Pseudoepitheliomatous keratotic and micaceous balanitis: A literature review

Malignant Transformation of Long-Standing Pseudoepitheliomatous Keratotic and Micaceous Balanitis (PKMB) Presenting as Urethral Obstruction

Hereby, we present a rare case of malignant transformation in a long-standing case of pseudoepitheliomatous keratotic and micaceous balanitis (PKMB), which typically affects older men. PKMB presents as whitish or silvery keratotic plaques on the glans and can remain stable for years, leading to potential confusion regarding its progression. The patient in this case experienced urinary obstruction due to tumorous ingrowth, prompting an investigation. Despite previous treatments, including fluorouracil (5-FU) and cryoablation, the lesion persisted, eventually growing in size and becoming malodorous. Initial biopsy showed PKMB without malignancy, but subsequent deeper biopsy revealed verrucous carcinoma. The patient underwent glansectomy and reconstruction with a full-thickness skin graft, achieving a disease-free state postoperatively. The paper underscores the importance of thorough investigation for malignancy in PKMB cases, the possibility of deeper malignancy missed by superficial biopsy, and the need for early diagnosis to enable organ-sparing treatments.

Pseudoepitheliomatous keratotic and micaceous balanitis: a series of eight cases

BACKGROUND

Pseudoepitheliomatous keratotic and micaceous balanitis (PEKMB) is a clinicopathological entity characterized clinically by micaceous scale on the glans, and histologically by acanthosis, hyperkeratosis and pseudoepitheliomatous hyperplasia. We present a series of eight cases of this rare condition, the first series of more than two cases to be reported.

OBJECTIVES

To determine the clinical and histological characteristics of cases of PEKMB, and evaluate treatments used and clinical course.

METHODS

This monocentric case series was conducted at the University College London Hospitals tertiary male genital dermatology clinic between April 2018 and August 2020. Eight patients with PEKMB were evaluated. Data were collected on demographics, clinical presentation, histological features, presence of human papilloma virus (HPV), history of lichen sclerosus, treatment of PEKMB and subsequent response, and presence or development of squamous cell carcinoma (SCC) or penile intraepithelial neoplasia (PeIN) during follow-up.

RESULTS

Eight Caucasian males presented with clinical and histological evidence of PEKMB. Seven had a background of lichen sclerosus; two had failed treatment with superpotent topical steroids and four had symptoms for three or more years prior to circumcision. There was no clinical or histological relationship with HPV infection, and p16 staining was negative. HPV PCR, performed in two cases, was negative. Basal atypia, insufficient to amount to PeIN, was present in six patients. One patient progressed to PeIN during follow-up, and no patient progressed to invasive malignancy. Five patients were treated successfully with glans resurfacing and split skin graft reconstruction.

CONCLUSIONS

Our observations demonstrate that PEKMB represents a form of chronic, undiagnosed or misdiagnosed, inadequately treated or treatment refractory, unstable lichen sclerosus. The significant potential for squamous carcinogenesis (differentiated PeIN and verrucous carcinoma) can be mitigated by timely diagnosis and treatment. Glans resurfacing and split skin graft reconstruction appears to be a successful treatment modality in patients with refractory disease.