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Recalcitrant genital papules

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This patient was initially told he had genital warts, but the appearance of the lesions, and the presence of a rash on his trunk and extremities, suggested another diagnosis.


 

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A 21-year-old man presented to the dermatology clinic with a 2-month history of painless genital and perianal lesions. The patient reported having unprotected sex in recent months, but had no prior history of oral, penile, or anal mucosal lesions or ulcers. He was not on any medications or immunosuppressive agents and noted that the lesions did not represent a recurrence. He also reported a nonspecific, asymptomatic rash on his trunk and extremities that had been present for an unknown period of time.

Soft and moist genital lesions image

The patient indicated that his primary care physician had looked at the genital/perianal lesions and told him they were genital warts. Previous treatments included an over-the-counter wart medication, cryotherapy, and a course of imiquimod, but none had helped.

Hyper-pigmented macules on the patient's sole image

The physical examination revealed multiple soft, moist, beefy papules and plaques around the genital area (FIGURE 1) and perianal region. In addition, there were multiple hyper-pigmented macules on the patient’s palms and soles (FIGURE 2), and reticulated, patchy eruptions on his arms, chest (FIGURE 3), and back.

Reticulated, patchy eruptions on the arms and chest image

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

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