Balanitis plasmacellularis N48.1

Zoon 1950

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.

Unclear; possibly irritative-toxic (urinary incontinence; increased urine concentration in the foreskin area due to reduced smegma production with age).

Poor hygiene! 

Plasmacellular balanitis and diabetes mellitus: Diabetes mellitus can indirectly contribute to this condition: glucosuria, increased susceptibility to infection, and frequent episodes of Candida balanoposthitis can contribute to chronic inflammation and irritation. This is particularly pronounced in cases of inadequate glycemic control or when taking SGLT2 inhibitors. However, this association primarily concerns infectious or fungal balanitis (Candida balanitis), not specifically plasma cell balanitis, which is defined as a noninfectious, reactive inflammation. Clinical Implication: In cases of chronic or recurrent balanitis, one should investigate for previously undiagnosed or inadequately controlled diabetes mellitus, for example, by measuring fasting glucose and HbA1c.

Note: The resolution of the condition following circumcision suggests a triggering and perpetuating toxic-irritative mechanism. 

It occurs primarily in older men (over 60 years of age) and rarely in men between the ages of 30 and 50. The condition does not occur in circumcised men (!).

One or more well-defined, sharply or indistinctly demarcated, glossy, deep red to brownish-red erosive plaques, often with petechial hemorrhages known as "Cayenne pepper spots." Occasionally, the lesions may appear as contact-reactive “kissing lesions.”

Notably,clinical symptoms are strikinglymild, consisting of a slight burning sensation, itching, or dysuria.

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.

PIN (histology is diagnostic): a well-defined, red plaque with sharp borders. Histology is diagnostic.

Candida infections of the glans penis: usually with indistinct borders, itchy; acute, frequently recurrent course.  

Bacterial infections (children and adolescents): usually an acute course, with microbiological detection of bacteria (often streptococci or staphylococci).

Hygiene-related balanitis (triggered by excessive hygiene measures): poorly defined, diffuse erythema and plaques. 

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

See also “Balanitisof Other Origins”!

Follow general hygiene measures; see“Candidal balanitis” below. Daily lukewarm baths with the addition of a diluted potassium permanganate solution (light pink) or preparations containing tannins (e.g., Tannolact, Tannosynt).

Consistent “drying of the prepuce” by inserting a piece of 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. Apply a zinc-containing ointment twice daily (alternatively: a hydrophilic, non-zinc-containing ointment). Follow up with active-ingredient-free bases such as emulsifying ointments or wound-healing ointments, e.g., preparations containing cod liver oil (Desitin ointment or Mirfulan ointment).

In cases of severe local inflammation, a glucocorticoid-containing ointment may be applied under controlled conditions. Topical steroid preparations (with or without added antibacterial agents, such as clobetasone butyrate with nystatin and oxytetracycline cream) should be applied once or twice daily for a short period of time

Alternatively: Antibacterial creams such as 2% mupirocin ointment, applied twice daily.

Alternatively: Topical calcineurin inhibitors may be effective (pimecrolimus/tacrolimus). Concerns remain regarding the risk of malignancy with continuous long-term use. A burning sensation may occur after the first application, which can be minimized by using skin care products (Edwards SK et al. 2023).

Alternatively: There have been reports of successful treatment withrituximab in isolated cases (Tchernev G et al. 2019).

Circumcision is recommended in cases of treatment resistance and is considered the gold standard in this context. Following the procedure, healing occurs in >80% of cases (Kumar B et al. 2006). 

Without circumcision, the disease has a distinctly chronic, chronically recurrent course lasting months or even years, as hygiene-related complications are unavoidable despite meticulous preventive measures. Malignancy (PIN/carcinoma in situ) must always be ruled out.    

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