penisrash

[noansweryet]

I am a 40 yr male. For 2-3 years I have had intense pruritus of the penis wo skin rash all STDs (-) including hsv1 &2.  Again tested 1 year ago all (-), includingHSV1&2.  My partner of four years saw her Ob/Gyn at that time and was (+) only for HSV type 1, without hx of cold sores but occasional canker sores.  She has no genital sx.

2 mnths ago the sx flared again.  Now the skin on the glans and coronal sulcus was visibly dry. The dry skin appeared as dandruff and became dry white cracks on the glans.  If stretched the skin on the glans or coronal sulcus would crack.

This lasted 4 wks, until 1 month ago.  I had sex on 2 occasions 4 days prior and 3 hours prior to a rash.  The rash burned with soap in the shower.  The glans rash had 1mm dots of bright red on left side and top with generalized erythema.  A series of small cuts in the skin,(left coronal sulcus).  The glans was painful, (dull aches), and hypersensitive to rubbing clothes.  Not painful if touched and healed in 3 to 4dys, followed by extensive dry flaking skin from the entire glans and sulcus(like the scales seen with psoriasis).  I had lower back discomfort which I attributed to travel and different beds.

One week from the appearance of the rash, I was retested for HSV and other STD's and serology yielded  HSV 1= 3.8 and HSV 2 <0.9.  No IgM.  All others (-).

2 wks later a 2nd painless rash developed in the same area.  No tingling prodrome, open sores, blisters. Some back pain again.  Small areas,  2-3mm,  of mild erythema with scatterd 1mm flat topped papules, no blisters. The entire glans again appeared dry.  This cleared in 4 days.  Inguinal pain was present and more severe than in the past. Is this  a genital HSV 1 infection or is it something else?  If notHSV what would it be and how can I prove it or treat it?

[H. Hunter Handsfield, M.D.]

Welcome to the STD forum.

Herpes does not behave at all like you describe.  It does not cause itching in the absence of overt herpes lesions (blisters, open sores, etc); skin dryness; or flaking or cracking of the involved skin.  Further, herpes symptoms always occur in discrete outbreaks, which never last more than 10-14 days; never recur more often than every 4-6 weeks; and there are no symptoms at all between outbreaks.  Herpes also does not cause inguinal pain or back pain, at least not in the absence of overt herpetic lesions.

Combining your clinical features with both your and your partner's negative tests for HSV-2, it is very unlikely you have genital herpes.

The HSV-1 results are an uncertainty here.  If I understand correctly, you had a negative blood test for HSV-1 a couple of years ago, but more recently it has become positive.  That is consistent with a new HSV-1 infection in the interim; you may have been infected from your wife.  Whether that was oral or genital, I cannot say -- but even if genital, it remains very unlikely that HSV-1 explains the symptoms you describe.  In addition to the reasons above, genital herpes due to HSV-1 causes few or no recurrent outbreaks in most persons.

As to the actual cause of your rash and pruritus, I really can't make even an educated guess.  Any of the many causes of skin rash anywhere on the body sometimes can affect the genital area; and many skin conditions other than herpes come and go in a recurrent pattern.  If you have not seen a dermatologist, that seems the logical next step -- preferably at a time there is visible rash.  In the meantime, I am quite certain that neither herpes nor any other STD is the problem.

I hope this helps start to sort things out.  I'll be interested to hear what a dermatologist says about it.  Good luck--

HHH, MD

[noansweryet]

Thank you for the prompt response.

I have not seen a dermatologist. On that last visit to my PMD when the rash had already resolved, they suggested that rash in the setting of a recent and strong +HSV1 serology suggested genital HSV1 infection, non primary initial episode or initial infection and said atypical presentations are common.  They thought the other sx were unrelated.   I was not fully comfortable with this and not sure if I needed to worry about infecting my partner genitally assuming her HSV+ site is oral.

Thanks again

[H. Hunter Handsfield, M.D.]

The blood test indicates you are infected with HSV-1, probably recently.  No lab test can determine where (anatomically) the infection was acquired.  However, if it was genital, I strongly believe that it does not explain any (not one!) of the symptoms you have described.  Something else is going on.  (By the way, your HSV-1 serology result is not "strong".  Positive is positive is positive.  Whether the number is high or low in the positive range says absolutely nothing about how long you have been infected or whether the infection is causing symptoms.)

Once a person is infected with HSV of either type, s/he is immune (or at least highly resistant) to catching the same type again, anywhere on the body.  Even if you have genital HSV-1, your partner cannot catch it from you.

Truly atypical presentations of herpes probably are not very common.  Mild (and therefore unrecognized) symptoms are the rule.  I have not changed my mind about my initial comments:  your symptoms are not suggestive of herpes.  Period.

See a dermatologist when the rash is active.  In the meantime, what does it matter whether or not you have herpes?  If your partner is not at risk and your symptoms aren't all that bothersome, what matters?

[noansweryet]

Thank you,

If there is no further risk, you  are right.  Although, an unpleasant idea, I suppose it does not matter.

Thank you again and take care.

[noansweryet]

Dr Handsfield,  It is six weeks since the episode I described previously.  The small cuts in the skin re-appeared to day.  Again no outright pain yet but they sting with soap.  I have uploaded pics from first episode while it waned first (7) and and the rest from today.  I would like ask your opinion again.  I would like to treat this correctly.  Keeping in mind what you said about my partners immunity, I am still concerned since we have no children and neonatal HSV seems to be a significant concern.

Thanks again

[H. Hunter Handsfield, M.D.]

I already told you how to "treat this correctly" with my comment November 6:   "See a dermatologist when the rash is active."  We do not examine posted photos on this forum.  See the dermatologist or other provider ASAP and feel free to report back what s/he says about it.  Other than that this thread is over.