Indian Journal of Dermatology
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CASE REPORT
Year : 2009  |  Volume : 54  |  Issue : 5  |  Page : 21-23
Dermatophyte infection of the male genitalia


Department of Dermatology, Vivekananda Institute of Medical Sciences, Ramakrishna Mission Seva Pratisthan, 99, Sarat Bose Road, Kolkata - 700 026, India

Correspondence Address:
Jayanta Kumar Das
Flat F 3, 50/A College Road, Howrah - 711 103, West Bengal
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Dermatophyte infection is a very common disease, but that of the male genitalia is said to be rare. Here we report four cases of dermatophyte infection of the male genitalia, of which one had lesion on the penis alone, one had lesions on the penis and the groins, one had lesions on penis and scrotum, and the other had involvement of scrotum, penis and groins. Two patients gave history of application of steroid-containing preparations and another had diabetes mellitus. Culture of the scraping of the lesional skin yielded Trichophyton rubrum in two cases and Epidermophyton floccosum in the other two. All cases resolved completely with topical terbinafine with or without oral antifungals.


Keywords: Genitalia, penis, tinea


How to cite this article:
Das JK, Sengupta S, Gangopadhyay A. Dermatophyte infection of the male genitalia. Indian J Dermatol 2009;54, Suppl S1:21-3

How to cite this URL:
Das JK, Sengupta S, Gangopadhyay A. Dermatophyte infection of the male genitalia. Indian J Dermatol [serial online] 2009 [cited 2019 Dec 11];54, Suppl S1:21-3. Available from: http://www.e-ijd.org/text.asp?2009/54/5/21/45436



   Introduction Top


Tinea cruris is a very common type of dermatophyte infection with incidence much higher in males than in females. [1],[2] However, dermatophytosis of the penis and scrotum is regarded as rare since the days of Hebra, and the same opinion has been expressed till recently by others, particularly in the standard textbooks of dermatology. According to one of the standard textbooks of dermatology, genitals are typically unaffected, [3] whereas another textbook goes so far as to say that the authors have never seen a dermatophyte infection of the penis. [4] It has also been said that while tinea of the penis and scrotum is uncommon, if it at all occurs it is usually associated with crural involvement. [5] Decreased scrotal skin barrier function facilitating permeation of antifungal factors into the stratum corneum and decreased eccrine sweat secretion in the penile skin resulting in lowered skin hydration have been proposed as the mechanism of the relative resistance, but neither has any rigorous proof. [1] On the other hand, this reported rarity of tinea of the penis has been questioned. [6] There are reports that give a rather high estimation of the incidence of penile and scrotal tinea, particularly from tropical countries like India. [7],[8]


   Case History Top


Case 1

A 14-year-old male student of middle class family presented with itching in the groins and the genitals for one month. He had hygienic habits, and he used cotton undergarments. He had no history of sexual exposure. On examination, there was an oval erythematous slightly scaly and itchy patch on the shaft of the penis with raised erythematous border and central clearing [Figure 1]. There were similar lesions in the groins, but no other similar lesion anywhere else including the scrotum. Potassium hydroxide preparation of skin scraping from penis and from groins showed fungal hyphae. Culture on media containing Sabouraud's dextrose agar with cycloheximide and chloramphenicol (SDACC) grew characteristic colonies of Trichophyton rubrum from both sites. He was treated with 1% terbinafine cream once daily application along with oral terbinafine 250mg daily, and showed gradual improvement and complete resolution after two weeks.

Case 2

A 32-year-old bachelor male restaurant worker of lower middle class background came with itching in the groins and the genitals for four months. He used nylon undergarments, and he had unhygienic habits such as washing the undergarments infrequently. He had no history of sexual exposure. Before coming to us he applied various creams, including one containing clobetasol propionate, gentamicin and miconazole. On examination, there was an oval erythematous slightly scaly and itchy patch on the glans penis, one oval scaly and itchy plaque on the skin of the shaft of the penis, and erythematous polycyclic itchy scaly plaques with raised red border and central clearing on the groins [Figure 2]. On the scrotum, there were erythematous scaly and itchy lesions with tendency to central clearing. Skin scraping was taken from each of the involved areas. Potassium hydroxide preparations of all the scrapings showed no fungal elements. Culture on SDACC media of the scrapings showed growth of characteristic colonies of Epidermophyton floccosum . The patient was treated with 1% terbinafine cream once daily topically and griseofulvin 250mg twice daily orally. He showed gradual improvement and complete resolution after six weeks.

Case 3

A 38-year-old married male shopkeeper of middle class family came with itching in the penis for one month. His habits were reasonably hygienic. He had no history of sexual exposure. On examination, there was an oval erythematous slightly scaly and itchy patch on the shaft of the penis and outer aspect of the foreskin, with raised red border with excoriated papules on and near the border, and central clearing [Figure 3]. There was no other similar lesion anywhere else including the scrotum and the groins. His wife was examined and was found not to have any lesions of tinea anywhere in her body. Potassium hydroxide preparation of skin scraping from penis failed to show fungal elements. Culture on SDACC media grew characteristic colonies of Trichophyton rubrum . He was treated with 1% terbinafine cream once daily application and showed gradual improvement and complete resolution after two weeks.

Case 4

A 23-year-old bachelor male medical student belonging to an affluent family came with itching in the scrotum for three months. His habits were hygienic, and he used cotton undergarments. He had no history of sexual exposure. He gave history of applying a cream containing beclomethasone, gentamicin, and miconazole on the scrotum for two weeks. On examination, there was diffuse erythema and scaling all over the scrotum extending up to the proximal end of the ventral aspect of the penis, but groins were not affected [Figure 4]. Potassium hydroxide preparation of skin scraping from the scrotal and penile lesions showed fungal elements. Cultures on SDACC media grew characteristic colonies of Epidermophyton floccosum from both penis and scrotum. He was treated with 1% terbinafine cream once daily application along with oral terbinafine 250mg once daily, and showed gradual improvement and complete resolution after two weeks.

In all the four patients general examination was unremarkable. While all the others were normoglycemic, case 3 had non-insulin dependent diabetes mellitus, managed with diet and exercise. None of the patients had history of tuberculosis or immunosuppressive therapy. Routine examination of stool and urine, hemogram, and routine blood biochemistry were all within normal limits, except for case 3 who showed mild hyperglycemia, with the fasting and postprandial blood sugar levels being 143mg/dl and 167mg/dl respectively. VDRL and ELISA for HIV were negative in all cases.


   Discussion Top


In our case series, the age of the patients with scrotal and/or penile tinea ranged from14 to 38 years. All had an urban background. They all were in good health, and none of them was immunocompromised. Case 3 had non-insulin dependent diabetes mellitus largely under control. Case 2 had unhygienic habits, and he used synthetic undergarments too. Steroid was used topically in case 2 and case 4, and it aggravated the disease. None of them reported any skin disease in the family, and the wife of the only married patient (case 3) was examined and found to be free from tinea. When tinea cruris is not present, another site of fungus infection acting as reservoir is usually identifiable. [1] But in our cases, two (case 3 and 4) had no sites involved other than the penis and/or the scrotum, and their inguinal regions, toe webs, and nails were all free from tinea. This is a new finding, for in all other reported cases of penile or scrotal tinea there was either tinea cruris [8],[9],[10],[11] or a consort with tinea. [12] Our cases strengthen the possibility raised by Dekio et al , that penis and scrotum may be infected with dermatophytosis de novo without involvement of any other area, and this may occur not necessarily by the sexual contact. [13] As penile lesion should resolve by topical antifungal treatment alone, our finding of isolated penile tinea has therapeutic significance. [1] Our case with isolated penile tinea resolved with topical therapy with 1% terbinafine cream once daily for two weeks, and there was no recurrence in the six-month follow-up period.

The lesions of tinea in the penis in previously reported cases are mostly described to be slightly raised and well demarcated with mild erythema. [1],[10],[13] In our cases the lesions on penis were typical (cases 1 and 3) or very suggestive (case 2). Scrotal lesions in case 2 were quite similar to the morphology of tinea of the glabrous skin, but case 4 showed diffuse erythema and scaling practically all over the scrotum, and there was not even a suggestion of the typical ring.

The incidence of tinea of the male genitalia is traditionally accepted to be very rare, [3],[4] but some studies report it as quite common. [7],[8],[11] La Touche recorded 6 positive cultures of dermatophytes from penis in his study involving 75patients with tinea cruris, but it is not clear how many of them had clinical tinea on penis. [7] The same study records 62.6% of the subjects with tinea cruris showing clinical scrotal involvement and 74% of these clinical lesions were confirmed mycologically. In another study, of 2200 Indian patients of dermatophytosis, approximately 1% had "clear-cut penile involvement". [8] On the other hand, there are three Indian studies that report the distribution of dermatophytosis in different areas of the body but fail to report any lesion on the male genitalia among 150, 250 and 100 patients respectively. [14],[15],[16] In Indian men with tinea cruris, penile involvement is reported to be associated with the use of langota, a tight undergarment that occludes the areas between penis and thighs. [9] None of our cases used similar undergarments, although one (case 2) used synthetic undergarments that could have caused occlusive effect.

To conclude, dermatophytosis of the male genitalia is possibly underestimated [17] and factors such as clothing, systemic disease, and a reservoir of fungus in the body are said to act alone or in tandem to cause tinea of the male genitalia in general and penile tinea in particular, [1] but as our cases show, it can sometimes happen in the absence of all such factors, too.

 
   References Top

1.Pielop J, Rosen T. Penile dermatophytosis. J Am A Dermatol 2001;44:864-7.  Back to cited text no. 1    
2.Blank F, Mann SJ. Trichophyton rubrum infection according to age, anatomical distribution and sex. Br J Dermatol 1975;92:171-4.  Back to cited text no. 2    
3.Nelson MM, Martin AG, Heffernan MP. Superficial fungal infections: Dermatophytosis, onychomycosis, tinea nigra, piedra. In : Freedberg IM, Eisen AZ, Wolff K, Austen KF, GoldsmithLA, Katz SI, editors. Dermatology in general medicine. 6 th ed. New York: McGraw-Hill; 2003. p. 1989-2005.  Back to cited text no. 3    
4.Odom RB, James WD, Berger TM, editors. Diseases resulting from fungi and yeasts. In : Andrew's diseases of the skin. 9 th ed. Philadelphia: WB Saunders Co; 2000. p. 358-416.  Back to cited text no. 4    
5.Bunker CB, Neill SM. The genitals, perianal and umbilical regions. In : Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. Vol 4, 7 th ed. Massachusetts/Oxford/Victoria: Blackwell Science Ltd; 2004. p. 1-104.  Back to cited text no. 5    
6.Palleschi GM, Guadagni R, Difonzo E, Panconesi E. Tinea of the penis: A rare occurrence? Int J Dermatol 1986;25:52-3.  Back to cited text no. 6    
7.La Touche CJ. Scrotal dermatophytosis. Br J Dermatol 1967;79:339-44.  Back to cited text no. 7    
8.Kumar B, Talwar P, Kaur S. Penile tinea. Mycopathologia 1981;75:169-72.  Back to cited text no. 8    
9.Pandey SS, Chandra S, Guha PK, Kaur P, Singh G. Dermatophyte infection of the penis - association with particular undergarments. Int J Dermatol 1981;20:112-4.  Back to cited text no. 9    
10.Pillai KG, Singh G, Sharma BM. Trichophyton rubrum infection of the penis. Dermatologica 1975;150:252-4.  Back to cited text no. 10    
11.Vora NS, Dave JN, Mukhopadhyay AK, Patel KB, Roy K, PatelDH. Incidence of dermatophytosis of the penis and scrotum. Indian J Dermatol Venerol Leprol 1994;60:89-91.  Back to cited text no. 11    
12.Mukhopadhyay A. Trichophyton rubrum infection of the prepuce. Indian J Dermatol Venerol Leprol 2005;71:130-1.  Back to cited text no. 12    
13.Dekio S, Jidoi J. Tinea of the glans penis. Dermatologica 1989;178:112-4.  Back to cited text no. 13    
14.Bindu V, Pavithran K. Clinico-mycological study of dermatophytosis in Calicut. Indian J Dermatol Venerol Leprol 2002;68:259-61.  Back to cited text no. 14    
15.Karmakar S, Kalla G, Joshi KR, Karmakar S. Dermatophytosis in a desert district of Western Rajasthan. Indian J Dermatol Venerol Leprol 1995;61:280-3.  Back to cited text no. 15    
16.Huda MM, Chakraborty N, Sharma Bordoloi JN. Clinico-mycological study of superficial mycoses in Upper Assam. Indian J Dermatol Venerol Leprol 1995;61:329-32.  Back to cited text no. 16    
17.D'Antuono A, Bardazzi F, Andalou F. Unusual manifeatations of dermatophytosis. Int J Dermatol 2001;40:164-6.  Back to cited text no. 17    


    Figures

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

This article has been cited by
1 Superficial fungal infections of the male genitalia: A review
Aridogan, I.A., Izol, V., Ilkit, M.
Critical Reviews in Microbiology. 2011; 37(3): 237-244
[Pubmed]



 

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    Abstract
    Introduction
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