A descriptive study of patterns of genital dermatoses in patients in south India and evaluation of their quality-of-life

INTRODUCTION

Skin in the genital area is an extension of the skin elsewhere in the body and can be affected by common skin disorders that may incidentally affect the genital area or with disorders predominantly confined to this area, including sexually transmitted diseases (STIs). Disorders affecting the external genitalia can be broadly classified as venereal and non-venereal dermatoses (NVD). Genital dermatoses are common; however, due to the stigma associated with these disorders, many patients do not seek medical attention and prefer self-treatment. They are known to cause a significant reduction in the quality of life (QOL). An online survey by the British Association of Dermatologists noted that patients with vulvar dermatoses were twice as likely to have suffered from depression, with 22% reportedly having contemplated self-harm or suicide due to the same.^[1] Interestingly in men, such statistics are not available in the literature for review. Most studies assessing QOL in patients with genital disorders currently available in the literature focus mainly on NVD. The purpose of this study was to describe various venereal and non-venereal genital dermatoses and to evaluate the QOL in patients with these dermatoses.

MATERIALS AND METHODS

This cross-sectional study was conducted in the Department of Dermatology, Venereology, and Leprosy of our tertiary care institution in South India after obtaining permission from the Institutional Ethics Committee for a period of 2 years. The participants included 100 consecutive patients aged more than 18 years who were clinically confirmed to have genital dermatoses. Pregnant women and those with pre-existing severe and chronic psychiatric disorders (schizophrenia, bipolar affective disorder, dementia, and obsessive-compulsive disorder) were excluded from the study. After the informed consent process, a detailed history including demographics, symptoms, duration of illness, use of topical agents, and sexual practices were recorded on a preformed pro forma. A clinical examination was done, and if warranted, tests such as skin biopsy for histopathology study, Gram stain, potassium hydroxide stain, and/or Tzanck smear were done to arrive at a diagnosis.

Following this, the patients were instructed to fill out the dermatology life quality index (DLQI) questionnaire (which is a dermatology-specific QOL questionnaire designed by Finlay and Khan) on the basis of which their QOL was assessed.^[2] The DLQI consists of ten specific questions about the impact of dermatological disease on QOL which covers six domains such as symptoms and feelings, daily activities, leisure, work and school, personal relationships, and treatment. Each question has four response alternatives, corresponding to scores from 0 to 3. The maximum score was 30. The higher the score, the more the impairment in QOL. The scores were assessed in the following way:

0-1 no effect on the patient’s life

2-5 small effects on the patient’s life

6-10 moderate effects on the patient’s life

11-20 large effects on the patient’s life

21-30 extremely large effects on the patient’s life.

The data were analyzed using the Statistical Package for the Social Sciences version 22 for descriptive statistics. Inferential statistics were done using the Mann-Whitney U-test and the Kruskal-Wallis H-test. P < 0.05 was considered statistically significant.

RESULTS

Among the 100 patients included in the study, 58% were male, and 42% were female. The demographic details are listed in Table 1. The age group of the patients ranged from 18 years to 75 years, with a mean of 40.52 years. In the study group, 72% of patients belonged to the lower middle and upper lower strata with respect to socioeconomic status, as assessed by the modified Kuppuswamy scale for the urban population of the country. Further, 68% of patients had basic and less than basic education status. With respect to marital status, 68% of patients were married. In the study group, 78% of patients had no history to suggest high-risk sexual behavior.

As for the clinical profile, 33% of patients in the study group had coexisting skin conditions. These included (a) autoimmune and inflammatory dermatoses such as vitiligo, urticaria, lichen planus, and seborrhoeic dermatitis, (b) bullous dermatoses such as pemphigus vulgaris, (c) infections such as tinea corporis, and (d) benign conditions such as acanthosis nigricans and acrochordons. It was observed that 76% of patients in the study group were symptomatic. Interestingly, 24% of females and 17% of males complained of multiple symptoms. Pain and burning sensation were the most common symptoms in the study group, and it was seen in 35% of females and 31% of males. This was followed by an “itch” which was noted in 19% and 22% of females and males, respectively. In the study group, 57% of patients had genital lesions of < 1-month duration.

Among the 100 patients examined, 63% patients were found to have NVD, and 37% had VD (Those patients with conditions such as genital candidiasis, which may have various modes of transmission, those with high-risk behavior, complicated candidiasis or partners with genital candidiasis were presumed to have candidiasis acquired by sexual mode of transmission and hence categorized under VD).

The NVDs observed in this study were grouped based on their etiopathogenesis as per Fitzpatrick and Gentry classification and are described in Table 2. The most common NVDs were inflammatory dermatoses (44.4%), followed by infestations and infections (28.5%).

Among the 37 patients with VD, 21.62% had genital warts and herpes genitalis. The various VD observed in this study are tabulated in Table 3. All six patients with genital molluscum contagiosum (MC) had spouses having similar genital lesions. Secondary bacterial infection of MC was observed in two females. All the five patients with syphilis were male. One had a primary chancre, while another was a serologically confirmed case of syphilis with a cigar paper scar suggestive of a healed primary chancre. The other three cases included annular and lichenoid syphilitic lesions on the scrotum.

The various venereal and NVD seen in this study in males and females are represented in Figures 1 and 2.

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Figure 1:

Genital dermatoses in males; (a): Steatocystoma; (b): Scrotal calcinosis with tinea cruris; (c): Lichen planus; (d): Scrotal dermatitis with herpes genitalis; (e): Fixed drug eruption; (f): Pseudo-epitheliomatous keratotic and micaceous balanitis; (g): Genital scabies with inguinal bubo; (h): Molluscum contagiosum; (i): Genital warts; and (j): Annular syphilis.

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Figure 2:

Genital dermatoses in females; (a): Ulcerative lichen planus; (b): Erysipelas; (c): Skin tag; (d): Vulvovaginal candidiasis; (e): Vitiligo; (f): Chancroid; (g): Molluscum contagiosum; (h): Genital wart; and (i): Herpes genitalis.

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The mean DLQI score in the study was 5.8 ± 4.437. The DLQI score in the overall study group, along with separate representations in patients with non-venereal and VD, is illustrated in Figure 3. Among the 100 patients in the study group, 33% of patients had small and 28% had moderate effects on the QOL. Only 18% of patients had a large effect, and none had an extremely large effect on their QOL with respect to their genital dermatoses. It was observed that 61.9% and 59.4% of patients with non-venereal and VD, respectively, had small and moderate effects in QOL due to their disease. It was interesting to observe that 34% of patients with NVD had a moderate effect on their QOL, whereas 43% of patients with VD had a mild effect on their QOL. Nonvenereal genital dermatoses with a history of high-risk sexual exposure did not affect the QOL.

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Figure 3:

The impact of genital dermatoses on quality of life based on dermatology life quality index score in entire study group, nonvenereal dermatoses, and venereal dermatoses.

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We further compared the DLQI scores with various demographic and clinical variables, as described in Table 4. Patients with genital dermatoses showed worsening in QOL with advancing education status and with the presence of co-existing skin diseases. Although the DLQI scores were higher in NVD (mean DLQI score 6.16 ± 4.84) as compared to VD (mean DLQI score 5.41 ± 4.84), the difference was not statistically significant.

DISCUSSION

Genital dermatoses may result from various etiologies, including STIs, non-sexually transmitted agents, inflammatory disorders, multi-system diseases, benign and malignant neoplasia, and external factors such as contact dermatitis and fixed drug eruption.^[3] They are broadly classified as venereal and NVD. Most are multifactorial and are modified by anatomical, hormonal, biological, and frictional influences, posing a diagnostic challenge to clinicians. Further, various studies postulate that the onset of genital dermatoses, which usually coincide with suspected sexual contact, dramatically increases the levels of depression, anxiety, and stress in those patients affected. This also has an adverse effect on their QOL, more so in those with symptoms such as pain, itching, discharge, and swelling.^[4,5] The purpose of this study was to describe the various venereal and nonvenereal genital dermatoses seen in patients attending the outpatient department of our institution and to assess their QOL using the DLQI questionnaire.

CONCLUSION

Genital dermatoses are more commonly reported in males and in the age group between 21 and 40 years. Overall, patients had only mild impairment of QOL due to genital dermatoses. Patients with genital dermatoses showed worsening in QOL with advancing education status and with the presence of co-existing skin diseases. There may be a need for quality research in the future to formulate genital dermatoses-orientated quality-of-life/outcome instruments for assessing patients with such disorders.