Dermatology Online Journal

Perianal dermatoses among men who have sex with men: A clinical profile of 32 Indian patients
Sudip Kumar Ghosh MD DNB DDermat, Debabrata Bandyopadhyay MD, Arghyaprasun Ghosh MD, Surajit Biswas MD, Rajesh Kumar Mandal MBBS, Najmus Saadat Zamadar MBBS
Dermatology Online Journal 17 (1): 9

Department Of Dermatology, Venereology, and Leprosy
RG Kar Medical College, Kolkata, India. dr_skghosh@yahoo.co.in

---

Abstract

INTRODUCTION: A wide range of perianal dermatoses including different forms of sexually transmitted infections can occur in men who have sex with men (MSM). OBJECTIVE: To determine the relative frequencies and types of perianal lesions in a group of men from eastern India who had a history of receptive anal intercourse. METHODS: This was a cross-sectional clinical observational study. Consecutive MSM, presenting with perianal symptoms to the Sexually Transmitted Disease clinic of a tertiary care hospital of eastern India were studied. RESULTS: A total of 32 patients (age 15-54 years, mean 38.5 years) were evaluated. Perianal wart was the most common (16, 50%) lesion detected, followed by fissure (3, 9.4%), herpes simplex infection (2, 6.2%), molluscum contagiosum (2, 6.2%), abscess (1, 3.1%), condyloma lata (1, 3.1%), candidiasis (1, 3.1%), furuncle (1, 3.1%), gonococcal infection (1, 3.1%), irritant contact dermatitis (1, 3.1%), and perianal psoriasis (1, 3.1%). Two patients had perianal tuberculosis. Four patients (12.5%) were HIV positive and syphilis was found in one. CONCLUSION: A variety of dermatoses and infections can present in the perianal area of MSM, the most common being perianal wart. A thorough genital and perianal exam should be a part of a physical examination in these patients.

---

Introduction

A variety of perianal dermatoses including different forms of sexually transmitted infections (STIs) [1, 2] can occur in men who have sex with men (MSM) owing to penetrative anal intercourse and associated practices. We sought to determine the relative frequencies and types of perianal lesions in a group of men from eastern India who had a history of receptive anal intercourse and presented with perianal symptoms.

Methods

This was a cross-sectional clinical observational study. Consecutive MSM (who had history of at least one episode of receptive anal intercourse), presenting with perianal symptoms to the STD clinic of a tertiary care hospital of eastern India during February 2007 to January 2009, were studied. Institutional ethics committee approval was obtained prior to the work. A detailed history, including sexual practices was obtained and every patient was thoroughly examined clinically. Particular attention was paid to perianal, genital, oral, and systemic involvement. Routine laboratory investigations, HIV screening, and VDRL tests were done in all the patients. Tzanck smear, skin biopsy, fungal scraping, serum immunoglobulin against herpes simplex virus, and Gram staining were done as required.

Results

Figure 1	Figure 2
Figure 1. A neglected case of huge perianal wart in an MSM Figure 2. A large perianal wart in an MSM

Figure 3	Figure 4
Figure 3. A few perianal molluscum contagiosum in a patient Figure 4. A perianal ulcer of tubercular origin

A total of 32 patients (age 15-54 years, mean 38.5 years) were evaluated. The mean duration of symptoms before presentation was 15.7 weeks (range, 1-64 week). Most of the patients (29, 90.6%) were married. Thirty patients (93.7%) had history of bisexuality. Nine (28.1%) patients also acted as concomitant active partners in anal intercourse. Although history of condom usage was present in 12 patients (37.5%), all the patients gave a history of at least one episode of unprotected receptive anal sex. Perianal swelling was the most common (16, 50%) presenting symptom, followed by difficulty in defecation (5, 15.6%), perianal pain (5, 15.6%), burning sensation (4, 12.5%), skin rash (1, 3.1%), and perianal ulcer (1, 3.1%). Five (15.6%) patients gave history of cleaning the perianal areas with antiseptics following anal intercourse. Four (12.5%) patients had multiple male partners. Perianal wart was the most common (16, 50%) lesion detected (Figures 1 and 2), followed by fissure (3, 9.4%), herpes simplex infection (2, 6.2%), molluscum contagiosum (MC) (2, 6.2%) (Figure 3), abscess (1, 3.1%), condyloma lata (1, 3.1%), candidiasis (1, 3.1%), furuncle (1, 3.1%), gonococcal infection (1, 3.1%), irritant contact dermatitis (1, 3.1%), and perianal psoriasis (1, 3.1%). Two (6.2%) patients had perianal tuberculosis. One had lupus vulgaris (diagnosed on the basis of clinical presentation, histopathology, and therapeutic response to antitubercular drugs) and the other had tubercular ulcer (diagnosed on the basis of histopathology, smear, and culture) (Figure 4). Despite extensive work-up, we could not detect any endogenous source of tuberculosis in the first patient. The second patient, whose details were published previously [3], had tubercular pleural effusion. Associated genital lesions in the form of genital wart (4, 12.5%) and MC (1, 3.1%) were also noted. Four patients (12.5%) were HIV positive and VDRL test was reactive significantly in one. Among the HIV positive patients, three had perianal warts and one had perianal MC; they also had concomitant genital involvement with the same lesions. All the HIV-positive patients had been both active and passive partners in anal sex.

Discussion

Inoculations with pathogenic organisms following receptive anal sex may result in a range of STIs located in the perianal areas. Lack of visibility of the affected area and the relatively asymptomatic nature of the most common dermatosis (perianal wart) might have resulted in late presentation and diagnosis in a majority of our cases. Since MSM are subjected to discrimination and prejudice particularly in countries like India, where anal sex is still a penal offence, shyness, ignorance, and the fear of being exposed are other probable contributory factors. Most (90.6%) of our patients were married and the percentage of bisexuality (93.75%) was also very high in comparison to the western population [4]. In south Asian countries like India, vast majorities of MSM are married and live with their wives [5] probably owing to the discriminatory laws or social stigmatization of male sexual relations. In consonance with existing data stating the risk of HIV infection to be 13.5 percent among Indian MSM (anal-receptive) [6], concomitant HIV infection was detected in 12 percent of our patients, which emphasizes the role of this subset of the population in transmission of HIV. Ritual practices like washing the perianal areas and genitalia with antiseptics immediately after intercourse can lead to problems such as irritant contact dermatitis, as we have seen in our patients. One of our patients had perianal psoriasis in addition to the typical plaques of psoriasis elsewhere in the body. This might be due to the Koebner phenomenon, resulting in appearance of new lesions at the sites of trauma. One of our important observations has been the occurrence of perianal tuberculosis. The possibility of exogenous inoculations during anal sex has to remain speculative. A major limitation of our study was our inability to perform notification and examination of the partners in most of the cases.

Conclusions

A variety of dermatoses and infections can present in the perianal area of MSM, the most common being perianal wart. A thorough genital and perianal exam should be performed in these patients.

References

1. Siegal FP, Lopez C, Hammer GS, Brown AE, Kornfeld SJ, Gold J et al. Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex lesions. N Engl J Med. 1981; 305:1439-44. [PubMed]

2. McMillan A, Smith IW. Painful anal ulceration in homosexual men. Br J Surg. 1984; 71:215-6. [PubMed]

3. Ghosh SK, Bandyopadhyay D, Ghosh A, Mandal RK, Bhattacharyya K, Chatterjee S. Non-healing perianal ulcer: A rare presentation of cutaneous tuberculosis. Dermatol Online J. 2009 Mar 15;15(3):9. [PubMed]

4. Kumar B, Ross MW. Sexual behaviour and HIV infection risks in Indian homosexual men: a cross-cultural comparison. Int J STD AIDS 1991; 2:442-4. [PubMed]

5. Tripathi BM, Malhotra S. Sexual behaviour and sexually transmitted diseases. In: Sharma VK eds. Sexually transmitted diseases and AIDS.1st ed. New Delhi: Viva Books. 2003:431-43

6. Brahmam GN, Kodavalla V, Rajkumar H, Rachakulla HK, Kallam S, Myakala SP, et al. Sexual practices, HIV and sexually transmitted infections among self-identified men who have sex with men in four high HIV prevalence states of India. AIDS. 2008; 22 Suppl 5:S45-57. [PubMed]

© 2011 Dermatology Online Journal