How would you diagnose this man’s persistent scrotum itching?

A 60-year-old male presented for evaluation and treatment of persistent itching involving the anterior half of his scrotum. He had been given a topical antifungal cream and a topical corticosteroid cream with only limited and temporary relief.

How would you diagnose his itch?

A. Scabies

B. Dermatophyte infection 

C. Intertrigo

D. Lichen simplex chronicus

(Answer and discussion on next page)

Answer: Lichen simplex chronicus 

The itchy red scrotum (otherwise known as the red scrotum syndrome) is a poorly understood condition that often defies treatment strategies. The goal is to identify an etiology if possible—such as infections, infestations, or inflammation—through skin scraping and cultures, laboratory testing, patch testing, and skin biopsy, but often there is no cause found as was seen in this case. 

Some success at relieving pressure on the pudendal and scrotal nerves with a hemorrhoid pillow and neurologic agent (eg, gabapentin) has been found in several cases when no etiology could be elicited. Anecdotal reports have shown relief with oral doxycycline though the mechanism of action is unknown. Topical therapy typically only provides temporary relief and care must given to avoid prolonged corticosteroid use or using potentially sensitizing medications. 

References:

1. Kantor GR. What to do about pruritus scroti. Postgrad Med. 1990;88(6):95-96, 99-102.

2. Narang T, Kumaran MS, Dogra S, et al. Red scrotum syndrome: idiopathic neurovascular phenomenon or steroid addiction? Sex Health. 2013;10(5):452-455. 

3. Abbas O, Kibbi AG, Chedraoui A, Ghosn S. Red scrotum syndrome: successful treatment with oral doxycycline. J Dermatolog Treat. 2008;19(6):1-2.

4. Prevost N, English JC 3rd. Case reports: red scrotal syndrome: a localized phenotypical expression of erythromelalgia. J Drugs Dermatol. 2007;6(9):935-936.

5. Koh WL, Liu TT. A cured patient who came back for consultation: neuropathic scrotal pruritus relieved after ipsilateral inguinal hernia repair. Int J STD AIDS. 2010;21(9):658-659.