Perineal pseudoverrucous papules in a child with ectopia vesicae and epispadias

Dear Sir,

A 2-year-old male child was brought by the parents with itchy reddish raised skin lesions over the perineal area of 6 months duration. The child was born with ectopia vesicae with associated epispadias. Abdominal repair of the existing defect along with urethroplasty was performed for the associated epispadias. The mother gives history on and off remissions and exacerbation of skin lesions for 6 months, with improvement seen after topical zinc cream application but relapses on stopping it. Continuous dribbling of urine was present from the surgical site. History of usage of diapers was not consistent; however, mother noticed exacerbation of skin lesions on diaper usage and, hence, avoided it. There was no history of encopresis or any other lesions elsewhere.

On examination, there were multiple discrete flat topped erythematous papules of size 3–4 mm present mainly around the surgical defect over the suprapubic and genital regions, along with some erosions and maceration [Figure 1]. The penis appeared buried, and the testes were undescended. Perianal area was relatively spared, and anal orifice was patent. There was no lymphadenopathy, or any other midline spinal defects. Based on the clinical features, a diagnosis of perineal pseudoverrucous papules and nodules was considered. Local genital hygiene was advised to prevent wetness and maceration of the affected area along with topical steroid 0.05% clobetasone cream and zinc cream twice daily after which there was symptomatic improvement. Child was referred to pediatric surgery to get a surgical repair done for the defect.

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Figure 1:

Multiple discrete erythematous papules surrounding the stomal site in the pubic area extending to the scrotum.

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Pseudoverrucous papules and nodules are a form of irritant contact dermatitis, first reported around urostomy sites.^[1] Can occur in conditions with diaper usage, urogenital anomalies, fistulas, chronic diarrhea, or encopresis. It is considered to appear along the spectrum of granuloma gluteale infantum and Jaquets erosive dermatitis called “erosive papulonodular dermatoses,” caused by excessive application of halogenated topical steroids and candidiasis.^[2] Hence, in the present case, a combination of barrier cream and non-fluorinated topical steroid lead to symptomatic improvement. The scrotal skin is usually affected secondary to the chronic maceration and increased permeability, aggravated by the ammonia present in the urine.^[3]

This can mimic a variety of other diseases such as condyloma lata, papular genital warts, condyloma acuminata, histiocytosis, iododerma, bacterial infections, nutritional dermatoses, herpes simplex, and cutaneous Crohn’s disease.^[4] Perianal lesions especially secondary to chronic encopresis can simulate condyloma lata, the older cases were sometimes referred to as “Lipschütz’s pseudosyphilis papulosa” attributing the clinical and histological similarities.

Definitive treatment mainly consists of eliminating the underlying irritating factors, which is mainly from any catheter sites, fistulas, stomal sites, or other anomalies and controlling the associated incontinence. Barrier creams application along with topical steroids can be advised for the treatment of pseudoverrucous papules and nodules. Furthermore, it is reported that loperamide works well especially in cases of Hirschsprung disease.^[5]

Hence, we report this case in view of the atypical presentation, along with the clinical background. This would help to avoid unwanted interventions for the child along with alleviating the anxiety of the parents.