Not even on the list of differentials

A while back, newFNP saw a guy who came into the clinic and was quite distressed about the painful ulcer he had on his penis.  He somewhat bashfully showed newFNP the lesion which required him to retract his foreskin.  What was revealed was a bright purple glans with a single ulceration.  

The first time newFNP saw the purple liquid covering something or other, she was quite surprised.  Tincture of violet, or violeta, is a much loved antiseptic in the Latino community.  NewFNP's patients don't seem to use it as advertised in the natural stores - as a tincture of be consumed - but rather paint it on any manner of superficial injuries including, it seems, the ones that show up on the penis.

Despite the violeta, newFNP did a herpes culture - negative -  as well as a syphilis test - also negative.  Her patient wasn't giving up any clues as to what may have caused this ulceration.  No zipper misjudgment, no history giving newFNP a single damned clue about why his penis had a big fat ulcer.

Well, newFNP's colleague elicited a story that is incredible.  She saw this gent for follow-up, penis still purple and ulcerated.  According to her, he must have felt like confessing because he told her how he got the ulcer. 

NewFNP knows this man to have been a former crack user.  Apparently, he had been a crack dealer as well.  His storage space: the cozy area between his foreskin and his glans.

Is that even possible?  There is no drawstring!  How does the crack stay there?  Not having a little foreskin pouch of her own, newFNP frankly just does not understand.  But if it's true, that is gross.  And apparently very dangerous.  And yet another reason to add to the 'con' column when considering crack smoking!

Dr. Dual-Ivy-League-Degrees had a good point about this one - the most important question in the history is often, "What do you think might be causing this?"