Balanitis plasmacellularis N48.1

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 11.12.2021

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Synonym(s)

Balanitis chronica circumscripta benigna plasmacellularis; Balanitis chronica circumscripta plasmacellularis; Balanitis nodularis Zoon; balanitis plasmacellularis; Balanitis plasmacellularis; Balanoposthitis chronica circumscripta plasmacellularis; Balanoposthitis chronica plasmacellularis; plasma cell balanitis; recurrent balanitis; zoon balanitis; Zoon balanitis; Zoon`s balanitis; Zoon`s erythroplasia

History
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Zoon 1950

Definition
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Chronic, circumscribed, focal erosive inflammation of glans penis and/or inner preputial leaf of unknown cause, occurring exclusively in non-circumcised men. S.a.u. Vulvitis chronica circumscripta plasmacellularis.

Etiopathogenesis
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Unexplained; possibly irritative-toxic (urinary incontinence; increase in concentration of urine in the foreskin environment with reduced smegma production in old age). Hygiene deficiencies?

Manifestation
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Predominantly occurring in older men (> 60 years), rarely in men between 30-50 years. The disease does not occur in circumcised men.

Clinical features
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One or more, circumscribed, sharply or blurredly defined, lacquer-like shiny, deep red to brownish-red, erosive plaques, often with petechial haemorrhages, which are called "cayenne pepper spots". Occasionally, the lesions may be contact-reactive as "kissing lesions".

Remarkable is only a slight clinical symptomatology with slight burning, itching or dysuria.

Histology
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Epidermis atrophically flattened with absent horny and granular cell layer. Edema of the stratum papillare, dilatation of the capillaries in the upper corium, partial erythrocyte extravasations; hemosiderin deposits; band-shaped diffuse lymphohistiocytic infiltrate (also eosinophilic and neutrophilic granulocytes) with varying density of plasma cells (>50%). Remark: The occurrence of plasma cells is not a specific feature of balanitis "plasmacellularis", but is to be understood as a site-typical inflammatory reaction of the mucosa.

Differential diagnosis
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PIN (histology is diagnostic): circumscribed, red plaque, sharply demarcated.

Candida infections of the glans penis: mostly blurred, recurrent course.

Bakerial infections (children and adolescents): usually acute course, microbiological evidence of bacilli (frequently strepto- or staphylococci)

Cleanliness balanitis (triggered by excessive hygienic measures): blurred, extensive erythema

Mechanical irritation due to sexual practices: usually combined with cracks, erosions and fresh hemorrhages. Medical history.

s.a.under balanitis of other genesis

Therapy
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Observe general hygiene measures, see below. Balanitis candidamycetica. Daily hand-warm baths with addition of diluted potassium permanganate solution (light pink) or preparations containing tannin (e.g. Tannolact, Tannosynt).

Consistent "draining of the preputial space" by inserting a gauze gauze. Regular cleaning of the glans and foreskin with water or vegetable oils (e.g. olive oil), especially after urination to remove traces of urine. 2 times/day application of an ointment containing zinc (alternative: hydrophilic ointment not containing zinc). Subsequent treatment with active substance-free bases such as Ungt. emulsif. or wound-healing ointments, e.g. preparations containing cod liver oil (Desitin ointment or Mirfulan ointment).

In cases of severe local inflammatory symptoms, an ointment containing glucocorticoids can be applied for a short time under controlled conditions.

Alternative: Successful therapy with the calcineurin inhibitor tacrolimus has been reported (experimental approach!).

Operative therapie
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Circumcision is recommended for patients resistant to therapy and represents the gold standard in this constellation. Afterwards healing occurs in >80%.

Progression/forecast
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Without circumcision, the disease progresses eminently chronically, chronically recurring, over months or even years, since hygiene errors cannot be avoided despite meticulous precautions. Malignancy (carcinoma in situ) must always be clarified.

Literature
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  1. Alessi E et al. (2004) Review of 120 biopsies performed on the balanopreputial sac. from zoon's balanitis to the concept of a wider spectrum of inflammatory non-cicatricial balanoposthitis. Dermatology 208: 120-124
  2. Daga SO et aal. (2017) Zoon's balanitis treated with topical tacrolimus. Urol Ann 9:211-213.
  3. Edwards S et al (2014) European guideline for the management of balanoposthitis. Int J STD AIDS 25:615-626
  4. Hugh JM et al (2014) Zoon's balanitis. J Drugs Dermatol 13:1290-1291
  5. Jolly BB et al (1993) Zoon's balanitis. Urol Int 50: 182-184
  6. Kumar B et al (2006) Plasma cell balanitis: clinicopathologic study of 112 cases and treatment modalities. J Cutan Med Surg 10: 11-15
  7. Lepe K et al (2021) Balanitis Circumscripta Plasmacellularis. 2021 Aug 27. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing Jan-. PMID: 29489180.
  8. Marcos-Pinto A et al (2018) Nonvenereal penile dermatoses: A retrospective study. Indian Dermatol Online J 9:96-100.
  9. Moreno-Arias GA et al (2005) Plasma cell balanitis treated with tacrolimus 0.1%. Br J Dermatol 153: 1204-1206
  10. Retamar RA et al (2003) Zoon's balanitis: presentation of 15 patients, five treated with a carbon dioxide laser. Int J Dermatol 42: 305-307
  11. Roe E et al (2007) Plasma cell balanitis of zoon treated with topical tacrolimus 0.1%: report of three cases. J Eur Acad Dermatol Venereol 21: 284-2855
  12. Zoon JJ (1950) Balanitis circumscripta chronica met plasmacellen-infiltraat. Ned Tijdschr Geneeskd 94: 1529-1530.

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Last updated on: 11.12.2021