Penile Angiokeratomas (PEAKERs) Revisited: A Comprehensive Review

Abstract

Angiokeratomas are benign vascular lesions. Genital angiokeratomas, also referred to as Fordyce angiokeratomas, usually occur on the scrotum in men and the vulva in women. Penile angiokeratoma (PEAKER) is a subtype of genital angiokeratoma in men; clitoral angiokeratoma (CLANKER) is its embryologic analog in women. The PubMed database was used to search the following words: angiokeratoma, clitoris, genital, peaker, penile, penis, rejuvenation, scrotal, scrotum and vulva. The relevant papers and references cited in those papers that were generated by the search were reviewed. The purpose of this article is to summarize the features of PEAKERs. PEAKERs have been described in 54 men. They usually appeared in younger men and had been present for a mean duration of 4 years prior to the individual seeking medical attention. Only 39% of the men had angiokeratoma-associated symptoms: usually bleeding and increasing size and less often abrupt onset, pain and pruritus. The glans penis (55.5%) and the penile shaft (35%) were the most common sites of PEAKERs; the angiokeratomas were also located on the foreskin (5.5%) or both the glans penis and penile shaft (4%). Thirty seven percent of patients with glans penis PEAKERs only had angiokeratomas on the corona. Scrotal angiokeratomas were also present in 20% of patients with PEAKERs. A solitary PEAKER was observed in 32% of the men. Most of the PEAKERs were 1-5 mm in size. The PEAKERs presented as purple, red and/or blue papules; 70% of the men's PEAKERs were more than one color. Clinical features often established the diagnosis; in addition, some of the men's angiokeratomas were biopsied or evaluated with dermoscopy. Laser therapy, in 56% of the men, was the most common treatment modality. Less common interventions included electrocautery, radiofrequency and excision. PEAKER recurrence or persistence was observed after excision (two men) or cryotherapy (one man), respectively. Several of the men (27%) decided to observe their PEAKERs without treatment.

Keywords: Angiokeratoma; Clitoris; Genital; PEAKER; Penile; Penis; Rejuvenation; Scrotal; Scrotum; Vulva.

Fig. 1

Penile angiokeratomas (PEAKERs) on the glans penis (urethral meatus) of a 16-year-old man. The PEAKERs were initially noticed 5 years ago, when he was age 11 years. He came for an evaluation since he was concerned that the lesions were warts. They had increased in number and had become more noticeable. Occasionally, they bled when they came in contact with his clothing. Examination showed a circumcised man with three 1–2 mm purple papules on the left side of his glans penis adjacent to the urethral meatus (black arrows). The diagnosis of angiokeratoma was established based on the clinical appearance of the lesions. The patient was concerned because the lesions periodically bled. Therefore, the PEAKERs were treated with electrocautery. Topical anesthetic (using a cream containing an equal mixture of lidocaine 2.5% and prilocaine 2.5%) was applied to the glans penis for an hour. The hyfrecator was set a 5, and each of the lesions received a single electrocautery application of < 1 s. All three of the lesions completely resolved; there has been no recurrence at 8 months following the treatment session

Fig. 2

A 67-year-old man with penile angiokeratomas (PEAKERs) on the corona of the glans penis and scrotal angiokeratomas. He presented for an evaluation of the vascular lesions on his scrotum, which had been present for 8 years and would occasionally bleed; he was unaware of the similar-appearing lesions on his glans penis. In addition, his history was remarkable for previously having redness on his distal penis that resolved with a whitening of the area. Cutaneous examination of his uncircumcised penis and scrotum was performed. Distant (a) and closer (b) views of the glans penis and the left side of the scrotum showed 6 < 1 mm purple papules on the glans penis (corona) (black arrows) and > 25 3-mm purple papules on the left side of the scrotum (red arrows); a confluent superficial white plaque with distal peeling was also noted on the glans penis. After the diagnosis of genital angiokeratomas was shared with the patient, he desired no additional treatment for the PEAKERs on the corona of his glans penis. He has been referred for laser treatment of the scrotal angiokeratomas

Fig. 3

Penile angiokeratomas (PEAKERs) and scrotal angiokeratomas on the genitalia of a 75-year-old man. His past medical history was significant for herpes simplex virus type 2 infection of his penis. Two years earlier—at age 73 years—he had developed concurrent chancroid and primary syphilis, which were adequately treated with 1 g of oral azithromycin and 2.4 million units of intramuscular benzathine penicillin, respectively. He presented for evaluation of scrotal erythema of 2-year duration; occasionally, he also experienced pruritus or pain (burning and stinging) or both of his scrotum, penile shaft and/or glans penis. Intermittent symptomatic relief was provided with topical corticosteroid (betamethasone dipropionate 0.05%) ointment or calcineurin inhibitor (tacrolimus 0.03%) ointment. Examination showed 1-mm purple papules on the left side of his penis (black arrows): four on the corona and one on the glans (a); in addition, he had diffuse erythema of his scrotum and two 2–3 mm purple papules on the left side of his scrotum (red arrows) (b). He had not been aware of the PEAKERs on his glans penis or the angiokeratomas on his scrotum; he was not interested in any therapeutic intervention for his genital angiokeratomas. His genital symptoms completely resolved after he began to treat the affected areas with a lotion containing menthol (0.5%) and camphor (0.5%)