Chronic Scrotal Dermatitis: Symptoms, Diagnosis, and Concerns

Severe issues with scrotal skin?

Hello Dr.
Du, about 4 to 5 years ago, I noticed a patch on my left scrotum (approximately 3cm x 4cm) that started to change color, becoming somewhat red, but it wasn't itchy and I didn't have any other issues.
Over the last 2 to 3 years, it began to feel slightly itchy, and I sometimes noticed a bit of dry skin flaking.
In the past year, the lesion has grown larger, and now the entire left scrotum has a different skin color, often very dry with a lot of flakes (similar to snake skin, which can be peeled off in large pieces; the skin underneath is smooth, but it quickly becomes dry and flaky again), and it is very itchy.
This condition has now extended to the base of my penis and my anus, where I have similar symptoms.
The anal area is particularly peculiar; it is not dry, has flakes, itches, and feels slightly sticky, with itching occurring even just inside the anal opening.
I became quite worried and went to see a dermatologist.
After examining me, the doctor diagnosed it as chronic eczema of the scrotum and prescribed an immunosuppressive ointment (Fluocinonide) for me.
After applying it for a week, there was minimal improvement; it was not as dry, but other symptoms did not improve.
The doctor then prescribed a 10% urea cream, which I also used for a week, but the condition remained similar to the previous week.
During my follow-up visit, I requested a biopsy, which the doctor agreed was necessary.
However, since I had issues on the entire left scrotum, the base of the penis, and the anus, they only took a small sample from the scrotum for examination.
The report stated: 0.5 x 0.4 x 0.3 cm, fully embedded.
There was hyperkeratosis, incomplete keratinization, with a small amount of neutrophil infiltration in the incomplete keratin layer, a reduction and disappearance of the granular layer, and acanthosis.
There was lymphocytic infiltration around the superficial dermal vessels, with the lesions being consistent with chronic eczema and psoriasis, and no malignant changes were observed.
After reading the report, I felt somewhat relieved, so I intended to search for information on these two conditions and their treatments online.
However, I came across information about extramammary Paget's disease, which is said to commonly occur in the scrotum.
It mentioned that eczema typically presents symmetrically, and treatment is usually effective, while Paget's disease tends to occur unilaterally and may not respond well to standard treatments.

Dr.
I am very worried because I am currently not in Taiwan but in Macau, where the medical standards are not very high.
I fear that either the clinical physician or the pathologist may misdiagnose my condition, and I am particularly concerned about the possibility of extramammary Paget's disease.
Therefore, I hope you can answer my following questions...
I am very anxious...
1.
Is it true that scrotal eczema always occurs symmetrically? If so, does scrotal psoriasis typically present unilaterally or symmetrically? My condition is unilateral, which aligns with many descriptions of Paget's disease online.
2.
If I have scrotal Paget's disease, is it possible that some areas of the affected skin do not contain Paget cells, and that the small piece of skin taken for the biopsy happened to be free of Paget cells, thus resulting in a negative finding?
3.
Based solely on the information provided, what do you think is the most likely diagnosis? Is there a possibility of having Paget's disease? What do you recommend I do next?

JC, 20~29 year old female. Ask Date: 2010/03/17

Dr. Du Zhiqiang reply Dermatology

Dear JC,
Hello.
The rough, dark black patches on your scrotum do not require concern since the pathology report confirms there are no cancerous changes.
As you are not a pathology expert, there is no need to compare your symptoms with textbooks.
Paget's disease of the breast is clinically and pathologically very characteristic and is not difficult to diagnose.
Constantly doubting yourself can lead to mental stress.
Since you reside in Macau, it would be best to seek treatment overseas.
It is challenging to diagnose and treat online without seeing the clinical presentation.

Wishing you peace and health.
Sincerely,
Dr.
Du Zhi-Liang
Director, Dermatology Department, Taoyuan Hospital, Health Bureau

Reply Date: 2010/03/17

More Info

Chronic scrotal dermatitis is a condition that can cause significant discomfort and concern, particularly when it presents with symptoms such as redness, itching, and scaling. Based on your description, it appears that you have been experiencing these symptoms for several years, with a gradual worsening over time. The histopathological report you received indicates findings consistent with chronic dermatitis and psoriasis, but importantly, it did not show any malignant changes.

1. Symmetry of Symptoms: Chronic dermatitis, including eczema, often presents symmetrically, but this is not a strict rule. Psoriasis can also present in various patterns, including unilateral or localized forms. Therefore, while many cases of eczema may be bilateral, it is not definitive that all cases must be. The unilateral presentation of your symptoms does not automatically indicate Paget's disease, especially since your biopsy results did not show malignancy.

2. Paget's Disease Consideration: Paget's disease of the skin, particularly extramammary Paget's disease, can indeed present with localized symptoms. However, the absence of Paget cells in the biopsy does not rule out the possibility entirely, as there can be variability in the distribution of these cells. However, the likelihood of having Paget's disease is significantly reduced given that your biopsy did not reveal any malignant cells, and the findings were more consistent with chronic dermatitis or psoriasis.

3. Diagnosis and Next Steps: Given the information provided, it is reasonable to conclude that your condition is more likely chronic scrotal dermatitis or psoriasis rather than Paget's disease. The treatment you received, including topical immunosuppressants and urea cream, is appropriate for managing dermatitis. However, if you are not experiencing significant improvement, it may be beneficial to explore other treatment options. This could include stronger topical corticosteroids, phototherapy, or systemic treatments if warranted.

Recommendations:
- Follow-Up: Continue to follow up with your dermatologist. If you feel your concerns are not being adequately addressed, consider seeking a second opinion, especially if you are in a region where medical expertise may vary.

- Symptom Management: In addition to the treatments you are currently using, consider lifestyle modifications such as wearing loose-fitting clothing, maintaining good hygiene, and avoiding irritants that may exacerbate your symptoms.

- Monitoring: Keep a close watch on any changes in your symptoms. If you notice any new lesions, changes in color, or increased discomfort, it is crucial to report these changes to your healthcare provider promptly.

In summary, while your concerns about Paget's disease are understandable, the evidence from your biopsy suggests a diagnosis of chronic dermatitis or psoriasis. It is essential to maintain open communication with your healthcare provider and to advocate for your health, ensuring that you receive the appropriate care and follow-up necessary for your condition.

Similar Q&A

Understanding Scrotal Skin Issues: Itchy, Peeling, and Eczema-Like Symptoms

Hello, recently I have been experiencing occasional localized itching on the skin of my scrotum, which is followed by the affected area developing small, thin patches of skin peeling (desquamation). Afterward, it tends to heal naturally and the skin regenerates. It feels like scr...

Dr. Du Shixi reply Urology
Hello: The skin of the scrotum is prone to infection in hot and humid weather. It is important to wear loose-fitting underwear and keep the skin clean and dry. If the problem persists despite these measures, medical treatment may be necessary. You can consult either a urologist o...

Understanding Scrotal Redness and Itching: Causes and Solutions

Scrotal redness and itching, followed by what seems to be a skin abrasion that oozes a yellowish fluid, can be concerning. The outer layer of the testicles is indeed called the scrotum. To address the redness and itching, as well as the potential skin abrasion, consider the follo...

Dr. Liu Jianting reply Urology
If you have a skin tear on your scrotum, please ask your parents to take you to the hospital to see a urologist for treatment as soon as possible.

Relieving Chronic Scrotal Itching: Tips Beyond Medical Treatment

Hello: I have been troubled by itching in the scrotum for 3 to 4 years. Sometimes it even affects my sleep quality. When it itches, I feel the urge to scratch, often to the point of breaking the skin, which provides temporary relief. However, once it scabs over, I experience peel...

Dr. Hong Zhengsheng reply Dermatology
Hello, Light: Based on your written description, it is currently difficult to determine your specific condition. The most significant characteristic of skin diseases is that "seeing is believing, and touching reveals texture." It is indeed challenging to convey a comple...

Understanding Scrotal Skin Issues: Causes and Treatment Options

Hello doctor, in the past few days, I have noticed that the epidermis of my left testicle, near the midline, has a break in the skin and feels moist. When I wipe it with tissue, I find a greenish fluid that resembles pus. I feel pain from friction against the skin whether I am si...

Dr. Sun Hongshun reply Urology
Hello: As you mentioned, the discharge of green pus may indicate a more serious bacterial infection. Please seek treatment at the infectious disease clinic immediately. Wishing you good health.