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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 2  |  Page : 122-125

Penile acrochordon: An unusual site of presentation- A case report and review of the literature


Department of Dermatology, M.V.J. Medical College and Research Hospital, Hoskote, Kolathur Post, Bangalore, India

Date of Web Publication27-Sep-2012

Correspondence Address:
Yadalla Hari Kishan Kumar
Associate Prof. of Dermatology, MVJMC and RH, Consultant Dermatologist and Cosmetologist, 'Skin Care Clinic', 70, Padma Nivasa, H.V. Halli, M.G. Extension, Raja Rajeswari Nagar, Bangalore - 560098, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.101719

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  Abstract 

Acrochordons are flesh-colored pedunculated lesions which occur in areas of skin folds. Although they are common in other sites of the body, herein we describe a case of acrochordon at an unusual site over the tip of glans penis which is a rarity. We report this case for its rarity, as there have been no similar reports and paucity of literature after extensive research according to our knowledge. Clinical presentation and pathological findings are presented and discussed.

Keywords: Acrochordon, penile fibroepithelial polyp, skin tag


How to cite this article:
Kishan Kumar YH, Sujatha C, Ambika H, Seema S. Penile acrochordon: An unusual site of presentation- A case report and review of the literature. Int J Health Allied Sci 2012;1:122-5

How to cite this URL:
Kishan Kumar YH, Sujatha C, Ambika H, Seema S. Penile acrochordon: An unusual site of presentation- A case report and review of the literature. Int J Health Allied Sci [serial online] 2012 [cited 2019 Aug 22];1:122-5. Available from: http://www.ijhas.in/text.asp?2012/1/2/122/101719


  Introduction Top


Acrochordons (also known as skin tags, cutaneous fibroepithelial polyps, soft fibroma, soft wart, fibroma molle, and fibroma pendulans) are skin-colored, asymptomatic, pedunculated lesions located at the neck, axillae, groin, perianal areas, and over the vulva. It affects any age, including infants and can be frequently seen alone, but in some cases, can be associated with colonic polyps (Gardner syndrome), diabetes, obesity, hyperlipidemia, insulin resistance, and acromegaly. [1],[2],[3] Skin tags are generally diagnosed by clinical features. However, histopathological examination may be needed for diagnosis in unusual cases. [4] We present a case of acrochordon occurring over the penis for its unusual site of presentation and paucity of reports in the literature.


  Case Report Top


A 29-year-old uncircumcised male presented to the Dermatology department with asymptomatic skin colored, pedunculated lesion over the glans penis of 1 month duration. The patient is married since 3 years and has a 5 month old child. There was no history of extramarital exposure. No past history of herpes genitalis or genital warts. The patient gave no history of generalized skin tags in the family or anywhere else over the body. The patient noticed the lesion following a vigorous sexual intercourse which was associated with injury and bleeding. There was no history of any symptoms of urinary tract infection such as burning micturition or any prior surgical intervention. On physical examination, the lesion was firm in consistency and was 0.5 cm in length, attached beneath the urethral meatus opening on the ventral surface of glans penis with intact frenulum [Figure 1], [Figure 2] and [Figure 3]. There was no communication with urethra. There was no inguinal lymphadenopathy. Routine blood investigations were within normal limits, VDRL was non-reactive, and HIV 1 and 2 was negative. Excision of the lesion was done under local anesthesia and the base was cauterized. The specimen was sent for histopathological examination with the clinical differentials of urethral polyp, acrochordon, and condyloma acuminatum.
Figure 1: Skin-colored pedunculated lesion over the glans penis

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Figure 2: Cutaneous tag of 0.5 cm in length, attached beneath the urethral meatus opening on the ventral surface of glans penis

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Figure 3: Ventral view of penis showing intact frenulum and skin tag

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Histopathology section studied shows polypoidal structure covered by hyperplastic squamous epithelium showing papillomatosis, hyperkeratosis, and acanthosis [Figure 4]. Subepithelium shows fibrous stroma with edema and congested blood vessel with no inflammatory infiltrate [Figure 5]. Histopathology confirmed the diagnosis of cutaneous fibroepithelial polyp. HPV typing of the specimen was not performed due to logistical problems. The patient was followed up at 3 months with normal findings and no recurrence.
Figure 4: Polypoidal structure covered by hyperplastic squamous epithelium with fibro-vascular core (H and E, 10×)

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Figure 5: Hyperplastic epidermis showing papillomatosis, hyperkeratosis, and acanthosis. Subepithelium shows fibrous stroma with edema and congested blood vessel (H and E, 100×)

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  Discussion Top


An acrochordon (plural acrochorda, and also known as a (cutaneous) skin tag, [1],[5] or fibroepithelial polyp) [1],[6] is a small benign tumor that forms primarily in areas where the skin forms creases, such as the neck, armpit, groin, perianal areas, and over the vulva. They may also occur on the face, usually on the eyelids. Acrochorda are harmless and typically painless, and do not grow or change over time. [5] Skin tags are usually<5 mm in size, though tags up to a half-inch long have been seen. The surface of an acrochordon may be smooth or irregular in appearance and is often raised from the surface of the skin on a fleshy stalk called a peduncle. Three types of acrochordons have been described as follows: (1) small, furrowed papules of approximately 1-2 mm in width and height, located mostly on the neck and the axillae; (2) single or multiple filiform lesions of approximately 2 mm in width and 5 mm in length occurring elsewhere on the body; (3) large, pedunculated tumor or nevoid, baglike, soft fibromas that occur on the lower part of the trunk. Microscopically, an acrochordon consists of a fibro-vascular core, sometimes also with fat cells, covered by an unremarkable epidermis or by acanthotic, flattened, or frond-like epithelium. [5],[6],[7],[8]

It is believed that skin tags occur from skin rubbing up against skin, since they are so often found in skin creases and folds. [1],[5] Studies have shown existence of low-risk HPV 6 and 11 in skin tags hinting at a possible role in its pathogenesis. [9] They are more common in people who are overweight, have diabetes, role of leptin levels and abnormal glucose tolerance have also been mentioned, [2] and in pregnant women. [1] Acrochorda have been reported to have an incidence of 46% in the general population. [1],[5] A causal genetic component is thought to exist. [4],[5] Rarely, they can be associated with the Birt-Hogg-Dubé syndrome and polycystic ovary syndrome. [1],[5]

The etiology of skin tags is not effectively understood. Omar S et al. studied the possible role of trauma in skin tags through the release of mast cell mediators and suggested that mast cells, TNF-a and its family member, TNF-related apoptosis-inducing ligand (TRAIL) might play a role in the pathogenesis of skin tags as a response to trauma. [10] Zaher et al. compared the mast cells count in skin tags to adjacent normal skin in diabetic and nondiabetic participants in an attempt to elucidate the possible role of mast cells in the pathogenesis of skin tags. [11]

On clinical examination, the differential diagnosis includes torn frenulum, urethral polyp, urethral caruncle, acrochordon, condyloma acuminatum, and even squamous or urothelial carcinoma. Urethral polyps are rare congenital lesions usually diagnosed in males within first decade of life occurring as polypoid mass arising in the prostatic urethra adjacent to the verumontanum presenting with hematuria, urinary retention, and infection. Histopathology of polyp shows lined by urothelium with variable stromal inflammation. Surface ulceration may be seen and squamous metaplasia may be present. [12]

Lymphedematous fibroepithelial polyps of the penis are histologically and clinically distinct from the standard cutaneous fibroepithelial polyps (acrochordons) commonly encountered in dermatology practice. Acrochordons are characterized by acanthotic, flattened, or frond-like epithelium. A papillary-like dermis is composed of loosely arranged collagen fibers and dilated capillaries and lymphatic vessels. Appendages are generally absent. Even in our case, the histopathological findings resembled that of a acrochordon ruling out the remote clinical possibility of a torn frenulum due to injury, which does not have the features of acanthosis and papillomatosis. In comparison to the cutaneous fibroepithelial polyps, lymphedematous fibroepithelial polyps of the penis are typically larger, show stromal hypercellularity with occasional multi-nucleated cells, stromal edema, and have a prominent vascular pattern with dilatation and thickening of vessels. In addition, lymphedematous fibroepithelial polyps have only been described occurring on the penis whereas the typical locations for cutaneous fibroepithelial polyps are neck, axilla, eyelid and inframammary folds. Lymphedematous fibroepithelial polyps of the penis have only recently been described and to our knowledge, only one series (7 cases) and five other individual case reports have been reported in the literature for a total of 12 cases [Table 1]. A history of chronic condom catheter use was noted in the majority of these published cases (7 out of 12 cases).
Table 1: Reported fibroepithelial polyps of penis

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Urethral caruncle is mostly seen in middle-aged and elderly women and protrudes through the external orifice as a raspberry-like mass. It is soft and bleeds easily upon manipulation. Microscopically, a urethral caruncle resembles a bed of granulation tissue covered by either squamous or transitional epithelium. Infolding of epithelium may create papillary architecture. Inflammatory infiltration is common. [19] The location and clinical appearance also raise the clinical impression of condyloma acuminatum; however, there are no features such as papillomatosis or koilocytosis to suggest this diagnosis. There are also no histologic features of a cutaneous or mucosal carcinoma present such as invasion of normal structures, cytologic atypia, or mitoses. The precise pathogenesis of these lesions is not known. It has been proposed that these lesions are secondary to the negative pressure of the condom catheter and the irritation and inflammation associated with its long-term use. [13],[15],[20] The irritation and inflammation may also be the cause for this lesion in the two reported cases not associated with condom catheter. [13],[17] one of which was associated with paraphimosis. [13] The reactive pathogenesis is less clear in the case by Yildirim et al. occurring in the 4-year-old boy. [14] However, this case has a limited discussion of the histologic findings and may in fact represent a regular fibroepithelial polyp occurring on the penis. Even in our present clinical experience, the probable cause is attributed to the injury followed by irritation and inflammation for the occurrence of fibroepithelial polyp. Only two cases similar to the present case have been published in literature are: A huge unusual mass on the penile skin: acrochordon by Emir et al.[21] and Penile shaft: An unusual location for skin tags by Thami et al.[22]

Because skin tags are benign, treatment is unnecessary unless the tags become frequently irritated or present a cosmetic concern. If removal is desired or warranted, a dermatologist or similarly trained professional may use cauterization, cryosurgery, surgical ligation, or excision to remove the acrochorda. [4],[5]


  Conclusion Top


We report this case of penile acrochordon for its unusual site of presentation, which is a rare case and to make aware the dermatologists and the clinicians of this entity, cutaneous fibroepithelial polyps occurring over the genitals, and to differentiate clinically with other benign genital lesions by their histological features.

 
  References Top

1.Banik R, Lubach D. Skin tags: Localization and frequencies according to sex and age. Dermatologica 1987;174:180-3.  Back to cited text no. 1
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2.Margolis J, Margolis LS. Letter: A frequent sign of diabetes mellitus. N Engl J Med 1976;294:1184.  Back to cited text no. 2
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3.Chobanian SJ. Skin tags and colonic polyps: A gastroenterologist`s perspective. J Am Acad Dermatol 1987;16:407-9.  Back to cited text no. 3
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4.Brodell RT, Pokorney DR. Fibroepithelial polyps and pathological evaluation. Arch Dermatol 1997;133:915-6.  Back to cited text no. 4
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5.Cutaneous skin tags: Medline Plus Medical Encyclopedia. Available from: http://www.nlm.nih.gov. [Last Retrieved on 2011-01-18].  Back to cited text no. 5
    
6.Edwards L, Lynch PJ. Genital Dermatology Atlas. Philadelphia: Lippincott Williams and Wilkins, 2010. p. 209. Retrieved 2011-01-18.  Back to cited text no. 6
    
7.Doe PT, Grattan CE. Guess what! Skin tag (acrochordon) on the labium majus. Eur J Dermatol 1998;8:587, discussion 588.  Back to cited text no. 7
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8.Canalizo-Almeida S, Mercadillo-Pérez P, Tirado-Sánchez A. Giant skin tags: Report of two cases. Dermatol Online J 2007;13:30.  Back to cited text no. 8
    
9.Dianzani C, Calvieri S, Pierangeli A, Imperi M, Bucci M, Degener AM. The detection of human papillomavirus DNA in skin tags. Br J Dermatol 1998;138:649-51.  Back to cited text no. 9
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10.El Safoury OS, Fawzy MM, Hay RM, Hassan AS, El Maadawi ZM, Rashed LA. The possible role of trauma in skin tags through the release of mast cell mediators. Indian J Dermatol 2011;56:641-6.  Back to cited text no. 10
    
11.Zaher H, El Safoury OS, El Komy MM, Mahmoud SB, Abd El Hamid H. Study of mast cell count in skin tags. Indian J Dermatol 2007;52:184-7.  Back to cited text no. 11
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12.Jain P, Shah H, Parelkar SV, Borwankar SS. Posterior urethral polyps and review of literature. Indian J Urol 2007;23:206-7.  Back to cited text no. 12
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13.Fetsch JF, Davis CJ Jr, Hallman JR, Chung LS, Lupton GP, Sesterhenn IA. Lymphedematous fibroepithelial polyps of the glans penis and prepuce: A clinicopathologic study of 7 cases demonstrating a strong association with chronic condom catheter use. Hum Pathol 2004;35:190-5.  Back to cited text no. 13
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14.Yildirim I, Irkilata C, Sumer F, Aydur E, Ozcan A, Dayanc M. Fibroepithelial polyp originating from the glans penis in a child. Int J Urol 2004;11:187-8.  Back to cited text no. 14
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15.Turgut M, Yenilmez A, Can C, Bildirici K, Erkul A, Ozyürek Y. Fibroepithelial polyp of glans penis. Urology 2005;65:593.  Back to cited text no. 15
    
16.Al-Awadhi NM, Al-Brahim N, Ahmad MS, Yordanov E. Giant fibroepithelial polyp of the penis associated with long-term use of condom catheter. Case report and literature review. Can J Urol 2007;14:3656-9.  Back to cited text no. 16
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17.Peña KB, Parada DD. Lymphedematous fibroepithelial polyp of the glans penis non-associated with condom catheter use. APMIS 2008;116:215-8.  Back to cited text no. 17
    
18.Mason SE, DeVilliers P, Andea AA. Lymphedematous fibroepithelial polyp of the penis associated with long-term condom catheter use: Case report and review of the literature. J Cutan Pathol 2009;36:906-9.  Back to cited text no. 18
    
19.Ozkurkcugil C, Ozkan L, Tarcan T. The effect of asymptomatic urethral caruncle on micturition in women with urinary incontinence. Korean J Urol 2010;51:257-9.  Back to cited text no. 19
    
20.Banerji JS, Shah S, Kekre NS. Fibroepithelial polyp of the prepuce: A rare complication of long-term condom catheter usage. Indian J Urol 2008;24:263-4.  Back to cited text no. 20
[PUBMED]  Medknow Journal  
21.Emir L, Ak H, Karabulut A, Ozer E, Erol D. A huge unusual mass on the penile skin: Acrochordon. Int Urol Nephrol 2004;36:563-5.  Back to cited text no. 21
    
22.Thami GP, Kaur S, Kanwar AJ, Mohan H. Penile shaft: An unusual location for skin tags. Indian J Dermatol 2003:48;103-4.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]


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