Case of the Month

March 2013

rans Radebe. National Institute of Communicable Diseases

A 24-year age man presented at a dedicated sexually transmitted infections (STI) clinic in Johannesburg complaining of recently noticed painless bumps on the sulcus of his penis. He was convinced that the condition was an STI and he was very anxious. He tried to use topical lotions and “natural remedies” that we recommended by a private practitioner. He noticed that there was no response or improvement to the condition. He had visited several doctors and healthcare facilities before.

No further laboratory investigations were necessary as this was a clinical diagnosis.

Question 1: What is the likely diagnosis and history in this case?

Answer to Q1

Pearly penile papules (PPP) are small done-shaped, skin-colored bumps seen on the sulcus or corona of the glans penis, arranged in one or several rows around the base of the head of the penis. It was assumed that this condition was more common in uncircumcised men probably due to the accumulation of sebaceous matter between the foreskin and the glans.

Incidence in developed countries ranges from 8-48%, greater in uncircumcised men (22%) than circumcised (12%). Black African circumcised men (21%) are more commonly affected than circumcised caucasians (7%), compared to 44% and 33% in uncircumcised. PPPs are mainly noted in men because of their anatomical distribution, but do occur in women. Men in the 2nd and 3rd decade are most commonly affected.

PPPs may persist throughout life and although PPPs are not infectious and aren’t related in any way to sexual activity and personal hygiene, the papules can still be worrying for those who do not know what they are and who mistake them as an STI1, 2.

PPPs have not been known to trigger any unfavorable or harmful health issues, but can cause some amount of unease prior to or during the sexual act. The condition can initiate feelings of dejection and hopelessness in any sexually active individual.

Question 2: What is the differential diagnosis and how would you do to confirm the diagnosis?

Answer to Q2

Even though PPPs are a clinical diagnosis, common misdiagnoses include:

  • Molluscum contagiosum
  • Warts (HPV)
  • Genital herpes
  • Condyloma acuminatum

Non-invasive methods that allow in vivo evaluation of colours and microstructures of the epidermis not visible to the naked eye, have been used to differentiate these lesions, but are generally unnecessary. Biopsy and histology are very rarely indicated. 3,4

Question 3: How would you treat the condition?

Answer to Q3

Typically, PPPs are asymptomatic and require no therapy. Topical application of Podophyllin is usually ineffective. Surgical options include:

  • Electrodesiccation with curettage
  • Excisional surgery
  • Cryotherapy
  • Ablation using carbon dioxide

There is no effective oral medical therapy and diet does not alleviate or influence the development of the condition. Some assumptions have been made about the use of toothpaste treatment, where the paste is applied over the affected areas and left overnight before being washed off. Application of creams and lotions intended to cure other skin conditions such as genital warts will not give relief from papules.

Most patients accept that treatment is not necessary once the benign nature of the lesions is explained. Patients should be discouraged from picking PPPs or attempt to squeeze them as this could lead to scarring and infection. Counseling for the patient’s sexual partner may alleviate anxiety about future complication 5.


  1. Agha K, AldersonS, Samraj S. et al. Pearly penile papules regress in older patients and with circumcision. Int J STD AIDS 2009; 20 (11): 768-70.
  2. Sonnex C, Dockerty WG. Pearly penile papules: a common cause of concern. Int J STD AIDS 1999; 10 (11): 726-7.
  3. Watanabe T, Yoshida Y, Yamamoto O. Differential diagnosis of pearly penile papules and penile condyloma acuminatum by dermoscopy. Eur. J Dermatol. 2010; Feb 22
  4. Ozeki M, Saito R, Tanaka M. Demoscopic features of pearly penile papules. Dermatology 2008; 217 (1):21-2.
  5. Lane JE, Peterson CM, Ratz JL. Treatment of pearly penile papules with CO2 laser. Dermatol Surg. 2002; 28 (7):617-8.
Outcomes of the case

The patient was reassured that the condition is harmless and that there is no need for treatment or to try to remove the papules by other means. It was also emphasized to him that this is not sexually transmitted and was encouraged to visit again with the partner if this is causing him more emotional stress so that further reassurance and counselling can be done by the healthcare-givers. Consent was obtained from the patient to use the picture for educational purpose.

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