Erythroplasia of Queyrat
EQ; penile intraepithelial neoplasia (PeIN); penile Bowen's disease
Erythroplasia of Queyrat is squamous cell carcinoma in situ of the glans penis or inner prepuce of an uncircumcised man, corresponding in modern terminology to HPV-driven undifferentiated penile intraepithelial neoplasia (PeIN). It typically presents in late middle age as one or more well-demarcated, glistening, velvety red plaques. High-risk HPV (especially HPV-16) drives most cases. Modern HPV-stratified data give progression rates of ~10–20% for differentiated PeIN, with lower rates for undifferentiated (HPV-driven) PeIN; older mixed-cohort series quote 10–30%. Accurate diagnosis and effective treatment are essential. Per the WHO 2016 classification of penile tumours, erythroplasia of Queyrat is specifically HPV-driven undifferentiated PeIN; differentiated PeIN is a separate entity arising on a lichen-sclerosus background and is not aetiologically HPV-driven.
Clinical features
- Solitary or multifocal, well-demarcated, bright red, velvety / shiny plaque on the glans, coronal sulcus or inner prepuce.
- Asymptomatic or mild irritation, soreness, or bleeding.
- Slowly progressive over years.
- Risk factors: lack of circumcision, chronic balanitis, smoking, lichen sclerosus, immunosuppression (HIV, transplant), high-risk HPV.
- "Bowenoid papulosis" — multiple small pigmented papules in younger men, also HPV-driven, much lower invasive risk and may regress spontaneously.
Differential diagnosis
- Zoon's plasma cell balanitis — orange-brown "cayenne pepper" macules; reactive lymphocytic infiltrate on histology.
- Lichen sclerosus / balanitis xerotica obliterans — white sclerotic plaques; itself a risk factor for SCC.
- Psoriasis / lichen planus / candida balanitis — generally inflammatory and bilateral.
- Invasive penile SCC — exophytic, indurated, ulcerated.
- Any persistent erythematous plaque on the glans not responding to topical antifungal/steroid within 4–6 weeks should be biopsied.
Diagnosis
- Punch or shave biopsy under local anaesthetic.
- Histology: full-thickness atypia of stratified squamous epithelium without invasion through the basement membrane; HPV often demonstrable.
- Examine the entire genital area, perianal skin and anus — synchronous lesions are common.
- HIV testing is appropriate in selected patients.
Management
- Topical 5% imiquimod — 3–5 nights/week for 6–16 weeks; complete response 40–70% but irritation can be intense.
- Topical 5-fluorouracil 5% twice daily for 4–6 weeks; similar response rates.
- MAL- or ALA-photodynamic therapy — selected centres; durable responses but recurrence common.
- CO₂ or Nd:YAG laser ablation — destruction with no histology.
- Circumcision — curative for prepuce-only lesions; otherwise enhances field control.
- Glans resurfacing (excision of glans epithelium with split-thickness skin graft) — provides histological clearance with cosmetic and functional preservation, performed in specialist andrology centres.
- Mohs micrographic surgery — for recurrent or extensive PeIN; preserves penile tissue.
- Refer to a urology MDT in any case of suspected invasion or recurrence after topical therapy.
Surveillance
- Lifelong, given high recurrence and second-field disease risk.
- 3-monthly review for the first year; 6-monthly thereafter.
- Counsel about smoking cessation, HPV transmission, and partner screening.
- HPV vaccination has a role for unaffected partners and adolescent boys.
References
- Mannweiler S et al. Penile intraepithelial neoplasia: pathology and HPV. Histopathology; 2013.
- European Association of Urology. EAU Guidelines on Penile Cancer. Arnhem: EAU; 2026.
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