Hsu, Tina

Nahmias, Zachary P

Rosman, Ilana S

Sheinbein, David

English

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Washington University School of MedicineDigital Commons@BeckerOpen Access Publications2018Extragenital condyloma acuminatum in the leftaxillary vaultTina HsuWashington University School of Medicine in St. LouisZachary P. NahmiasWashington University School of Medicine in St. LouisIlana S. RosmanWashington University School of Medicine in St. LouisDavid SheinbeinWashington University School of Medicine in St. LouisFollow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubsThis Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in OpenAccess Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationHsu, Tina; Nahmias, Zachary P.; Rosman, Ilana S.; and Sheinbein, David, ,"Extragenital condyloma acuminatum in the left axillaryvault." JAAD Case Reports.4,9. 947-949. (2018).https://digitalcommons.wustl.edu/open_access_pubs/7261CASE REPORTExtragenital condyloma acuminatumin the left axillary vaultTina Hsu, BA,a Zachary P. Nahmias, MD,b Ilana S. Rosman, MD,b and David Sheinbein, MDbSt Louis, MissouriKey words: axillary condyloma; condyloma acuminatum; extragenital condyloma.INTRODUCTIONCondyloma acuminatum is a benign epithelialproliferation attributed to the epidermotropic humanpapillomavirus (HPV) and generally associated withsexual transmission. More than 100 types ofHPV have been discovered, but strains 6 and 11 arefound to cause approximately 90% of condylomaacuminatum. Lesions occur most frequently on themucous membranes of the anogenital region, butalso may occur in the conjunctiva and oral mucosa.Extragenital condyloma acuminatum not associatedwith sexual activity is rare, having previously onlybeen described in the groin and inframammary fold.1We report a patient with condyloma acuminatumoccurring on the skin of the axilla.REPORT OF A CASEA 30-year-old African-American man presentedwith a 3-year history of growths in the left axilla. Thelesions were painful, especially when caughton clothing, and were increasing in size. Onexamination, there were numerous cerebriformand verrucous pedunculated papules in the left axillacoalescing into a 2-cm plaque (Fig 1). The patientdenied a history of oral or genital lesions, and therewere no lesions at the time of examination. Theclinical differential diagnosis included epidermalnevus, acrochordon, and condyloma acuminatum.A shave biopsy was performed. On histopathology,there was papillated epidermal hyperplasia withhyperkeratosis, hypergranulosis, and dilated bloodvessels at the tips of the dermal papillae andkoilocytic changes within the superficial spinouslayers, compatible with a diagnosis of condylomaacuminatum (Fig 2). At higher power, there waskoilocytic change within the keratinocytes of thesuperficial spinous layers (Fig 3). Additional in situhybridization studies for human papillomaviruswere performed; the lesion was positive forlow-risk strains (6 and 11) but negative forhigh-risk strains (16 and 18) (Fig 4). The patient didnot return to the clinic after the diagnosis.DISCUSSIONTo our knowledge, this is the first report in theliterature of axillary condyloma acuminatumwithouta history of genital warts. The lesion is definedboth by its exophytic, verrucous appearance ofcondyloma acuminatum and its findings on pathol-ogy, including koilocytotic change, hypergranulosis,and papillated epidermal hyperplasia. Thedifferential diagnosis includes fibroepithelial polyp,verruca vulgaris, and squamous papilloma.Fibroepithelial polyps usually lack the complexexophytic features of condyloma acuminatum.Squamous papillomas do not have koilocyticchanges or acanthosis. Condyloma acuminatum hasbeen reported intraorally and within intertriginousareas, such as the groin and the inframammary fold,but it is rare to see lesions in other areas of the bodywithout their presence in the anogenital area.2The patient could have acquired condylomaacuminatum through several mechanisms. Hemay have been immunocompromised, which wouldhave produced a favorable environment forinfection by HPV with subsequent epidermaltransformation. Testing for HIV was not performedAbbreviation used:HPV: human papillomavirusFrom Washington University School of Medicinea and Division ofDermatology, Washington University School of Medicine.bFunding sources: None.Conflicts of interest: None disclosed.Correspondence to: Zachary P. Nahmias, MD, Division ofDermatology, Washington University School of Medicine, 660S Euclid Ave, Campus Box 8123, St Louis, MO 63110. E-mail:nahmias@wustl.edu.JAAD Case Reports 2018;4:947-9.2352-5126 2018 by the American Academy of Dermatology, Inc. Publishedby Elsevier, Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).https://doi.org/10.1016/j.jdcr.2018.07.022947in this patient, given the lack of follow-up, but wouldbe a reasonable next step in evaluating a patient withextragenital condyloma acuminatum. Anotherpossibility is viral transmission from the genital regionto the axilla by a contaminated object, such as a razorused for shaving both areas. Although unusual,maschalagnia, or armpit fetishism, may sometimeslead to armpit intercourse, which could provide ameans of transmission of the HPV virus.3 No specificantiviral treatment is currently recommendedfor condyloma acuminatum, but some successfultreatments include intralesional interferon, topicalimiquimod, and electrocoagulation.4HPV is a ubiquitous virus. Strains of HPV arecausative in various verruca with some site-specifictendencies. For example, HPV types 2 and 4 causeverruca vulgaris, which occurs primarily on thehands and feet but can be seen on other areas ofthe body. Verruca plantaris is typically caused byHPV type 1. It is thought that each HPV type is onlyable to infect a few specific areas on the body.However, given the vast number and diversity ofHPV subtypes, some which have only been detectedby preliminary data and have yet to be fullydescribed, and the virus’s ability to establishlong-term latent infections in stem cells, it is possiblethat HPV types 6 and 11 could spontaneously infectextragenital areas such as the axilla, as viral strainscould be more promiscuous in sites of infection thanclassically thought.Given the rarity of extragenital condylomaacuminatum, it is imperative that clinicians be awareFig 1. Clinical presentation of extragenital condylomaacuminatum. There are verrucous pedunculated papulescoalescing into a 2-cm plaque in the left axilla.Fig 2. Histopathology of extragenital condyloma acumi-natum. There is hyperkeratosis, hypergranulosis, andpapillated epidermal hyperplasia. (Hematoxylin-eosinstain; original magnification: 320.)Fig 3. Histopathology of extragenital condyloma acumi-natum. At higher power, there is koilocytic change withinthe keratinocytes of the superficial spinous layers.(Hematoxylin-eosin stain; original magnification: 3200.)Fig 4. HPV in situ hybridization testing. Keratinocytesshow positivity with low-risk HPV strains (6 and 11) in situhybridization. (Original magnification: 3200.)JAAD CASE REPORTSOCTOBER 2018948 Hsu et alof, and inquire about, a patient’s medical andsurgical history, including HIV status, transplantstatus, sexual practices, and other factors that maypredispose to the condition. Additionally, becausehigh-risk strains of HPV (16, 18, 31, and 33) areassociated with malignant transformation incondyloma acuminatum in the anogenital area,HPV testing in suspected extragenital condylomaacuminatum is warranted to guide treatment andprognosis.REFERENCES1. Ashiru JO, Ogunbanjo BO, Rotowa NA, Adeyemi-Doro FA,Osoba AO. Intraoral condylomata acuminata: a case report.Sex Transm Infect. 1983;59(5):325-326.2. Googe PB, Chung SJ, Simmons J, King R. Giant-sized condylomaof the breast with focal acantholytic changes. J Cutan Pathol.2000;27(6):319-322.3. Aggrawal A. References to the paraphilias and sexual crimes inthe Bible. J Forensic Leg Med. 2009;16(3):109-114.4. Centers for Disease Control and Prevention. SexuallyTransmitted Diseases Treatment Guidelines, 2015. Vol 64; 2015.https://doi.org/10.1097/00008480-200308000-00006.JAAD CASE REPORTSVOLUME 4, NUMBER 9Hsu et al 949

Extragenital condyloma acuminatum in the left axillary vault

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Extragenital condyloma acuminatum in the left axillary vault

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