Sexually Transmitted Diseases/Is this HPV or something else?

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white penile circles
white penile circles  
penile sore
penile sore  
QUESTION: Hi Mark,
     I just stumbled upon your site while looking for pictures of something similar to what keeps happening to my penis. I am a 28 year old transsexual woman and I already have HIV n HPV. I have had 4 surgeries in and around my anus/rectum in the past year to try to remove all the precancerous dysplasia and the warts that kept coming back. Now I understand all of that, but my GP has had no answer for what's been happening to my penis.
   Every few months it seems since Oct. 2012 I have been getting what appears the be a yeast or bacterial infection down there, mainly forming around the head and the top of the shaft. It first just made it red and swollen. Then every time after it has gotten worst  leading to discoloration of purple red and white... eventually it started to make these white circles underneath the skin that would raise but slightly sink in. Those have left permit scarring it seems along with now the head of my penis is really wrinkly and the skin just looks weathered. Where those circles were are still indented but have filled in most the way. My doctor says I need to keep it keep n I try to as much as possible, but I am a transsexual I have to tuck it most the day. This infection only seems to happen around the same time me n my boyfriend have sex too.
    And the last couple of things is there waa a sore that was created during the last infection 3/4weeks ago....it also caused a rash to form on my stomach n calf about 2 by2 1/2 inches...along with a few small  nickel size red rashes on my neck n hands. I would love a second opinion...well since I've asked three doctors in my HIV clinic, I guess it would be a fourth opinion.  
  They always put me on a few different antibiotics (one for yeast infections, bactrim and something with a D..)and give me a anti fungal cream to apply twice a day....do you know what this might be? And is there any preventative care I can do besides washing my crotch more then when I shower (once to twice a day...which I currently do)?

Thank,
     Brooke
San Diego, USA

ANSWER: Hi Brooke,
Because you tuck penis inbetween your legs, it tends to stay warm and moist, and possibly exposed to some fecal germs, which may include fungi. Since it appears you are not circumcised either, you have yet another risk factor for a skin infection from yeast or other fungi. Now you also have a history of HIV and HPV, which further complicates the situation!! You didn't mention if you have other medical problems, such as diabetes, eczema, or other skin conditions, or if your HIV viral load and CD4 counts are good, bad, or otherwise!  And, when and how you were treated for the HPV (freezing, laser, chemical acids or immune system modulation creams).

Hopefully, your doctors are checking you periodically for syphilis with appropriate blood tests. The white area on your penile glans look like thickened epithelium, which may be mildly reactive-- meaning, it's a reaction to the skin germ/fungus you have, or a recent result of treatment.

The most likely cause is a skin fungus (uncirc'd, tucked penis inbetween legs near fecal germs and fungi, warm and moist), and should therefore be treated twice daily with something like terbinefine (Lamisil), tolnaftate (Tinactin), miconazole (Micatin), for at least 2 weeks, even though everything appears to be healing. Stopping the treatment too soon, may cause a recurrence of the fungal rash.

The next step is to find a dermatologist sensitive to transgender women.  A good place to look is the provider directory on the Gay and Lesbian Medical Association' web site (GLMA.org).

Good luck!
--mark


---------- FOLLOW-UP ----------

QUESTION: Hey Mark,
  Well my Tcell count is 834 at the present time and my viral load is undetectable. I am circumcised and I have just been diagnosed as anemic this week (I have to follow up with them in the coming weeks on treatment). As for my HPV treatment they have cut and burned them off, followed up by and IR light sessions which I currently still doing bi-monthly. The treatment cream I have is miconazole. Thanks for your opinion!

Best Regards,
        Brooke

Answer
Hi Again, Brooke,
HIV status seems great with stable CD4s and undetectable viral load! Good job. However, there is NO GOOD REASON for a biologic male (you don't have menstrual periods) to have anemia, unless there is some evidence of bleeding from the gastrointestinal tract, or heavy alcohol use, or a few other reasons. You may wish to ask your doctors to try an immune modulator cream such as imiquimod (Aldara), since your immune system is intact. Some fungi are now resistant to the topical antifungal miconazole (Micatin, Monistat), so I would try a different one, such as terminefine (Lamisil) or tolnaftate (Tinactin).  Void clotrimazole, which is much older and has much more fungal resistance.

Good luck!
--mark  

Sexually Transmitted Diseases

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Mark P. Behar

Expertise

Almost any question or concern about gay men's health issues, sexually transmitted infections, abnormal Pap smears, anal cytology (anal "Pap smears"), etc. There is no such thing as “d/d free” or “clean” (free of infection), so why do so many of us deceive ourselves into thinking that some people are indeed totally free from a potentially infectious disease, like HIV, herpes, hepatitis, syphilis, chlamydia, warts, gonorrhea, etc., just because they say so? Clinical laboratory tests are not perfect, and having a “negative” or “nonreactive” test does not mean that a person is free from infection. Perhaps at the moment the test was taken, the person was uninfected; or, perhaps, the test wasn’t sensitive enough to detect presence of the infection. There is really no way that anyone can determine that they are truly “disease free,” and there are over a hundred of infectious conditions that can be spread without your knowing anything. Rather than trying to “pre-screen” or “serosort” a potential sex-mate with deceptive questions that are impossible to know by today’s technologies, a wiser option may be to consider everyone infected with something, and either use appropriate protective measures (“safer sex”), or accept the responsibility and consequences of possibly “catching” something from someone who’s hotter than expected (pun intended!). There is much research that supports the contention that an HIV positive person reliably taking HIV medications, and having an undetectable viral load, presents a lower risk for transmission of HIV than people who may think or say they are HIV negative, but are not. Food for thought!

Experience

Family Practice PA since 1981; Volunteer Clinician for Brady East STD (BESTD) Clinic, Milwaukee, since 1977; answered STD questions submitted to their web site. Professionally lectured at national and regional Physician Assistant and Nurse Practitioner conferences, and at national gay & lesbian health conferences on topics including HIV/AIDS, herpes, hepatitis, STDs, human papilloma virus (the cause of venereal warts), abnormal Pap smears, gay and lesbian health issues, among others.

Organizations
Co-Founder, Lesbian, Bisexual, & Gay Physician Assistant Caucus of the American Academy of Physician Assistants, Inc.; American Academy of Physician Assistants; Wisconsin Academy of Physician Assistants; National Co-Chair (2012-16), National Association of Black and White Men Together: A Gay, Multiracial Organization for All People (NABWMT)

Publications
Journal of the American Academy of Physician Assistants (JAPA) Q Visions, Quarterly Newsletter of the NABWMT

Education/Credentials
Bachelor's of Arts, 1972 (University of Wisconsin, Milwaukee, WI) Graduate Credits Experimental Psychology, 1972-75 (Tulane University, New Orleans, LA) Physician Assistant, Bachelor's of Science, 1981 (George Washington University, Washington, DC); Masters in Physician Assistant Studies, 2000 (University of Nebraska Medical Center, Omaha, NE)

Awards and Honors
Colposcopy Recognition Award (CRA), the American Association of Colposcopy and Cervical Pathology; Distinguished Fellow, Clinical Preceptor, American Academy of Physician Assistants; Fellow, Wisconsin Academy of Physician Assistants

Past/Present Clients
Brady East STD Clinic, Milwaukee, WI Milwaukee Health Services, Inc. (Martin Luther King Heritage Health Center), Dept. of Family Medicine and Early Intervention Program for HIV Infected Persons

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