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Pink pearly papules: An epidemiologic study
594
Clinical and laboratory observations
The Journal of Pediatrics October 1984
Pink pearly papules." An epidemiologic study Lawrence S. Neinstein, M.D., and John Goldenring, M.D., M.P.H. Los Angeles, California
SEVERAL ARTICLES describe a benign lesion of the penile corona called pink pearly papules, t'9 However, this common condition seems to be relatively unknown to practicing pediatricians and other clinicians. This is of particular concern in the current epidemic of sexually transmitted diseases among adolescents, because PPP may be confused with condylomata accuminata, leading to misdiagnosis and inappropriate therapy. Additionally, the only reported study of prevalence rates included predominantly adult patients treated at a venereal disease clinic. 1Our study was undertaken to examine the prevalence of PPP in teenagers and college students undergoing a general physical examination. METHODS The subjects were 87 successive adolescent male patients who came to the Teenage Health Center at Childrens Hospital of Los Angeles for a comprehensive history and physical examination. Additionally, 68 consecutive male college athletes at a local college student health center were examined as part of a routine physical examination for sports. In addition to examination for PPP, data were collected on age, race, sexual maturity rating, presence of circumcision, and sexual activity. Statistics were analyzed using a chi-square analysis from the Abstat Statistical Package? ~ RESULTS The 151 study participants had a mean age of 17.2 years (range 11 to 22 years). Sexual maturity rating H in 100 (66.7%), including all the college students, was 5; in 23 (15.3%) was 4; in 17 (11.3%), 3; in nine (6%), 2; and in one (0.7%), 1. Of the 151 participants, 59.6% were white, 13.9% were Hispanic, and 25.8% were black; only one was Asian. Eighty-three percent of the subjects were circumcised. The overall prevalenee of PPP was 15.2% (23 of 151). The prevalence at the Teenage Health Center was 12% (10 From the division of Adolescent Medicine, Childrens Hospital of Los Angeles, and the Departments of Pediatrics and Medicine, USC School of Medicine; and the Department of Pediatrics, Loyola Marymount University. Submitted for publication March 26, 1984; accepted May 4, 1984. Reprint requests: Lawrence S. Neinstein, M.D., Division of Adolescent Medicine, Childrens Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027.
of 83), and 19.1% (13 of 68) at the college health center. No PPP were found in the 17 boys 11 to 13 years of age, and none in 10 boys with a sexual maturitY rating of 1 or 2. PPP were found in 20% (15 of 75) of white patients, 25% (four of 16) of Hispanic patients, and 7.7% (three of 36) of black patients. PPP were found in 14.3% of circumcised patients and 22.7% of uncircumcised patients. Chi-square analysis showed no statistically significant relationship of PPP to race, sexual activity, or circumcision. DISCUSSION Lesions similar to pink pearly papules were described as early as 1700 by Littre. 5 Duhring 6 reported similar lesions in 1888, and these were thought to be a nerve organ. The lesions have variously been described as Tyson glands, papillae in the corona glandis, hirsutoid papules, and corona capilliti) The lesions are elongated papillae, usually 1 to 3 mm in diameter, located on the coronal margin of the penis, especially the anterior border (Figure). They often appear PPP
Pink pearly papules
[
in one to five rows and are usually of uniform size and shape. The color tends to be a pearly white. Microscopically, PPP have a normal epidermal appearance except for absent pigment in the basal layer. 9 A dense fibrillary collagen layer is present, with prominent capillaries and venules? No nerve endings or glandular structures are found, A sparse infiltrate of lymphocytes, histiocytes, and plasma cells may b~ present. Glicksman and Freeman 1 found a prevalence of 20% in 229 males aged 1 6 t o 78 years at a clinic for venereal disease. They noted a higher prevalence in uncircumcised males (22% vs 12%). We also found a higher, but not statistically different, prevalence in uncircumcised males (22.7% vs 14.3%). There was no relationship to race in either study. Winer and Winer 9 reviewed the literature up to 1955 and found that patients were all --<41 years of age. Glicksman and Freeman ~ also found no PPP in patients >41 years of age. Conversely, we found no PPP in patients <14 or with a sexual maturity rating <3, indicating that PPP are found primarily in the pubertal and young adult age group.
Volume 105 Number 4
Clinical and laboratory observations
595
cents with prominent PPP seek medical attention, not with a sense of cosmetic abnormality but with concern that they have developed "VD" or have acquired a tumor as a result of masturbation. With simple reassurance all of our patients have been relieved and completely satisfied with the explanation. None has ever asked about cosmetic surgical revision. We have been surprised by most clinician's lack of familiarity with this normal developmental variant. Many physicians may confuse PPP with some form of genital wart or tumor and treat unnecessarily, with potentially painfiil results. Pink pearly papules require no treatment other than reassurance to the patient. Figure. Pink pearly papules On penile corona. (From Fragola LA Jr, Watson PE: Cutaneous penile lesions. A Famous Teaching in Modern Medicine (FTMM) program,@ Garden Grove, Calif., 1972, Medcom Inc. Reprinted by permission.) The differential diagnosis includes verrucae accuminata (venereal warts) and ectopic sebaceous glands. Venereal warts tend to be of less uniform size and shape, usually change over time, and are not neatly arranged around the corona of the penis. Ectopic sebaceous glands are common penile lesions characterized by barely elevated discrete yellow papules on the penile shaft? The lesions increase in appearance on stretching the penile skin and a cheesy material may be expressible. Pink pearly papules seem to originate at the time of maximum physiologic pubertal changes, when males may have questions about changes in genital size and coloration. Adolescence is also a time of sexual experimentation and incomplete knowledge in the areas of sexuality and sexually transmitted diseases. In our experience, adoles-
REFERENCES 1. Glicksman JM, Freeman RG: Pearly penile papules a statistical study of incidence, Arch Dermatol 93:56, 1966. 2. Johnson BL, Baxter DL: Pearly penile papules, Arch Dermatol 90:166, 1964. 3. Hyman AB, Brownstein MH: Tysons "glands": Ectopic sebaceous glands and papillomatosis penis. Arch Dermatol 99:31, 1968. 4. Ackerman AB, Kornberg R: Pearly penile papules, acral angiofibromas. Arch Dermatol 108:673, 1973. 5. Littre: French Academy of Sciences Report, 1700, p 307. 6. Duhring EV: Monatschr Prakt Dermatol 7:117, 1888. 7. Ferrer D: Case presentation, Cuban Dermatology Association, June 7, 1928; Hirsutes papillaris penis (abstract). Arch Derm Syph 19:157, 1929. 8. Wigley JEM, Haber H: Hirsutes papillaris penis. Br J Dermatol 61:427, 1949. 9. Winer JH, Winer LH: Hirsutoid papillomas of coronal margin of glands penis. J Urol 74:375, 1955. 10. Abstat, release 3.03. Littleton, Colo., 1981, 1982, AndersonBell Company. 11. Tanner JM: Growth at adolescence, ed 2. Oxford, 1962, Blackwell Scientific Publications.
Craniofacial features of isotretinoin embryopathy Paul M. Fernhoff, M.D., and Edward J. Lammer, M.D. Atlanta, Georgia
From the Department of Pediatrics, Division of Medical Genetics, Emory University School of Medicine; and the Birth Defects Branch, Chronic Disease Division, Center for Environmental Health, Centersfor Disease Control. Submitted for publication Feb. 20, 1984; accepted April 20, 1984. Reprint requests: Department of Pediatrics, Division of Medical Genetics, Emory University School of Medicine, 2040 Ridgewood Dr. NE, Atlanta, GA 30322.
See related articles, pp. 583 and 597.
VITAMIN A AND OTHER RETINOIDS are terat0genic in a variety of animals, l, 2 Isotretinoin, 13-cis-retinoic acid (Accutane) was marketed in the United States in September 1982 for the treatment of severe cystic acne. From June
Clinical and laboratory observations
The Journal of Pediatrics October 1984
Pink pearly papules." An epidemiologic study Lawrence S. Neinstein, M.D., and John Goldenring, M.D., M.P.H. Los Angeles, California
SEVERAL ARTICLES describe a benign lesion of the penile corona called pink pearly papules, t'9 However, this common condition seems to be relatively unknown to practicing pediatricians and other clinicians. This is of particular concern in the current epidemic of sexually transmitted diseases among adolescents, because PPP may be confused with condylomata accuminata, leading to misdiagnosis and inappropriate therapy. Additionally, the only reported study of prevalence rates included predominantly adult patients treated at a venereal disease clinic. 1Our study was undertaken to examine the prevalence of PPP in teenagers and college students undergoing a general physical examination. METHODS The subjects were 87 successive adolescent male patients who came to the Teenage Health Center at Childrens Hospital of Los Angeles for a comprehensive history and physical examination. Additionally, 68 consecutive male college athletes at a local college student health center were examined as part of a routine physical examination for sports. In addition to examination for PPP, data were collected on age, race, sexual maturity rating, presence of circumcision, and sexual activity. Statistics were analyzed using a chi-square analysis from the Abstat Statistical Package? ~ RESULTS The 151 study participants had a mean age of 17.2 years (range 11 to 22 years). Sexual maturity rating H in 100 (66.7%), including all the college students, was 5; in 23 (15.3%) was 4; in 17 (11.3%), 3; in nine (6%), 2; and in one (0.7%), 1. Of the 151 participants, 59.6% were white, 13.9% were Hispanic, and 25.8% were black; only one was Asian. Eighty-three percent of the subjects were circumcised. The overall prevalenee of PPP was 15.2% (23 of 151). The prevalence at the Teenage Health Center was 12% (10 From the division of Adolescent Medicine, Childrens Hospital of Los Angeles, and the Departments of Pediatrics and Medicine, USC School of Medicine; and the Department of Pediatrics, Loyola Marymount University. Submitted for publication March 26, 1984; accepted May 4, 1984. Reprint requests: Lawrence S. Neinstein, M.D., Division of Adolescent Medicine, Childrens Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027.
of 83), and 19.1% (13 of 68) at the college health center. No PPP were found in the 17 boys 11 to 13 years of age, and none in 10 boys with a sexual maturitY rating of 1 or 2. PPP were found in 20% (15 of 75) of white patients, 25% (four of 16) of Hispanic patients, and 7.7% (three of 36) of black patients. PPP were found in 14.3% of circumcised patients and 22.7% of uncircumcised patients. Chi-square analysis showed no statistically significant relationship of PPP to race, sexual activity, or circumcision. DISCUSSION Lesions similar to pink pearly papules were described as early as 1700 by Littre. 5 Duhring 6 reported similar lesions in 1888, and these were thought to be a nerve organ. The lesions have variously been described as Tyson glands, papillae in the corona glandis, hirsutoid papules, and corona capilliti) The lesions are elongated papillae, usually 1 to 3 mm in diameter, located on the coronal margin of the penis, especially the anterior border (Figure). They often appear PPP
Pink pearly papules
[
in one to five rows and are usually of uniform size and shape. The color tends to be a pearly white. Microscopically, PPP have a normal epidermal appearance except for absent pigment in the basal layer. 9 A dense fibrillary collagen layer is present, with prominent capillaries and venules? No nerve endings or glandular structures are found, A sparse infiltrate of lymphocytes, histiocytes, and plasma cells may b~ present. Glicksman and Freeman 1 found a prevalence of 20% in 229 males aged 1 6 t o 78 years at a clinic for venereal disease. They noted a higher prevalence in uncircumcised males (22% vs 12%). We also found a higher, but not statistically different, prevalence in uncircumcised males (22.7% vs 14.3%). There was no relationship to race in either study. Winer and Winer 9 reviewed the literature up to 1955 and found that patients were all --<41 years of age. Glicksman and Freeman ~ also found no PPP in patients >41 years of age. Conversely, we found no PPP in patients <14 or with a sexual maturity rating <3, indicating that PPP are found primarily in the pubertal and young adult age group.
Volume 105 Number 4
Clinical and laboratory observations
595
cents with prominent PPP seek medical attention, not with a sense of cosmetic abnormality but with concern that they have developed "VD" or have acquired a tumor as a result of masturbation. With simple reassurance all of our patients have been relieved and completely satisfied with the explanation. None has ever asked about cosmetic surgical revision. We have been surprised by most clinician's lack of familiarity with this normal developmental variant. Many physicians may confuse PPP with some form of genital wart or tumor and treat unnecessarily, with potentially painfiil results. Pink pearly papules require no treatment other than reassurance to the patient. Figure. Pink pearly papules On penile corona. (From Fragola LA Jr, Watson PE: Cutaneous penile lesions. A Famous Teaching in Modern Medicine (FTMM) program,@ Garden Grove, Calif., 1972, Medcom Inc. Reprinted by permission.) The differential diagnosis includes verrucae accuminata (venereal warts) and ectopic sebaceous glands. Venereal warts tend to be of less uniform size and shape, usually change over time, and are not neatly arranged around the corona of the penis. Ectopic sebaceous glands are common penile lesions characterized by barely elevated discrete yellow papules on the penile shaft? The lesions increase in appearance on stretching the penile skin and a cheesy material may be expressible. Pink pearly papules seem to originate at the time of maximum physiologic pubertal changes, when males may have questions about changes in genital size and coloration. Adolescence is also a time of sexual experimentation and incomplete knowledge in the areas of sexuality and sexually transmitted diseases. In our experience, adoles-
REFERENCES 1. Glicksman JM, Freeman RG: Pearly penile papules a statistical study of incidence, Arch Dermatol 93:56, 1966. 2. Johnson BL, Baxter DL: Pearly penile papules, Arch Dermatol 90:166, 1964. 3. Hyman AB, Brownstein MH: Tysons "glands": Ectopic sebaceous glands and papillomatosis penis. Arch Dermatol 99:31, 1968. 4. Ackerman AB, Kornberg R: Pearly penile papules, acral angiofibromas. Arch Dermatol 108:673, 1973. 5. Littre: French Academy of Sciences Report, 1700, p 307. 6. Duhring EV: Monatschr Prakt Dermatol 7:117, 1888. 7. Ferrer D: Case presentation, Cuban Dermatology Association, June 7, 1928; Hirsutes papillaris penis (abstract). Arch Derm Syph 19:157, 1929. 8. Wigley JEM, Haber H: Hirsutes papillaris penis. Br J Dermatol 61:427, 1949. 9. Winer JH, Winer LH: Hirsutoid papillomas of coronal margin of glands penis. J Urol 74:375, 1955. 10. Abstat, release 3.03. Littleton, Colo., 1981, 1982, AndersonBell Company. 11. Tanner JM: Growth at adolescence, ed 2. Oxford, 1962, Blackwell Scientific Publications.
Craniofacial features of isotretinoin embryopathy Paul M. Fernhoff, M.D., and Edward J. Lammer, M.D. Atlanta, Georgia
From the Department of Pediatrics, Division of Medical Genetics, Emory University School of Medicine; and the Birth Defects Branch, Chronic Disease Division, Center for Environmental Health, Centersfor Disease Control. Submitted for publication Feb. 20, 1984; accepted April 20, 1984. Reprint requests: Department of Pediatrics, Division of Medical Genetics, Emory University School of Medicine, 2040 Ridgewood Dr. NE, Atlanta, GA 30322.
See related articles, pp. 583 and 597.
VITAMIN A AND OTHER RETINOIDS are terat0genic in a variety of animals, l, 2 Isotretinoin, 13-cis-retinoic acid (Accutane) was marketed in the United States in September 1982 for the treatment of severe cystic acne. From June