Kissing lesions in dermatology

1. Congenital

The ‘divided’ or ‘kissing’ naevus was first reported by Van Michael Paul in 1908 and named by Fuchs in 1919. Fuchs described a congenital melanocytic naevus on adjacent parts of the upper and lower eyelid giving the appearance of a single lesion when the eye was closed. Kissing or divided naevus can only be seen on those parts of the body at which separation occurs during embryogenesis.³ Because this separation occurs after melanoblast migration to the skin, the resulting pigmented lesion appears to be divided in two. Some of the commonly involved sites include upper and lower eyelids separated by palpebral fissure and inner foreskin and dorsal glans penis separated by coronal sulcus.

• A.

  Kissing or divided congenital melanocytic naevus – In rare cases, melanocytic naevi may exhibit lesions in a mirror image configuration or kissing pattern. They have been reported to occur on eyelids, penis [Figure 1], lips, and labia majora.^4–6 Kissing naevus of eyelids has also been called as ‘split ocular naevus’ or ‘panda naevus’.⁷

• B.

  Divided spotted grouped pigmented naevus – On upper and lower eyelids.⁸

• C.

  Divided naevus spilus – On upper and lower eyelids.⁸

• D.

  Divided epidermal naevus – On adjacent fingers.⁹

• E.

  Divided mastocytoma – Described as divided mast cell naevus located on adjacent fingers.¹⁰

• F.

  Kissing café au lait macules – On upper and lower eyelids.¹¹

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Figure 1:

Kissing melanocytic naevus of the penis.

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2. Infections

Sexually transmitted infections

• A.

  Kissing chancre – Kissing syphilitic chancres, often the first sign of primary syphilis, are usually symmetrical around the coronal sulcus [Figure 2]. A few prior documented cases exist demonstrating mirror image-like lesions.¹³

• B.

  Kissing chancroid – Kissing chancroid can occur on the glans and adjacent inner foreskin [Figure 3].

• C.

  Kissing condyloma lata – Condyloma lata, a manifestation of secondary syphilis, typically present as raised gray-white lesions on mucosal areas. These lesions often have a wart-like appearance and can occur in the genital and anal regions and often demonstrate a kissing morphology.¹⁴

• D.

  Genital warts and molluscum contagiosum: These may present as kissing lesions due to pseudo-koebnerisation.

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Figure 2:

Kissing chancre (resolving) of the penis.

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Figure 3:

Kissing chancroid of the penis.

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3. Irritant

• A.

  Paederus dermatitis (blister beetle dermatitis or dermatitis linearis) – It presents with an intensely burning linear or serpiginous rash in a kissing or mirror image pattern [Figure 4]. The kissing pattern is caused by the crushing of the beetle against two flexor surfaces, causing a release of Pederin toxin (which is found in the hemolymph of Paederus) onto the skin.¹⁵

• B.

  Zoon’s balanitis – Kissing lesions on the glans and foreskin are commonly described in Zoon’s balanitis or plasma cell balanitis, which are hypothesised to occur due to the irritant effect of smegma and urine, in an uncircumcised male with dysfunctional prepuce [Figure 5].¹⁶

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Figure 4:

Kissing paederus dermatitis on the right upper limb.

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Figure 5:

Kissing Zoon’s balanitis

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4. Inflammatory and Metabolic

• A.

  Lipschütz ulcer – This is a rare and acute form of genital ulcers that primarily affects young, sexually active women. While it was initially described in the context of infectious mononucleosis, these ulcers can occur in the absence of this infection. Other factors, such as viral or bacterial infections, systemic illnesses, and hypersensitivity reactions, have been suggested as potential triggers. The condition is characterized by the sudden appearance of painful, shallow ulcers on the labia minora, vestibule, or perineum. The ulcers are typically solitary or few, with well-defined borders. They may be associated with systemic symptoms such as fever and malaise.¹⁷

• B.

  Kissing hidradenitis suppurativa – They have been described on the penile shaft and opposing scrotum.¹

• C.

  Porokeratosis ptychotropica – It is a disorder of keratinization clinically characterised by a symmetrical reddish to brown-coloured hyperkeratotic, verrucous or psoriasiform plaques on the perianal and gluteal regions in a kissing-like or butterfly pattern.¹⁸

• D.

  Kissing xanthelasma – There is only one documented case of kissing xanthelasma in a five-year-old girl with unilateral kissing xanthelasma on the upper and lower left eyelids without abnormal serum lipid levels.¹⁹

5. Neoplastic

• A.

  Kissing basaloid follicular hamartoma – Basaloid follicular hamartoma is a rare benign neoplasm that typically presents as multiple small papules or nodules on the skin. They have been reported to occur in a kissing fashion over the upper and lower eyelids.²⁰

• B.

  Kissing melanoma – This rare entity was reported on the prepuce and glans of a 30-year-old male arising in a pre-existing kissing melanocytic naevus of the penis.²¹

• C.

  Kissing sebaceous carcinoma – This has been reported on upper and lower eyelids. The kissing tumors might have independently developed in the adjacent eyelids, or one tumour appeared first and then invaded to the neighbouring eyelid through pagetoid spreading in a continuous way.²²

Some of the well-described causes of kissing lesions have been summarised in Figure 6.

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Figure 6:

Flowchart showing the classification of kissing lesions in dermatology. CMN: congenital melanocytic naevus, STD: sexually transmitted disease.

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