An Adolescent With Asymptomatic Nodules of the Scrotum

AUTHORS:
Alexander K. C. Leung, MD, and Benjamin Barankin, MD

CITATION:
Leung AKC, Barankin B. An adolescent with asymptomatic nodules of the scrotum. Consultant Pediatr. 2014;13(8):374.

A 17-year-old boy presented with a 2-year history of numerous asymptomatic nodules on the scrotal skin. The nodules had begun as papules and had gradually increased in size and number over time. His past health history was unremarkable. In particular, there was no history of trauma or systemic disease. He was not on any medications or vitamin supplements. No family members had similar skin lesions.

Physical examination revealed numerous firm skin-colored, papular and nodular lesions of varying sizes within the scrotal skin. The lesions were nontender. The rest of the examination findings were normal.

What could be the cause of these lesions? Are they benign or concerning?

(Answer and discussion on next page)

Answer: Idiopathic Scrotal Calcinosis

A 17-year-old male presented with a 2-year history of numerous asymptomatic nodules on the scrotal skin. The nodules had begun as papules and had gradually increased in size and number over time. His past health history was unremarkable. In particular, there was no history of trauma or systemic disease. He was not on any medications or vitamin supplements. No family members had similar skin lesions.

Physical examination revealed numerous firm, skin-colored, papular and nodular lesions of varying sizes within the scrotal skin. The lesions were nontender. The rest of the examination results were normal.

His serum levels of creatinine, calcium, phosphate, alkaline phosphatase, parathyroid hormone, calcitonin, and vitamin D were normal. An excisional biopsy of one of the nodules was performed. Histologic examination results showed normal epidermis, amorphous basophilic deposition of calcium in the dermis on hematoxylin and eosin staining, and histiocytes and giant cells in the adjacent area. Neither squamous epithelial lining around the calcified nodule nor glandular structures were identified. These findings were consistent with idiopathic scrotal calcinosis. The patient was reassured of the benign nature of the condition.

Scrotal calcinosis refers to deposits of insoluble calcium salts in the scrotal skin with resultant formation of papules and nodules within the scrotal skin. The condition was first described by Lewinski in 1883.¹ The term idiopathic scrotal calcinosis was coined by Shapiro and colleagues in 1970.²

Epidemiology and Etiopathogenesis

The exact incidence is not known, since information on this condition mostly is derived from case reports. Scrotal calcinosis typically presents in adolescence and early adulthood.³ The condition is more common in dark-skinned individuals.^4,5

Scrotal calcinosis may result from dystrophic calcification of an epidermal inclusion cyst or eccrine epithelial cyst.^5,6 Epithelial lining surrounding the calcified material has been demonstrated by some investigators.⁷ Scrotal calcinosis also may result from dystrophic calcification of the degenerated dartos muscle of the scrotum.³ Idiopathic scrotal calcinosis occurs in the absence of known tissue injury or systemic disease, and there is no evidence of residual cyst and epithelial lining around the calcified nodule. Rarely, scrotal calcinosis may result from metastatic calcification secondary to abnormal calcium and phosphate metabolism that predisposes to calcium precipitation.

Histopathology

Histopathologic examination of a classic lesion reveals deposition of calcium in the dermis surrounded by histiocytes, macrophages, giant cells, and lymphocytic infiltrates.⁷ Basophilic staining calcium deposits can be demonstrated with hematoxylin and eosin stain.⁷ With von Kossa stain, the calcium deposits stain black. Cyst wall or keratin may or may not be present. The presence of keratin in the tissue suggests that the cyst wall had at one time been present.⁶

Clinical Manifestations

Scrotal calcinosis typically presents with numerous slow-growing, firm to hard papules or nodules within the scrotal skin.³ However, lesions may be solitary or pedunculated.^3,6 They are initially skin-colored but may become whitish to yellowish or brownish over time. The lesions vary from 1 mm to 2 cm in diameter. Scrotal calcinosis usually is bilateral and asymptomatic.³ Seldom, scrotal calcinosis may be pruritic.³ Some patients experience a feeling of heaviness or dragging sensation in the scrotum. Lesions may break down spontaneously or when compressed to produce a white chalky material.

Diagnosis and Differential

The diagnosis usually is clinical. A biopsy of the lesion can confirm the diagnosis.

The differential diagnosis includes epidermal inclusion cyst, steatocystoma multiplex, angiokeratoma, fibroma, lipoma, and lymphangioma circumscriptum.⁶

Complications

Scrotal calcinosis can be socially embarrassing and may affect intimate relationships with sexual partners. Inflammation, infection, and ulceration of the lesions also may occur.⁵

Prognosis and Management

The condition is benign, and the prognosis is good.

Usually, no treatment is necessary except for cosmetic purposes or symptomatic lesions. If treatment is desired, surgical excision is the treatment of choice.

Alexander K. C. Leung, MD, is a clinical professor of pediatrics at the University of Calgary and a pediatric consultant at the Alberta Children’s Hospital in Calgary.

Benjamin Barankin, MD, is medical director and founder of the Toronto Dermatology Centre.

REFERENCES

1. Lewinski HM. Lymphangiome der Haut mit verkalktem Inhalt. Virchows Arch Pathol Anat Physiol Klin Med. 1883;91(2):371-373.
2. Shapiro L, Platt N, Torres-Rodriguez VM. Idiopathic calcinosis of the scrotum. Arch Dermatol. 1970;102(2):199-204.
3. Pompeo A, Molina WR, Pohlman GD, Sehrt D, Kim FJ. Idiopathic scrotal calcinosis: a rare entity and a review of the literature. Can Urol Assoc J. 2013;7(5-6):E439-E441.
4. Noël B, Bron C, Künzle N, De Heller M, Panizzon RG. Multiple nodules of the scrotum: histopathological findings and surgical procedure. A study of five cases. J Eur Acad Dermatol Venereol. 2006;20(6):707-710.
5. Tela UM, Ibrahim MB. Scrotal calcinosis: a case report and review of pathogenesis and surgical treatment. Case Rep Urol. 2012;2012:475246. doi:10.1155/2012/475246.
6. Lei X, Liu B, Cheng Q, Wu J. Idiopathic scrotal calcinosis: report of two cases and review of literature. Int J Dermatol. 2012;51(2):199-203.
7. Holliday AC, Clos A, Kelly B. Firm papules on the penis and the scrotum. Dermatol Online J. 2014;20(2):15. http://escholarship.org/uc/item/7s43p5x8. Accessed June 25, 2014.