Penile Pearls

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During the first physical examination of a baby boy, evaluation of the genitals revealed 2 small, white, pearly lesions at the tip of the foreskin, partially obscuring the urethral meatus. There was no spontaneous drainage from the lesions. The infant was voiding without difficulty, feeding well, and acting normally. There was no maternal history of sexually transmitted infections.

The lesions in this boy are penile pearls—small white nodules that contain keratin, akin to Epstein pearls found on a newborn’s palate. The incidence of prepucial pearls has been reported to be 7.3 per 1000 live-born male neonates. The lesions are benign and are believed to be the accumulation of keratinized epithelial cells during fetal development.

The differential diagnosis mainly consists of molluscum contagiosum and genital warts. The rash of molluscum contagiosum consists of dome-shaped papules with central umbilication and is rare in newborns. Condyloma acuminatum is usually papillary and cauliflower-like. Neonatal herpes infections, when accompanied by skin findings, are characterized as clusters of discrete vesicles on an erythematous base, not pearly nodules. Sebaceous hyperplasia also manifests as small nodular lesions, but the lesions are more yellow than penile pearls and more common in older adults than
in children. Lichen nitidus could also be considered in the differential; however, this condition consists of multiple tiny skin-colored papules that often present in groups.

Penile pearls spontaneously exfoliate, and reassurance is the only management necessary. This baby was circumcised the following day, and the penile pearls were removed along with the foreskin. They were not sent for histopathological analysis.