Yellow-white paint dot-like lesions of the scrotum infected by Candida parapsilosis

Dear Editor,

Scrotal white paint dot-like lesions are prone to misdiagnosis and inappropriate treatment.¹ Prior reports have linked these lesions to a specific type of Nannizzia gypsea infection.^1,2 Here, we report a case of scrotal yellow-white paint dot-like lesions attributed to Candida parapsilosis.

A 26-year-old man presented with persistent, and adherent lesions on the scrotal skin for one year. He had previously sought treatment at another hospital, where he was diagnosed with scrotal eczema and prescribed a low-potency steroid ointment. While the lesions transiently resolved during therapy, they recurred promptly upon cessation. Dermatological examination revealed multiple yellow-white paint dot-like of varying sizes measuring 0.2 to 0.4 cm in diameter on the scrotum [Figure 1a], which were difficult to dislodge. There was no surrounding erythema, vesicles, erosions, or exudates. Bilateral groin, buttocks, hands, and feet were normal. He denied any history of direct contact with soil, domestic animals, or systemic use of immunosuppressive drugs, such as glucocorticoids. Laboratory tests showed negative results for HIV and syphilis serology. Dermatoscopic examination revealed yellow homogeneous structures of varying sizes resembling calcinosis [Figure 1b]. Direct microscopic examination of skin scrapings stained with Calcofluor white staining showed numerous septate hyphae [Figure 1c]. The scrapings were inoculated onto multiple sets of Sabouraud’s dextrose agar with chloramphenicol and were incubated at 25℃. After nine days of culture, all the agar slants yielded white, cheese-like colonies [Figure 2a]. When subculture on the Chromogenic Candida Agar Candida plate, the cheese-like colonies were lavender in the centre, and white at the edges [Figure 2b]. Based on the sequence of the internal transcribed spacer (ITS), the organism was identified as Candida parapsilosis (GenBank accession: PV650300). A definitive diagnosis of scrotal candidiasis caused by Candida parapsilosis was established. Treatment with topical 1% butenafine cream applied twice daily for 4 weeks resulted in complete resolution of lesions, with no recurrence observed during a 3-month follow-up period [Figure 2c].

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Figure 1a:

Before treatment: multiple yellow-white paint dot-like lesions on the scrotum.

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Figure 1b:

Dermatoscopic examination showing yellow homogeneous structures of varying sizes resembling calcinosis. (Polarised, 20x).

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Figure 1c:

Skin scrapings showing numerous septate hyphae (red arrow) (Calcofluor white, non-polarised, 400x).

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Figure 2a:

Cultures of multiple skin lesions on Sabouraud’s dextrose agar with chloramphenicol showing white, cheese-like colonies.

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Figure 2b:

The cheese-like colonies on the chromogenic candida agar candida culture medium.

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Figure 2c:

Resolution of the lesions after treatment.

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Cutaneous candidiasis typically involves moist intertriginous areas, presenting with erythema, erosions, and easily removable white pseudomembrane, and often accompanied by pruritus.³ In contrast, our case of scrotal candidiasis presented with dry and yellow-white paint dot-like lesions. We hypothesise that these unique manifestations observed in this patient, infected by Candida parapsilosis, may be attributed to prior misdiagnosis and inappropriate treatment with low-potency steroid ointment. This likely could have led to significant fungal hyphae accumulation in the scrotal area (a region particularly prone to wrinkling and friction), resulting in this distinctive clinical manifestation. While previous reports link similar scrotal lesions to Nannizzia gypsea infection,^1,2 our findings indicate that scrotal white paint dot-like lesions are not exclusively linked to Nannizzia gypsea infection and may represent a distinct clinical manifestation influenced by various factors (e.g., repeated friction, moisture, improper treatment) in this region. Notably, some lesions in our patient exhibit a brown surface discolouration. This feature may represent a specific characteristic of Candida parapsilosis infection or relate to the patient’s hygiene practices.