V Pulse-Dye [595-
was observed. Patients were asked to use
nm] laser; Cynosure) was used with the
an over-the-counter topical antibiotic cream
immediate expectation of purpura after
for 5 days after treatment. A total of 1 to 3
treatment.
treatments were performed, with results
ranging from a significant reduction to com-
REPORT OF A CASE plete clearance. All patients reported being
satisfied with the treatment results. For de-
Four healthy patients with a history of PPPs tails regarding individual treatment, refer
Author Affiliations: Institute of ranging from 3 to 20 years presented them- to the Table. Author Aff
Cosmetic and Laser Surgery, selves in an office visit. All patients re- With patient 1, a biopsy was per- Cosmetic a
Oakville, Ontario, Canada. ported no complaints of physical discom- formed and a diagnosis of PPPs was made. Oakville, O

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Patients 2 through 4 were not biopsied as a diagnosis of ter the procedure and was informed that additional treat-
PPPs was either previously made or the biopsy was un- ments could be performed; however, he was pleased with
necessary for diagnosis. the results, so no further treatments were given.
Patient 3 received only 1 treatment in the area, and a
significant reduction was noted in the appearance of the DISCUSSION
papules. This patient returned to the clinic 2 months af-
Lesions analogous to PPPs have been studied and examined
A B since the 1700s.1,5,6 Treatment of PPPs is unnecessary be-
cause the lesions are entirely benign. However, certain pa-
tients report that the lesions affect them psychologically and
still seek treatment due to aesthetic concerns.7-9 As a result,
avarietyofremediesfortheconditionhavebeenusedtoelimi-
nate the appearance of PPPs among patients. Over time, such
therapies have included curettage and cryotherapy with liq-
uid nitrogen and carbon dioxide laser.1-3,9 Reports comment-
ing on these methods have had varying results. First, cer-
tain patients treated with curettage and cryotherapy with
liquid nitrogen, have experienced scarring in the affected
area after the procedure.1 The use of the carbon dioxide la-
ser has been successful in producing aesthetically appeas-
ing results1; however, despite the commendation for the
carbon dioxide laser, its use should be limited for 2 reasons.
Figure 1. Pretreatment (A) and posttreatment (B) views of an 18-year-old
First, there is an increased risk of infection due to the ex-
man (patient 2) with pearly penile papules. A, View of pearly penile papules posure of raw skin after the procedure.3 Second, an exten-
located around the border of the corona of the penis. B, Complete clearance sive home-care regime exists, including changing dressings
of pearl penile papules after treatment with a pulsed dye laser. andperformingsoaksasawaytoimprovehealing;thus,mak-
ing postoperative care discommoding for the patient.3
A B As mentioned previously, the PPPs are structurally simi-
lar to angiofibromas, exhibiting orthokeratosis and hyper-
granulosis in the epidermal layer, as well as a dense colla-
gen layer under the epidermis.1,5,6 A prominent vascular
network also exists within this collagen layer.5 Such char-
acteristics make the lesion eligible for treatment by PDL.
Herein we report the successful treatment of PPPs with PDL
in 4 postpubertal males. All patients reported little to no
discomfort during the course of the procedure. No infec-
tions, complications, or scarring were noted in any of these
patients. Each patient experienced a minimal amount of
bruising, but this diminished over time.

CONCLUSIONS

Figure 2. Pretreatment (A) and posttreatment (B) views of a 21-year-old


man (patient 4) with pearly penile papules. A, View of pearly penile papules
The case reports described earlier illustrate the superi-
located around the border of the corona of the penis. B, Complete clearance ority of the PDL in treating PPPs, because there is only
of pearly penile papules after treatment with a pulsed dye laser. minimal discomfort for the patients, unlike other cur-

Table. History and Treatment of Patients

Variable Patient 1 Patient 2 Patient 3 Patient 4


Age, y 31 18 43 21
Location Corona of penis Corona of penis Corona of penis Corona of penis
Type of treatment PDL PDL PDL PDL
No. of treatments 3 2 1 2
No. of pulses × fluence, J/cm2
Treatment 1 161 × 7 85 × 9.5 67 × 10 35 × 10
Treatment 2 149 × 6 130 × 10 NA 37 × 9
Treatment 3 20 × 7 NA NA NA
Spot size, mm 5 5 5 5
Pulse duration, ms 0.50 0.50 0.50 0.50
Response Complete clearance Complete clearance Significant reduction to patient’s satisfaction Complete clearance

Abbreviations: NA, not available; PDL, pulsed dye laser.

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rent treatments available. In addition, the absence of post- Cosmetic Update Meeting, which is funded by Medasis,
procedural scarring and infection in conjunction with the Valeant Pharmaceutical, Allergan, Merz Pharma, sanofi-
accessible nature of the PDL offer dermatologists an ef- aventis, and Johnson & Johnson. Clinical trials under Dr
ficient treatment for the PPPs. Moreover, the home-care S. Sapra since 2007 include the following: Pfizer, Novar-
regimen is simple, requiring only the application of an tis, Kythera Biopharmaceuticals, Galderma, Amgen, Merz,
over-the-counter topical antibiotic cream, and does not Allergan, Abbott, Astellas Pharma, sanofi-aventis, Cen-
involve arduous tasks that have been noted with other tocor, Johnson & Johnson Pharmaceuticals, Schering-
modalities. Not only are the PPPs reduced or abolished Plough, Cipher Pharmaceuticals, Leo Pharma, Medicis,
entirely by PDL treatment, but an excellent cosmetic re- GSK, Biogen, BMS, and Zeltiq Asthetics.
sult is also achieved through a low number of succes- Additional Contributions: Carmen Rosekat, BSc, clini-
sive treatments. These experiences have led us to be- cal trials coordinator, at The Institute of Cosmetic and
lieve that the PDL encompasses all characteristics that a Laser Surgery, provided editorial skills and assistance with
therapeutic method should possess: effectiveness, safety, the coordination of the project.
and exceptional aesthetic results.
REFERENCES
Accepted for Publication: December 7, 2012.
Published Online: April 17, 2013. doi:10.1001 1. Agrawal SK, Bhattacharya SN, Singh N. Pearly penile papules: a review. Int J Dermatol.
/jamadermatol.2013.3130 2004;43(3):199-201.
Correspondence: Priya Sapra, Institute of Cosmetic and 2. McKinlay JR, Graham BS, Ross EV. The clinical superiority of continuous expo-
Laser Surgery, 1344 Cornwall Rd, Ste 100, Oakville, ON sure versus short-pulsed carbon dioxide laser exposures for the treatment of pearly
L6J 7W5, Canada (priyasapra01@gmail.com). penile papules. Dermatol Surg. 1999;25(2):124-126.
3. Rokhsar CK, Ilyas H. Fractional resurfacing for the treatment of pearly penile papules.
Author Contributions: Dr S. Sapra and Mss P. Sapra and Dermatol Surg. 2008;34(10):1420-1422.
Singh had full access to all the data in the study and take 4. Pang MLT, Eichenfield LF. Miscellaneous dermatological disorders. In: Neinstein
responsibility for the integrity of the data and the accu- LS, ed. Adolescent Healthcare: A Practical Guide. 5th ed. Philadephia, PA: Lippin-
racy of the data analysis. Study concept and design: S. Sapra. cott Williams and Wilkins; 2008:324.
5. Neinstein LS, Goldenring J. Pink pearly papules: an epidemiologic study. J Pediatr.
Acquisition of data: S. Sapra and Singh. Analysis and in- 1984;105(4):594-595.
terpretation of data: P. Sapra. Drafting of the manuscript: 6. Ozeki M, Saito R, Tanaka M. Dermoscopic features of pearly penile papules.
P. Sapra. Critical revision of the manuscript for important Dermatology. 2008;217(1):21-22.
intellectual content: S. Sapra and Singh. Administrative, tech- 7. Agha K, Alderson S, Samraj S, et al. Pearly penile papules regress in older pa-
nical, and material support: P. Sapra and Singh. Study su- tients and with circumcision. Int J STD AIDS. 2009;20(11):768-770.
8. Sonnex C, Dockerty WG. Pearly penile papules: a common cause of concern. Int
pervision: S. Sapra. J STD AIDS. 1999;10(11):726-727.
Conflict of Interest Disclosures: Dr S. Sapra has a con- 9. Porter WM, Bunker CB. Treatment of pearly penile papules with cryotherapy. Br
sultancy contract with Medicis and conducts an annual J Dermatol. 2000;142(4):847-848.

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