When patients ask me how I made their diagnosis so quickly, I politely tell them that if any particular lesion takes more than 25 milliseconds to diagnose, they really do have a problem.
Today I saw a patient that made me pause – and I’m still thinking about him. He is a 12 year old healthy, non-sexually active, athlete, with inguinal and scrotal lesions that had been present for about 2 months. He was treated with antibiotics without much benefit. The only topical therapy was that he was using saline soaks twice a day for several weeks. Physical examination demonstrated innumerable, edematous, somewhat umbilicated, slightly yellow papules in the inguinal folds and on the scrotum. Slight eczematization was appreciated on the scrotum. The prior dermatologist thought that these might be molluscum and biopsied the lesions – there was necrosis and neutrophils, but no evidence of molluscum or changes characteristic of a viral infection. (I repeated the biopsy today and checked bacterial and fungal cultures). His social history ruled out condyloma lata or acuminatum.
Given the clinical and histologic picture, I am reasonably convinced that he had “pseudoverrucous papules “(PVP). While there is no history of urinary or fecal incontinence, I believe that his hygiene and continued use of soaks gave the proper milieu to mimic PVPs. Here is the rub – he does not wear diapers, there are no perianal lesions (some authors still refer to the tem perianal pseudoverrucous papules), and the lesions are far more reminiscent of molluscum contagiosum. I advised him to discontinue his saline soaks, keep the area dry, and use mupirocin. Despite his mother’s skepticism (she wanted me to check a blood test, but I could not imagine what test to get!), I think that he will do fine with these conservative measures.
If we are going to use the term “pseudo” before a noun, the description should be as specific as possible. In this case pseudomolluscoid papules (PMP) would be a far better term.
Not to confuse the matter further, but his lesions have nothing to do with molluscoid pseudotumors of Ehlers-Danlos or the recently described molluscoid pseudovesicles of Sweet syndrome (1).
Diagnosing PPV is not difficult in the right context – either a neonate in diapers, or in an incontinent adult. It may be rather confusing, however, when out of context, such as in this boy, under an ostomy (2), or when someone has odd behavior such as never taking off a surgical glove for months on end (3).
Perhaps cinching the diagnosis would be a little easier if the term was PMP rather than PPV.
- Bubra AK, Rangarajan S. Molluscoid pseudovesicles: An unusual presentation of Sweet’s syndrome. Indian J Dermatol 2015; 60: 636.
- Fernandéz IS, et al. Pseudoverrucous irritant peristomal dermatitis with a histological pattern of nutritional deficiency dermatitis. Dermatol Online J 2010; 16(9): 16.
- Nelson J, Maroon M. Images in clinical medicine. Pseudoverrucous papules. N Engl J Med 2011; June 9: 364 (23: e50.