Penile Syringoma: Reports and Review of Patients with Syringoma Located on the Penis

| June 13, 2013
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Philip R. Cohen, MD; Jaime A. Tschen, MD; Ronald P. Rapini, MD

Dr. Cohen is from The University of Houston Health Center, University of Houston, Houston, Texas; The Division of Dermatology, University of California San Diego, San Diego, California; The Department of Dermatology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; and The Department of Dermatology, University of Texas-Houston Medical School, Houston, Texa. Dr. Tschen is from The Department of Dermatology, University of Texas-Houston Medical School, Houston, Texas, St. Joseph Dermpath, Houston, Texas; and The Department of Dermatology, Baylor College of Medicine, Houston, Texas. Dr. Rapini is from The Division of Dermatology, University of California San Diego, San Diego, California, and The Department of Dermatology, University of Texas-Houston Medical School, Houston, Texas.

Disclosure: The authors report no relevant conflicts of interest.

Abstract
Background: Syringoma of the penis is rare. Purpose: This paper describes two men with syringoma of the penis and summarizes the clinical features of previously reported men with this condition. Methods: A 25-year-old African man presented with a nonpruritic flesh-colored papule on the right side of his proximal dorsal penile shaft and a 22-year-old Caucasian man presented with multiple asymptomatic flesh-colored papules on his ventral and lateral penis. Neither man had similar lesions elsewhere or a family member with this condition. Reports of patients with penile syringoma were identified using a medical search engine (PubMed Central) and references included in the published papers on this subject. Results: Microscopic examination of both men’s papules showed syringoma. Including these individuals, syringoma exclusively localized to the penis has only been reported in 11 men. It usually presents as multiple asymptomatic flesh-colored papules on the dorsal penile shaft of men less than 30 years of age. Epithelial-lined cystic spaces containing homogenous eosinophilic material are noted in the fibrotic upper dermis. The papules do not recur following excisional biopsy. Conclusion: Syringoma exclusively located on the penis is extraordinary and has only been reported in 11 men. It presents as a solitary papule or multiple asymptomatic papules on the penile shaft. Microscopic examination shows epithelial structures and eccrine ducts with comma-like tails resembling tadpoles in the fibrotic upper dermis; amorphous pink secretion is often present in the epithelial-lined spaces. Excision of the penile papules not only provides the diagnosis, but also successfully removes the individual lesion without recurrence.
(J Clin Aesthet Dermatol. 2013;6(6):38–42.)

Syringomas are benign eccrine tumors that typically present as symmetrically distributed dermal papules on the lower eyelids; however, they may appear on other areas of the body—particularly in individuals who experience an eruptive onset of the lesions. Penile syringoma are rare. The authors present the cases of two men with penile syringomas and review the characteristics of previously reported individuals with syringomas exclusively located on their penis.[1–8]

Case Reports
Case 1. A 25-year-old healthy heterosexual African man presented with a two-year history of an asymptomatic papular lesion on the penis that was slowly increasing in size. He was beginning a new relationship and wanted to be certain that he did not have a contagious disease. No similar lesions were present elsewhere. No other family member had a similar problem.

Clinical examination showed a firm, smooth, 2x2mm, flesh-colored papule on the right proximal dorsal penile shaft (Figure 1). The remaining physical examination revealed no other physical abnormalities.

An excisional biopsy of the lesion was performed under local anesthesia. Microscopic examination of the penile papule showed a normal epidermis with a proliferation of ductal spaces and aggregates of epithelial cells in the upper dermis, which had a fibrous stroma (Figure 2). Many of the spaces were predominantly lined by two layers of epithelial cells and some were filled with amorphous pink secretion (Figure 3).

Correlation of the clinical presentation and the pathologic findings established a diagnosis of a solitary syringoma of the penis. Complete healing of the biopsy site occurred. There was neither recurrence nor additional new lesions.

Case 2. A 22-year-old healthy heterosexual Caucasian man presented with a less than one-year history of multiple asymptomatic papular lesions on the penis. He was concerned regarding the possibility of venereal warts. He had no similar lesions elsewhere. No other family member had a similar problem.

Clinical examination showed numerous, firm, smooth, 1 to 4mm, flesh-colored papules on the ventral and lateral penile shaft (Figure 4). The remaining physical examination revealed no other physical abnormalities.

A biopsy of one of the lesions was performed under local anesthesia. Microscopic examination of the penile papule showed a proliferation of ducts predominantly lined by two rows of epithelial cells in the upper dermis; some of the ducts had comma-like tails giving them the appearance of tadpoles. The surrounding stroma was fibrous and some of the ductal spaces were filled with homogenous eosinophilic material.

Correlation of the clinical presentation and the pathologic findings established a diagnosis of multiple syringomas of the penis. Complete healing of the biopsy site occurred. The patient was reassured that the lesions were neither condyloma nor a sexually transmitted disease; he decided to observe the remaining lesions without any additional therapeutic intervention.

Discussion
Syringomas are benign, small, soft, usually asymptomatic, flesh-to-yellow-colored, dermal papules that are derived from the intraepidermal portion of eccrine sweat ducts. Penile syringomas are an uncommon phenomenon. To the best of the authors’ knowledge, there are only 11 men (including the patients described herein) with syringomas exclusively located on the penile shaft (Table 1).[1–8]

Syringomas, particularly in some of the individuals with eruptive onset of their lesions, may be present in more than one family member.[9–11] However, there was no family history of similar lesions in the men with penile syringomas. Also, none of these individuals had any of the conditions that have been associated with development of syringomas, such as Costello syndrome, Down (trisomy 21) syndrome, Ehlers-Danlos syndrome, Nicolas-Balus syndrome, and Marfan syndrome.[11–15]

The penile syringoma initially appeared when the patients were between the ages of 12 to 40 years (mean=20 years; median=18 years); indeed, the onset age of the syringomas on the penis was less than 20 years old for 60 percent of the men and less than 30 years old for 80 percent of the patients. The new lesions were present from four weeks2 to 20 years6 (median=1.5 years) before the individuals sought medical attention.

The most common reason that the men with syringomas on the penis went to see a physician—including both of the patients described herein—was concern that the penile lesions were a manifestation of a sexually transmitted disease.[5–8] Some of the men were distressed by the cosmetic appearance of the papules[4–6]; for example, one of the individuals, a 30-year-old man, noticed that his erection was associated with a bright red color change of the lesions.[4] Another patient, a 35-year-old man who had a history of biopsy-confirmed condyloma acuminata and whose wife had cervical dysplasia, presented for a second opinion when his residual lesions did not improve following topical application of 25% podophyllum in tincture of benzoin.[7]

Syringomas of the penis usually present as multiple lesions (91% of patients) on the dorsal and lateral penile shaft (5 patients); only one patient, the 25-year-old African man described in this report, presented with a solitary lesion on the dorsal shaft of his penis. Less commonly, syringomas appeared on either the dorsal (2 patients), dorsal and ventral (1 patient), or the ventral and lateral (1 patient) penile shaft. None of the men with penile syringomas had lesions on their scrotum; this is in contrast to women who develop genital syringomas, which typically occur on their vulva either as the only location or as part of a widespread eruption of similar lesions.[16]

The dermal papules of penile syringomas were asymptomatic. They ranged in size from 1 to 7mm and were described as smooth, rounded, or dome-shaped. The individual lesions were either flesh (or skin) colored, brown, reddish-brown, white-yellow, or pink.

The clinical differential for penile syringomas is listed in Table 2.[1–8] An excisional biopsy can readily be performed to not only remove one or more of the lesions, but also for pathology evaluation. The changes noted on the microscopic examination of a penile syringoma are similar to those observed in a syringoma that is not located on the shaft of the penis. There are epithelial-lined ductal spaces and cysts in the upper dermis. Some of the spaces contain homogenous eosinophilic material. Some of the epithelial structures and cystic spaces have comma-like tails resembling tadpoles.

Treatment of syringomas on the penis is elective; indeed, treatment was only commented on for seven of the patients. Surgical removal of multiple lesions was performed in a 30-year-old man4 and microelectro-coagulation of many lesions over several sessions was done in a 20-year-old man.[3] The biopsy removed the entire syringoma in one of the patients described in this article and no further therapeutic intervention was necessary. The other four individuals (including the other patient described in this article), after being reassured of the benign biological behavior of the lesions, decided to observe their remaining syringomas without any additional treatment.[5,7,8]

Conclusion
Syringoma of the penis is a benign, albeit rare, condition usually appearing as multiple asymptomatic papules on the penile shaft of young men less than 30 years of age. They are often small, 1 to 4mm, flesh-colored, smooth lesions. The patients frequently seek medical attention because they are worried about the possibility of a sexually transmitted disease, such as condyloma accuminata, or are concerned regarding the cosmetic appearance of the lesions. The clinical differential diagnosis of penile syringoma includes other benign adnexal tumors, cutaneous lesions associated with sexually transmitted diseases, and even inflammatory or neoplastic skin conditions. A lesional biopsy readily establishes the diagnosis. Characteristic pathological changes associated with syringoma are observed: epithelial structures and epithelial-lined (predominantly by 2 cell layers) ductal spaces containing eosinophilic homogenous material in a fibrous dermal stroma. Some of the patients elected to have either surgical removal or destruction of some of their additional syringoma. However, most patients, after being reassured of the benign biological behavior of the lesions, decided to observe the remaining syringomas without any subsequent intervention.

References
1.    Petersson F, Mjornberg P-A, Kazakov DV, Bisceglia M. Eruptive syringoma of the penis. A report of 2 cases and a review of the literature. Am J Dermatopathol. 2009;31: 436–438.
2.    Yalisove BL, Stolar EH, Williams CM. Multiple penile papules: syringoma. Arch Dermatol. 1987;123:1391–1396.
3.    Sola Casas MA, Soto de Delas J, Redondo Bellon P, Quintanilla Gutierrez E. Syringomas localized to the penis (case report). Clin Exp Dermatol. 1993;18:384–385.
4.    Zalla JA, Perry HO. An unusual case of syringoma. Arch Dermatol. 1971;103:215–217.
5.    Olson JM, Robles DT, Argenyi ZB, et al. Multiple penile syringomas [letter]. J Am Acad Dermatol. 2008;59:S46–S47.
6.    Lipshutz RL, Kantor GR, Vonderheid EC. Multiple penile syringomas mimicking verrucae. Int J Dermatol. 1991;30:69.
7.    Lo JS, Dijkstra JWE, Bergfeld WF. Syringomas of the penis [letter]. Int J Dermatol. 1990;29:309–310.
8.    Cassarino DS, Keahey TM, Stern JB. Puzzling penile papules. Int J Dermatol. 2003;42:954–956.
9.    Pruzan DL, Esterly NB, Prose NS. Eruptive syringoma. Arch Dermatol. 1989;125:1119–1120.
10.    Soler-Carrillo J, Estrach T, Mascaro JM. Eruptive syringoma: 27 new cases and review of the literature. J Eur Acad Dermatol Venereol. 2001;15:242–246.
11.    Marzano AV, Fiorani R, Girgenti V, et al. Familial syringoma: report of two cases with a published work review and the unique association with steatocystoma multiplex. J Dermatol. 2009;36:154–158.
12.    Nguyen V, Buka RL, Roberts BJ, Eichenfield LF. Cutaneous manifestations of Costello syndrome. Int J Dermatol. 2007;46:72–76.
13.    Dupre A, Bonafe JL. Syringomas, mongolism, Marfan’s disease and Ehlers-Danlos’ disease. Ann Dermatol Venereol. 1977;104:224–230.
14.    Dupre A, Carrere S, Bonafe JL, et al. Eruptive generalized syringomas, milium and atrophoderma vermiculata. Nicolau and Balus’ syndrome. Dermatologica. 1981;162:281–286.
15.    Urban CD, Cannon JR, Cole RD. Eruptive syringomas in Down’s syndrome. Arch Dermatol. 1981;117:374–375.
16.    Garman M, Metry D. Vulvar syringomas in a 9-year-old child with review of the literature. Pediatr Dermatol. 2006;23: 369–372.

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Category: Case Series, Literature Review, Past Articles

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